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Fatality Management
Topic Collection
December 7, 2022

Topic Collection: Fatality Management

According to the Centers for Disease Control and Prevention’s Public Health Preparedness Capabilities: National Standards for State and Local Planning, “Fatality Management” is defined as, “the ability to coordinate with other organizations (e.g., law enforcement, healthcare, emergency management, and medical examiner/coroner) to ensure the proper recovery, handling, identification, transportation, tracking, storage, and disposal of human remains and personal effects; certify cause of death; and facilitate access to mental/behavioral health services to the family members, responders, and survivors of an incident.” This broad scope of activities requires coordinated plans and response from healthcare, public health, and emergency management as well as medical examiners/coroners, funeral/ cremation services, and many other governmental and non-governmental entities. 

Mass fatality incidents are defined as those in which there are more bodies than can be handled using local resources. Since communities vary in size and resources, there is no minimum number of deaths for an event to be considered a mass fatality incident. When planning for and responding to mass fatality events, it is the responsibility of healthcare and fatality management professionals to ensure the respectful and orderly management of deceased persons. For information on Family Assistance Centers, access the Family Reunification and Support Topic Collection. 

Managing decedents during the COVID-19 pandemic posed unique and significant challenges. Select related resources are included in this collection; access the ASPR TRACIE COVID-19 Fatality Management Resources Collection for more comprehensive resources. The Ebola/VHF Topic Collection contains links to resources specific to the management of VHF-infected human remains.

This ASPR TRACIE Topic Collection was refreshed in October 2022. Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.

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Must Reads

ASPR TRACIE. (2022). Issue 16: Decedent Management during Disasters.
The articles in this issue highlight federal, state, local, and rural experiences with decedent management after mass violence incidents and during the COVID-19 pandemic.
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Centers for Disease Control and Prevention. (2018). Capability 5: Fatality Management.
This capability includes the definition of fatality management and identifies the five functions, along with specific tasks, that need to occur for public health agencies to achieve this capability. The five functions include the following: 1) determine the role for public health, 2) activate public health fatality management operations, 3) assist in the collection and dissemination of antemortem data, 4) participate in survivor mental/ behavioral health services, and 5) participate in fatality processing and storage operations.
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Corfield, J. and the Central Florida Regional Medical Coalition (CFDMC). (2023). Family Reunification and Assistance Center Plan.
Hospital emergency planners can use this downloadable Word template to develop/update their own plans to create/activate a family reunification and assistance center.
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Gershon, R.R., Orr, M.G., Zhi, Q, et al. (2014). Mass Fatality Preparedness among Medical Examiners/Coroners in the United States: A Cross-Sectional Study. BioMed Central Public Health. 14: 1275.
In the U.S., Medical Examiners and Coroners have the legal authority for the management of mass fatality incidents. The purpose of this study was: 1) to identify appropriate measures of preparedness as they relate to U.S. medical examiners and coroners, and 2) to assess their preparedness levels and factors significantly associated with preparedness.
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Greater New York Hospital Association. (2020). Fatality Management Document Portal & Resource Hub for NYC Hospitals.
This webpage (specific to New York City) includes links to information on body collection, a survey designed to maintain morgue census, and guidance on reporting COVID-19-related deaths as well as hospital information and plan templates.
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Seattle and King County Public Health (2015). Mass Fatality and Family Assistance Operations Response Plan.
This plan describes a coordinated response among city and county agencies involved with conducting fatality management operations in Seattle and King County.
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Seattle and King County Public Health, King County Medical Examiner, and Northwest Healthcare Response System (2012). Healthcare Mass Fatality Management Guidelines.
This document provides guidelines for healthcare professionals on pronouncing, reporting, and certifying death. It also addresses topics such as cultural considerations, death investigation, tracking of human remains, personal effects, care of human remains, communications with families, and health risks associated with human remains.
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U.S. Army Research Development and Engineering Command, Military Improved Response Program, and U.S. Department of Justice, Office of Justice Programs, Office for Domestic Preparedness (2005). The Capstone Document: Mass Fatality Management for Incidents Involving Weapons of Mass Destruction.
This report is geared towards fatality management professionals who may be called upon to respond to domestic and international acts of terrorism. It provides a comprehensive review of forensic issues associated with managing contaminated human remains of known toxic agents.
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Wiersema, J. and Woody, A. (2014). Mass Fatality Management: A Multi-Disciplinary Approach to Preparedness and Response. (Free registration required.) University of Washington, Northwest Center for Public Health Practice.
This one-hour webinar features representatives from the Harris County Institute of Forensic Sciences in Texas, who share their experiences in developing partnerships and protocols to manage mass fatalities. They discuss the various components of mass fatality management, the primary agency responsible for coordinating each operational component, and the current challenges of the medicolegal system and their potential effects on mass fatality incident response.
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Contaminated or Infectious Decedents

