In the event of a public health emergency, there may be a surge in the number of deaths that requires management in terms of investigating, recovering, transporting, identifying, storing, tracking, and processing large numbers of fatalities in a short time period. Accordingly, licensure requirements for physicians, funeral directors, and first responders may need to be waived in order to facilitate this management. Interstate transportation may be required to dispose of hazardous material, which is governed by federal regulations. Mutual aid agreements with neighboring jurisdictions may be necessary for cremation or mass burial if there is a large number of fatalities.
12.2.1 Mass Fatality Incident
The Draft Districtwide All-Hazards Mass Fatality Management Plan (Draft MFM Plan) defines “Mass Fatality Incident” as any situation resulting in more human remains to be investigated, recovered and examined than can be managed using local resources, or any situation that results in the inability to process human remains under routine conditions.
12.2.2 Mass Fatality Management
The Draft MFM Plan defines “Mass Fatality Management” as the ability to train and cooperate with governmental and nongovernmental agencies, organizations, associations, and other entities to ensure that in mass fatality incidents the proper recovery, handling, identification, transportation, tracking, storage, certification of cause and manner of death is utilized; and to facilitate access to mental and behavioral health services to family members, responders, and survivors.
12.3 Mass Fatality Incident Management
The Draft MFM Plan sets forth procedures for responding to a fatality surge (a surge in the number of deaths). Specifically, the Draft MFM Plan provides for investigating, recovering, transporting, storing, tracking, and processing large numbers of decedents over a relatively short period of time.
The District of Columbia Office of the Chief Medical Examiner (OCME) assumes primary responsibility for fatality management operations under the Draft MFM Plan, focusing on accurate decedent identification and return of decedents to the legal next-of-kin.
OCME’s fatality management role includes the following core responsibilities:
- Perform an incident-specific scene assessment;
- Conduct a full medicolegal investigation to establish cause and manner of death;
- Perform decedent recovery;
- Secure remains and associated personal effects (PE);
- Gather, secure, document, track, and preserve evidence;
- Arrange for temporary decedent storage and transport;
- Track decedents;
- Manage the establishment of field mortuary operations necessary to support the investigation and identification of decedents, if applicable;
- Oversee the Disaster Victim Identification (DVI) process;
- Preserve human remains, if applicable;
- Arrange for temporary interment or long-term disposition, if applicable; and
- Support family management efforts.
12.3.1 Conditions that Warrant Activation of the Draft Mass Fatality Management Plan
The following conditions warrant activation of the Draft MFM Plan:
- Issuance of public health emergency executive order by the Mayor of the Department of Health (the Mayor). D.C. Official Code § 7-2304.01. See section 4.2.2;
- Any confirmed incident associated with five (5) or more fatalities tied to a single event;
- Multiple, simultaneous incidents that produce any number of fatalities, and have the potential to be man-made, coordinated or terror-related, such as complex coordinated attacks (CCAs);
- Any confirmed incident with the potential for mass fatalities (5 or more deaths), such as a mass casualty incident;
- Anticipated events such as:
- Impending or predicted natural disasters; and
- National security special events (NSSEs), or any large gatherings greater than 100,000 persons. (See section 4.5.1 of the Manual).
- Credible knowledge of a perceived threat, at the discretion of the OCME Director or appointed designee(s), District of Columbia Department of Health (DC Health), District of Columbia Fire and Emergency Medical Services Department (FEMS), Metro Police Department (MPD), The District of Columbia Homeland Security and Emergency Management Agency (HSEMA), or the Emergency Operations Center (EOC); and
- Unique fatality scenarios that would exceed routine OCME operational capacity such as:
- Greater than 20 fatalities in a single day;
- Pandemic-related or highly infectious deaths;
- Remains contaminated with any hazardous material or exposed to a Chemical, Biological, Radioactive, Nuclear, or Explosive (CBRNE) agent;
- A single event that produces multiple highly fragmented remains; and
- Protracted and/or complex fatality scenarios (i.e. building collapse, water recovery).
12.4 Decedent Information
OCME plays a critical role in victim identification in a mass fatality incident. Victim identification aids the determination of the cause and manner of death, informs the death investigation, and ultimately helps to reunite the decedent with loved ones. In instances of a mass fatality, normal identification protocols via visual identification may not be possible or desirable and alternate means of identification may be used, including scientific (e.g. fingerprints, radiograph comparison, DNA); and circumstantial (based upon circumstantial evidence). Victim identification will also inform the order of priority for the release of remains to control decedent disposition and any District of Columbia (District) notification obligations in the event of mandatory mass burial, mass cremation, or other executive directive that affects the decedent’s disposition.