Centers for Disease Control and Prevention. (2020). Recommended Postmortem Preparation of Human Remains Containing Ebola Virus.
This video discusses how to safely handle human remains containing Ebola virus or other viral hemorrhagic fever. Information for healthcare and mortuary workers on effective personal protective equipment use, best practices (e.g., not performing an autopsy or removing medical equipment from human remains), and requirements for body bags, decedent management, and required decontamination equipment and decontamination procedures are provided.
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Centers for Disease Control and Prevention. (2021). Guidelines for Handling Decedents Contaminated with Radioactive Materials.
These guidelines are intended for medical examiners, coroners, funeral directors, and other mortuary affairs staff. The authors discuss how to manage radioactively contaminated decedents so that medical professionals can deal with issues such as surface contamination, internal contamination, and shrapnel.
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Fusco, F., Scappaticci, L., Schilling, S., et al. (2016). A 2009 Cross-Sectional Survey of Procedures for Post-Mortem Management of Highly Infectious Disease Patients in 48 Isolation Facilities In 16 Countries: Data from EuroNHID. Infection. 44:57-64.
The authors visited 48 isolation facilities in Europe equipped to treat patients or decedents affected by Ebola virus or other highly infectious diseases and evaluated the sites’ preparedness using a standardized checklist. They found that 81.2% of facilities reported written procedures to manage infectious human remains, but only 8.3% had all features required to deal with these human remains safely. The article concludes that improvements in post-mortem management are required.
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Le, A., Brooks, E., and McNulty, L. (2019). U.S. Medical Examiner/Coroner Capability to Handle Highly Infectious Decedents. Forensic Science, Medicine and Pathology. 15(1):31-40.
The authors of this article surveyed medical examiners and coroners across the U.S. to understand their infection prevention practices when handling highly infectious decedents. Tables in the article cover survey responses as to how medical examiners currently use personal protective equipment, procedures performed on highly infectious decedents, information on biosafety levels, and pathogen categorization. The authors recommend updating standard operating procedures and medical examiner education to integrate handling infectious remains and choosing appropriate personal protective equipment. Relationships between local health departments, funeral homes, and crematories could also be strengthened to create multi-sectoral operations for handling infectious remains.
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* Le, A., Brown, C., Gibbs, S., et al. (2022). Best Practices of Highly Infectious Decedent Management: Consensus Recommendations From an International Expert Workshop. Journal of Occupational and Environmental Hygiene. 19(3):129-138.
This article is based on findings from a workshop where subject matter experts discussed how to handle decedents safely for those who may have died of highly infectious diseases, such as Ebola, Lassa fever, SARS-CoV-2, or other coronaviruses. Consensus recommendations focused on defining “highly infectious remains,” scalability and storage, more comprehensive integration of academic mortuary care training programs, infection control and facility considerations, decedent transportation and ultimate disposition considerations, care issues and autopsy, psychological, cultural, and ethical considerations.
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Radiation Emergency Medical Management. (2022). Management of the Deceased in Radiation Emergencies. U.S. Department of Health and Human Services.
This webpage includes information on how to handle human remains that have been exposed to radiation.
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* U.S. Army Research Development and Engineering Command, Military Improved Response Program, and U.S. Department of Justice, Office of Justice Programs, Office for Domestic Preparedness (2005). The Capstone Document: Mass Fatality Management for Incidents Involving Weapons of Mass Destruction.
This report is geared towards fatality management professionals who may be called upon to respond to domestic and international acts of terrorism. It provides a comprehensive review of forensic issues associated with managing contaminated human remains of known toxic agents.
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Education and Training

Goldbaum, G. (2014). Public Health's Response to the Oso Mudslide. (Free registration required.) University of Washington, Northwest Center for Public Health Practice.
This one-hour webinar features Gary Goldbaum of the Snohomish Health District who shares how his health district worked with partner agencies in response to the Oso, Washington mudslide in March 2014. He also discusses the roles of public health when responding to a mass fatality disaster, key barriers to effective response during a mass fatality disaster, strategies for overcoming those barriers, and key partners for assuring effective response to a mass fatality disaster.
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Luna, M. (2008). Dead or Alive: Managing Both in Mass Fatality Incidents.
This Wyoming lecture is intended for local and state public health practitioners, public health nurses, local and state emergency management staff, medicolegal death investigators, and funeral professionals. The speaker discusses the importance of local jurisdictions developing a fatality management infrastructure to include a multi-disciplinary approach including rural environments. Also addressed is the importance of identifying and returning the dead to their families, and using the best practices to protect workers in the aftermath of such an event.
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* Office of the Assistant Secretary for Preparedness and Response. (2020). Coronavirus Disease 2019 (COVID-19) Fatality Management Tabletop Exercise. U.S. Department of Health and Human Services.
This coronavirus fatality management tabletop exercise can be used by government, private sector, and nonprofit organizations. Access the Situational Manual here: https://files.asprtracie.hhs.gov/documents/covid19-fatality-management-ttx-sitman-25march2020-508.docx. The Situation Manual provides exercise participants with a hypothetical scenario that depicts numbers of confirmed COVID-19 cases and deaths at the state, regional, and national levels over a period of 40 days and includes discussion questions regarding the following topics: coordination of fatality management operations; information collection and reporting; legal and regulatory considerations; supply chains and resource management; infection control; continuity of operations; mental and behavioral health services; and public messaging and risk communications. The accompanying slide deck provides an overview of the scenario to set the stage for discussion.
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University of Minnesota Center for Public Health Preparedness (n.d.). Mass Fatalities: Public Health Emergency Training Module. (Accessed 9/22/2022. Free registration required.)
This online training module defines mass fatalities incidents, describes the operational sites and roles involved in responses to these types of disasters, and identifies key issues related to planning and implementing response efforts. This module will take between 20-40 minutes to complete.
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Wiersema, J. and Woody, A. (2014). Mass Fatality Management: A Multi-Disciplinary Approach to Preparedness and Response. (Free registration required.) University of Washington, Northwest Center for Public Health Practice.
This one-hour webinar features representatives from the Harris County Institute of Forensic Sciences in Texas, who share their experiences in developing partnerships and protocols to manage mass fatalities. They discuss the various components of mass fatality management, the primary agency responsible for coordinating each operational component, and the current challenges of the medicolegal system and their potential effects on mass fatality incident response.
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Emergency Operations Planning

Centers for Disease Control and Prevention. (2018). Capability 5: Fatality Management.
This capability includes the definition of fatality management and identifies the five functions, along with specific tasks, that need to occur for public health agencies to achieve this capability. The five functions include the following: 1) determine the role for public health, 2) activate public health fatality management operations, 3) assist in the collection and dissemination of antemortem data, 4) participate in survivor mental/ behavioral health services, and 5) participate in fatality processing and storage operations.
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Federal Emergency Management Agency (2013). National Incident Management System: Intelligence/Investigations Function Guidance and Field Operations Guide.
This document provides guidance on utilizing and integrating the Intelligence/ Investigations Function of the National Incident Management System. It describes how this function fits into the Unified Command or Incident Command System, which may include the Mass Fatality Management Group, along with other groups/branches, such as forensic, intelligence, missing persons, and investigative. It also provides a list of roles and responsibilities of the Mass Fatality Management Group.
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Kilbane, E.M. (2015). Fatality Management Federal Perspective: Operational Medicine/National Disaster Medical System. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
Emergency Support Function #8 of the National Response Framework establishes the U.S. Department of Health and Human Services as the lead and coordinating agency for federal response in disasters for Fatality Management. This PowerPoint presentation addresses the Federal role in fatality management and provides an overview of priorities during the immediate, response, and recovery phases of a mass fatality event.
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World Health Organization, Public Health England, and Partners (2013). Emergency Risk Management for Health: Mass Casualties/Dead Bodies.
This factsheet emphasizes that larger-scale disasters may result in tens of thousands of deaths (e.g., the 2010 earthquake in Haiti) while smaller-scale disasters may exceed the local capacities for mass fatality management. It also addresses the health risks to the general public, including the negative mental health effects that mass casualty events can have on community members and responders.
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Evaluation and Studies