The identification of the victim may also impact the court when determining standing, resolving disputes, and any civil considerations resulting from the District’s action that affects the decedent’s remains and next-of-kin rights.
12.5 Professional Licensure
The OCME staff includes board certified forensic pathologists who determine cause and manner of death. In instances of a mass fatality incident, the OCME may utilize non-staff physicians to assist with these functions. D.C. Official Code § 5-1410.
There may be a need to waive licensure requirements for the following individuals:
- Funeral directors; and
- First responders.
See section 11.2 of the Manual.
12.6 Decedent Disposition
The District does have locations to accommodate burial of human remains; however, the space limitations and locations may not be suited for mass burial or infected or contagious remains. The District currently has no crematorium. All human remains to be cremated must be transported out of state.
In the event decedent remains require direct transport outside of the District (e.g., in cases of Ebola or other infectious diseases), or for other purposes, licensure requirements for non-District licensed funeral directors may need to be modified or waived to effectuate out-of-state transfers of human remains. See section 11.2 of the Manual.
12.6.1 Special Rules Regarding Decedent Disposition When Death Caused by Certain Diseases
Special rules apply in cases of death from the following diseases:
- Plague (bubonic and pneumonic);
- Smallpox; or
- Louse-borne typhus fever.
When death is caused by one of the diseases listed above, the physician issuing the certificate of death must give immediate notice by telephone of the death to the Director of the Department of Health (DC Health Director). 22B DCMR § 214.1. See section 7.5 of the Manual. Certain steps must be taken with the body of a person who died from one of the diseases listed above. In addition, the body of a person who died from one of the diseases listed above may not be moved from the place of death except after issuance of a permit by the DC Health Director. 22B DCMR §214.2.
A public funeral service for a person who has died of any of the diseases listed above must not be held in the presence of the body unless the body has been embalmed and placed in a sealed casket. Quarantined persons may not attend a public funeral service; but may, at the discretion of the DC Health Director, be taken to places of burial provided they do not mingle with the non-quarantined persons present. 22B DCMR § 214.6.
During the West African Ebola epidemic in 2014, DC Health determined that, in the event of a death in the District in which Ebola may be the cause or suspected cause, the OCME would assume all control and management of disposition of the involved human remains. It was decided that all human remains of Ebola patients would be promptly cremated. All funeral directors were notified of this protocol. A plan was adopted, the Interim Draft Concept of Operations for the Management of Decedents with Confirmed or Suspected Viral Hemorrhagic Fever (the ConOps Plan), that was consistent with the CDC Guidance for Safe Handling of Human Remains of Ebola Patients in U.S. Hospitals and Mortuaries.
12.7 Interstate Transportation
An infectious substance is regulated as a hazardous material under the United States Department of Transportation's (U.S. DOT) Hazardous Materials Regulations (HMR). The HMR apply to any material U.S. DOT determines is capable of posing an unreasonable risk to health, safety, and property when transported in commerce. An infectious substance must conform to all applicable HMR requirements when being transported.
Solid materials contaminated with the Ebola virus are classified as Category A infectious substances according to the HMR. Category A infectious substances, including the Ebola virus, may only be transported in two scenarios:
- In full compliance with classification and packaging requirements of the HMR; or,
- Under the terms of a special permit.
The U.S. DOT’s Pipeline and Hazardous Materials Safety Administration (PHMSA) issued a safety advisory that provides an inventory of all relevant information PHMSA has issued for the reference of state and local governments in dealing with the Ebola Virus contaminated waste.
The U.S. DOT has additional information regarding transporting infectious substances available at https://phmsa.dot.gov/hazmat/packaging-of-ebola-contaminated-waste.
Thomas Duncan died of Ebola in Texas in 2014. Six truckloads of Ebola-contaminated waste were removed from his apartment after his death. The U.S. DOT granted an emergency special permit authorizing waste removal company to transport this Ebola-contaminated waste for autoclaving or incineration. The waste was incinerated in Texas, with the ashes to be transported out-of-state to Louisiana to be buried in a landfill. Louisiana took legal action to prevent the ashes from entering the state and was ultimately successful in barring the ashes from being buried in a Louisiana landfill.
12.8 Mutual Aid Agreements
There may be consideration for the District to enter into Mutual Aid Agreements with neighboring jurisdictions in the National Capital Region for cremation and/or mass burial in the event of a mass fatality incident. These agreements are authorized through EMAC and various Mayor’s Orders, including:
During the West African Ebola epidemic in 2014, Maryland’s Board of Morticians and Funeral Directors and Maryland’s Secretary of Health and Mental Hygiene’s Office agreed that it was acceptable to transport any infected decedents from the District to Maryland for the purposes of cremation consistent with the protocols set forth in the ConOps plan.