Adams, B., Warnke-Sommer, J., Odien, J., et al. (2022). Victim Identification from the September 11, 2001 Attack on the World Trade Center: Past Trends and Future Projections. (Abstract only.) Forensic Science International. 340.
The authors describe a study that tracks identification trends from the 2753 known World Trade Center victims and the 21,905 recovered remains. The emphasize the benefits of using DNA testing strategies for victim identification in mass fatality situations, particularly when body fragmentation occurs.
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Carroll, E., Johnson, A., DePaolo, F., et al. (2017). Trends in United States Mass Fatality Incidents and Recommendations for Medical Examiners and Coroners. Academic Forensic Pathology. 7(3):318-329.
The authors collected information from incidents with more than ten fatalities in the United States between 2000 and 2016, finding 137 such incidents. They examined the characteristics of the incidents, whether the incident was human caused or natural (e.g., mass shooting or hurricane). While plans often assume large numbers of fatalities, the authors emphasize the need for local authorities to plan to manage smaller incidents on their own. The authors also encourage medicolegal jurisdictions to work closely with incident command to ensure fatality management priorities are met immediately following an incident (e.g., notifications, forensics, and transparent communication).
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Gavin, C.S., and Nesler, J. (2013). National Thought Leadership Group Develops Complex and Mass Fatality Management Papers, Including Key Perspectives. International Association of Emergency Managers Bulletin. Volume 30(5):26-28.
The authors discuss both the importance and complexities of mass fatality management. They explain how the complexities arise from a variety of factors, which include public expectations, perceptions, and the extent to which responding agencies are capable of organizing a safe, respectful, and timely response. The authors also discuss the need to apply a more scientific approach to mass fatality management preparedness planning, training, and exercises.
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Gershon, R.R., Orr, M.G., Zhi, Q, et al. (2014). Mass Fatality Preparedness among Medical Examiners/Coroners in the United States: A Cross-Sectional Study. BioMed Central Public Health. 14: 1275.
In the U.S., Medical Examiners and Coroners have the legal authority for the management of mass fatality incidents. The purpose of this study was: 1) to identify appropriate measures of preparedness as they relate to U.S. medical examiners and coroners, and 2) to assess their preparedness levels and factors significantly associated with preparedness.
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Merrill, J., Orr, M., Chen, D., et al. (2015). Are We Ready for Mass Fatality Incidents? Preparedness of the US Mass Fatality Infrastructure. (Abstract only.) Disaster Medicine and Public Health Preparedness. 10(1):87-97.
The authors surveyed participants from five sectors (medical examiners, the death care industry, health departments, and emergency managers) to measure preparedness for mass fatality incidents (MFI). Of the 879 respondents, 15% had previously responded to an MFI, while 42% had conducted related staff training. Less than 35% of respondents from the death care industry reported they felt “operationally” prepared for an MFI. The authors emphasized the need for better national “sector-specific and infrastructure-wide preparedness.”
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Morgan, O.W., Sribanditmongkol, P., Perera, C., et al. (2006). Mass Fatality Management following the South Asian Tsunami Disaster: Case Studies in Thailand, Indonesia, and Sri Lanka. PLOS Medicine. 3(6).
The authors of this report conducted three descriptive case studies after the tsunami disaster in December 2004 to systematically document how the deceased were managed in Thailand, Indonesia, and Sri Lanka. The following parameters were considered: body recovery and storage, identification, disposal of human remains, and health risks from dead bodies. Through their case studies, the author’s found the following: refrigeration for preserving human remains was not available soon enough after the disaster, none of the countries had sufficient forensic capacity to identify thousands of victims, and the lack of national or local mass fatality plans limited the quality and timeliness of response.
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Rocha, L., Fromknecht, C., Davis Redman, S., et al. (2017). Medicolegal Death Scene Investigations After Natural Disaster- and Weather-Related Events: A Review of the Literature. Academic Forensic Pathology. 7(2):221-239.
This literature review describes efforts by the Centers for Disease Control and Prevention to improve death reporting methods by various agencies after a disaster. The authors found that there was not a consistent method for attributing deaths caused by a disaster, leading to differing counts and challenging public health surveillance. The authors planned to use the findings to begin developing guidelines to consistently capture data on deaths during disasters. Tables include information on search terms, inclusion and exclusion criteria, operations and protocols on the scene of a mass fatality incident, and select information specific to scene investigation worksheets.
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Rutty, G., Biggs, M., Brough, A., et al. (2020). Remote Post-mortem Radiology Reporting in Disaster Victim Identification: Experience Gained in the 2017 Grenfell Tower Disaster. International Journal of Legal Medicine. 134(2):637-643.
In 2017, nearly 75 people died in the worst residential fire since the end of the Second World War in West London, UK. The authors explain how disaster victim identification radiology reporting was conducted remotely, and how this process can support identification in future mass casualty incidents.
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Stanley, S. (2008). Regional Mass Fatality Management in Pandemic Surge. Naval Postgraduate School, Monterey, CA.
This thesis explores pathways to reach operational regional mass fatality management capability in Ohio, but also has implications for planning across the nation. Research was conducted with three key stakeholder groups: county coroners, emergency management directors, and health commissioners. The survey addressed realistic and actionable mass fatality management planning by: 1) identifying state guidance gaps; 2) identifying local/regional operational gaps; 3) assessing regional resource capabilities; 4) categorizing proposed solutions to address identified gaps; and 5) listing legal, financial, and organizational barriers to the solutions.
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Guidelines and Protocols

ASPR TRACIE. (2018). Mass Violence/Active Shooter Incidents: Fatality Management.
This ASPR TRACIE tip sheet (which is part of a series) shares fatality management factors healthcare emergency planners should take into consideration when creating a no-notice incident plan.
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Centers for Disease Control and Prevention. (2020). Collection and Submission of Postmortem Specimens from Deceased Persons with Known or Suspected COVID-19. U.S. Department of Health and Human Services.
This guidance is for medical examiners, coroners, pathologists, and others involved in postmortem care of deceased persons under investigation for COVID-19. It includes information on collection and submission of postmortem specimens, biosafety and infection control practices, autopsy procedures, and transportation of human remains.
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Chemical Hazards Emergency Medical Management. (2022). Management of the Deceased. U.S. Department of Health and Human Services.
This website discusses management of decedents, especially in the context of a mass chemical or biological exposure event. The information encompasses incident planning, remains recovery, managing contaminated remains, morgue operations, transportation of remains, family assistance, and creating a personal effects depot.
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* Le, A., Brown, C., Gibbs, S., et al. (2022). Best Practices of Highly Infectious Decedent Management: Consensus Recommendations From an International Expert Workshop. Journal of Occupational and Environmental Hygiene. 19(3):129-138.
This article is based on findings from a workshop where subject matter experts discussed how to handle decedents safely for those who may have died of highly infectious diseases, such as Ebola, Lassa fever, SARS-CoV-2, or other coronaviruses. Consensus recommendations focused on defining “highly infectious remains,” scalability and storage, more comprehensive integration of academic mortuary care training programs, infection control and facility considerations, decedent transportation and ultimate disposition considerations, care issues and autopsy, psychological, cultural, and ethical considerations.
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National Academies of Sciences, Engineering, and Medicine. (2020). A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters.
A committee reviewed how mortality and significant morbidity are assessed and quantified following large-scale disasters (particularly those declared under the Robert T. Stafford Disaster Relief and Emergency Assistance Act). Practices and methods for data collection, recording, sharing, and use across state, local, tribal, and territorial stakeholders; best practices; and areas for future resource investment are covered in this report.
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Pan American Health Organization, World Health Organization (2006). Management of Dead Bodies after Disasters: A Field Manual for First Responders.
This field manual describes the recovery, basic identification, and storage and disposal of dead bodies following disasters. It also provides information about working with family members, the public, and the media.
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The Technical Working Group for Mass Fatality Forensic Identification. (2005). Mass Fatality Incidents: A Guide for Human Forensic Identification. U.S. Department of Justice, Office of Justice Programs, National Institute of Justice.
This guide addresses issues facing medical examiners, coroners, and other forensic professionals involved in the identification of human remains resulting from a mass fatality incident. It is designed to assist all jurisdictions in creating new mass fatality plans or reviewing existing plans.
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* U.S. Army Research Development and Engineering Command, Military Improved Response Program, and U.S. Department of Justice, Office of Justice Programs, Office for Domestic Preparedness (2005). The Capstone Document: Mass Fatality Management for Incidents Involving Weapons of Mass Destruction.
This report is geared towards fatality management professionals who may be called upon to respond to domestic and international acts of terrorism. It provides a comprehensive review of forensic issues associated with managing contaminated human remains of known toxic agents.
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Lessons Learned: COVID-19

ASPR TRACIE. (2022). Issue 16: Decedent Management during Disasters.
The articles in this issue highlight federal, state, local, and rural experiences with decedent management after mass violence incidents and during the COVID-19 pandemic.
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Cegan, J., Trump, B., Joyner, M., et al. (2021). A Systems Approach for Resources Management During the COVID-19 Pandemic: Multi-Agency Perspectives from New England. (Abstract only.) Journal of Emergency Management. 18(7):209-223.
This article discusses the approach New England states took to distribute resources when they were faced with an increased need for cremation and burial services due to COVID-19. It includes modelling tools for shortages of medical supplies, staff, and fatality management. The framework can bolster health authorities’ and decision makers’ understanding of local outbreaks and resource allocation when faced with mass fatality incidents.
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Entress, R., Tyler, J., and Sadiq, A. (2020). Managing Mass Fatalities during COVID-19: Lessons for Promoting Community Resilience during Global Pandemics. Public Administration Review. 80(5):856-861.
The authors discuss the handling of decedents during the COVID-19 pandemic and note that many lessons learned from fatality management during the 2010 Haiti earthquake have yet to be incorporated. The article highlights the challenges of managing mass fatalities during the pandemic and other recent examples across the world (the Haiti earthquake and recent Ebola outbreaks). It concludes with practical steps for local, state, and federal governments to take before and during mass fatality incidents, such as developing a mass fatality management plan, stockpiling resources to handle a surge of decedents, and providing psychological support to first responders and families.
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Federal Emergency Management Agency. (2020). COVID-19 Best Practice Information: Mass Casualty Management. U.S. Department of Homeland Security.
This document offers best practices related to mass casualty management. It includes key considerations, lessons learned from mass casualty operations, death determination, identification of temporary storage sites, and management of contagious contaminated remains.
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Furuness, I., Tavarez, M., McGinty, M., et al. (2022). Innovations in Fatality Management During the COVID-19 Pandemic. Health Security. 20(S1):90-96.
This article shares innovations implemented by a healthcare system in New York City during the first surge of the COVID-19 pandemic to supplement fixed morgue space, expand staffing capacity, share supplies, leverage information technology systems, and provide psychological support to staff managing a large number of decedents.
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* Greater New York Hospital Association. (2020). Fatality Management Document Portal & Resource Hub for NYC Hospitals.
This webpage (specific to New York City) includes links to information on body collection, a survey designed to maintain morgue census, and guidance on reporting COVID-19-related deaths as well as hospital information and plan templates.
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Kaul, S., Colement, C., and Gotz, D. (2020). A Rapidly Deployed, Interactive, Online Visualization System to Support Fatality Management During the Coronavirus Disease 2019 (COVID-19) Pandemic. Journal of the American Medical Informatics Association. 27(12):1943-1948.
The authors describe a web application and online dashboard that allowed local and state health officials in North Carolina to collect and visualize COVID-19 data in a timely manner. Stakeholders found the dashboard useful to understand surges in their communities and individual facilities (Table 1).
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Petrone, P., Joseph, D., Jacquez, R., et al. (2021). Management of Mass Casualties Due to COVID-19: Handling the Dead. European Journal of Trauma and Emergency Surgery. 47(5):1343-1349.
The authors share how Body Collection Points (BCP) (temporary refrigeration units used to handle decedents when hospital morgues reach capacity during a disaster or pandemic) were used during the COVID-19 pandemic. Photos of various BCPs and a "COVID-19 death flowchart” illustrate promising practices for handling many decedents at once. The authors provide additional recommendations for management and encourage planning for future global disasters.
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Treisman, R. (2021). Cremation Limits Lifted In LA Due To 'Backlog' As COVID-19 Deaths Skyrocket: Coronavirus Updates. National Public Radio (NPR).
Typically, crematoriums limit the number of cremations performed to comply with air quality standards. This article discusses how these limits were suspended in Los Angeles in 2021 during the COVID-19 emergency when the number of decedents overwhelmed the systems created to manage them.
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Lessons Learned: Natural Disasters

Anderson, M., Leditschke, J., Based, R., et al. (2017). Mortuary Operations Following Mass Fatality Natural Disasters: A Review. Forensic Science, Medicine and Pathology. 13:67–77.
The authors conducted an international literature review of post-disaster mortuary practices. Tables throughout the article illustrate key considerations for disaster mortuary planning including body storage, location of emergency mortuary facilities, security, communications, staff training, and staff wellbeing. The authors recommend that mortuaries likely to respond to mass fatality events share information on lessons learned and best practices, in particular emphasizing areas for improvement.
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Arnold, C. (2019). Death, Statistics and a Disaster Zone: The Struggle to Count the Dead After Hurricane Maria. Nature. 566:22-25.
The author seeks to understand how many people died in Puerto Rico after Hurricane Maria in 2017, by estimating excess mortality, by determining the number of people who died in the storm, and subtracting the average number of people who would have died anyway. The author found that estimating the deaths due to a disaster can be difficult without a standardized method to determine excess mortality, but that combining data from surveys and death certificate information can be of use to understand whether fatalities are associated with a disaster. Other innovative methods can also be used, such as “capture-recapture,” a technique adapted from measurements of wildlife populations.
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Howland, R., Li, W., Madsen, A., et al. (2015). Evaluating the Use of an Electronic Death Registration System for Mortality Surveillance During and After Hurricane Sandy: New York City, 2012. American Journal of Public Health. 105(11):e55-e62.
This article discusses mortality surveillance in New York City after Hurricane Sandy in 2012. The authors found that the electronic death registration system of the city was stable and timely in identifying storm-related deaths. The authors also identified areas of weakness for improvement in future disasters, such as not all data being available in the preliminary record, nationwide differences in nomenclature, no documentation of deaths indirectly caused by Hurricane Sandy, and minor system outages.
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Issa, A., Baker, K., Pate, D., et al. (2020). Evaluation of Oklahoma’s Electronic Death Registration System and Event Fatality Markers for Disaster-Related Mortality Surveillance – Oklahoma USA, May 2013. Prehospital Disaster Medicine. 34(2):125-131.
To accurately count the number of deaths attributable to natural disasters, the authors piloted a procedure to track 48 tornado-related deaths in Oklahoma in May 2013 using three event fatality markers. The authors found that a tornado-specific flag in the death record was the most sensitive event fatality marker, a tornado term in the death certificate was second most sensitive and using a certain ICD-10 code (namely X37, “Victim of a Cataclysmic Storm”) in the death record was the third most sensitive measure. The authors suggest that a written protocol to coordinate the three methods may improve disaster mortality surveillance in the future.
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Sullivan, J. (2014). Toll Remains 17: Why Identifying Victims Seems to Take So Long. The Seattle Times.
This article discusses the process in which Snohomish County officials identified victims of the 2014 mudslide. The author highlights the protocols for handling the remains, and for making public announcements regarding the number of confirmed deaths.
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Plans, Tools, and Templates

California Hospital Association. (2017). Mass Fatality Checklist.
This downloadable checklist can help hospitals plan for a mass fatality incident and comply with the Joint Commission and the National Incident Management System requirements. The checklist covers activation, incident management, communication, morgue surge, staff training, next of kin notification, and recovery.
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Centers for Disease Control and Prevention. (2017). Determining Deaths from a Radiation Emergency.
This webpage can help medical examiners, coroners (and emergency healthcare providers, planners, and responders) better understand radiation scenarios that may cause death and related illnesses and injuries that may cause death.
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Colorado State Emergency Operations Center. (2020). COVID-19 Fatality Management Plan: Annex F to COVID-19 CO-COEM-1070 UCC State Support Plan #2 (27 Mar 2020).
This annex to Colorado's COVID-19 plan informs the state's coordinated recovery, storage, transportation, processing, identification, final dispositions of remains, and death notification activities.
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Corfield, J. and the Central Florida Regional Medical Coalition (CFDMC). (2023). Family Reunification and Assistance Center Plan.
Hospital emergency planners can use this downloadable Word template to develop/update their own plans to create/activate a family reunification and assistance center.
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Forrester, C., Dixon, R., Judy, C., et al. (2008). Managing Mass Fatalities: A Toolkit for Planning. Santa Clara County Public Health Department.
This toolkit provides scalable and operational tools to help guide jurisdictions in developing a mass fatality plan. It includes guidance on infection and other health and safety threats, as well as requirements and recommendations for managing mass fatalities during a worst-case scenario pandemic influenza event.
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* Greater New York Hospital Association. (2020). Fatality Management Document Portal & Resource Hub for NYC Hospitals.
This webpage (specific to New York City) includes links to information on body collection, a survey designed to maintain morgue census, and guidance on reporting COVID-19-related deaths as well as hospital information and plan templates.
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Los Angeles County Department of Public Health. (2020). Coronavirus (COVID-19) Death Report Form.
This form is an example of information healthcare providers are required to report to one county health department on COVID-19 associated deaths.
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Los Angeles County Emergency Medical Services Agency (2013). Mass Fatality Management Guide for Healthcare Entities.
This planning guide was created to help healthcare partners develop a detailed mass fatality plan. It provides a framework for mass fatality management during events of all sizes, including large-scale disasters (earthquakes); smaller, more localized incidents (explosion, shooting); and long-term events (widespread disease outbreaks). It is organized into two primary components, a base guide and appendices. The base guide provides step-by-step directions in the development of mass fatality plans, and the appendices include supplemental resources to aid in plan development.
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Los Angeles County Emergency Medical Services Agency. (2020). Mass Fatality Management Plan Template.
This template provides a framework to develop or refine a healthcare facility's mass fatality management plan. For additional details, planners may refer to the Los Angeles County Emergency Medical Services Agency Mass Fatality Management Guide for Healthcare Entities.
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National Funeral Directors Association. (2022). State Mass Fatality Plans.
This webpage includes links to several state mass fatality plans.
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National Vital Statistics System. (2017). A Reference Guide for Certification of Deaths in the Event of a Natural, Human-induced, or Chemical/Radiological Disaster. Centers for Disease Control and Prevention.
This guide provides recommendations and examples for recording the name and type of disaster on death certificates to ensure consistency and accuracy and help jurisdictions promote a common framework for measuring "disaster relatedness."
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* Office of the Assistant Secretary for Preparedness and Response. (2020). Coronavirus Disease 2019 (COVID-19) Fatality Management Tabletop Exercise. U.S. Department of Health and Human Services.
This coronavirus fatality management tabletop exercise can be used by government, private sector, and nonprofit organizations. Access the Situational Manual here: https://files.asprtracie.hhs.gov/documents/covid19-fatality-management-ttx-sitman-25march2020-508.docx. The Situation Manual provides exercise participants with a hypothetical scenario that depicts numbers of confirmed COVID-19 cases and deaths at the state, regional, and national levels over a period of 40 days and includes discussion questions regarding the following topics: coordination of fatality management operations; information collection and reporting; legal and regulatory considerations; supply chains and resource management; infection control; continuity of operations; mental and behavioral health services; and public messaging and risk communications. The accompanying slide deck provides an overview of the scenario to set the stage for discussion.
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Public Health Seattle-King County. (2015). Mass Fatality and Family Assistance Operations Response Plan. Seattle and King County Public Health.
This resource is an attachment to the Seattle and King County All Hazards Mass Fatality Management Plan. It includes several templates and other tools including, but not limited to: a template mass fatality plan, a mass fatality management flow chart for healthcare facilities, a sample and information on decent identification tags, a decedent information form, a personal affects tracking form, and job action sheets. It was also merged with the Family Assistance Center Plan in 2015.
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Redman, S., Fromknecht, C., Hodge, S., et al. (2017). Death Scene Investigation After Natural Disaster or Other Weather-Related Events. Centers for Disease Control and Prevention.
The authors conducted a literature review and discovered variance in the tools used in disaster death scene data collection. They formed a work group comprised of medical examiners and coroners, forensic pathologists, death scene investigators, forensic anthropologists, and epidemiologists that developed and pilot tested this toolkit. The toolkit includes templates and checklists by hazard.
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Santa Clara County Public Health Department Advanced Practice Center. (2011). Managing Mass Fatalities: A Toolkit for Planning. National Association of County and City Health Officials.
Based on lessons learned from actual events (e.g., the Oklahoma City bombing, 9/11, and Hurricane Katrina) this robust resource document and toolkit provides customizable operational strategies and tools that can help jurisdictions create a plan for managing mass fatalities. Tips for communicating with the public are included in the toolkit.
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Seattle and King County Public Health (2015). Mass Fatality and Family Assistance Operations Response Plan.
This plan describes a coordinated response among city and county agencies involved with conducting fatality management operations in Seattle and King County.
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Seattle and King County Public Health, King County Medical Examiner, and Northwest Healthcare Response System (2012). Healthcare Mass Fatality Management Guidelines.
This document provides guidelines for healthcare professionals on pronouncing, reporting, and certifying death. It also addresses topics such as cultural considerations, death investigation, tracking of human remains, personal effects, care of human remains, communications with families, and health risks associated with human remains.
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Sledzik, P. (2002). Flight 93 Morgue Protocols. Disaster Mortuary Operational Response Teams (DMORT).
This document was developed by DMORT III to detail the mortuary operations for the United Airlines Flight 93 response on 9/11. It is intended to serve as an example of morgue protocols, and may be used to develop a local disaster morgue protocol as part of an overall mass fatality plan.
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Agencies and Organizations

Alabama Department of Public Health Fatality Management During a Pandemic and Other Emergency Events.
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Greater New York Hospital Association. Fatality Management Document Portal & Resource Hub for NYC Hospitals.
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National Funeral Directors Association. State Mass Fatality Plans.
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Scientific Working Group on Disaster Victim Identification Disaster Victim Identification.
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U.S. Department of Health and Human Services, Administration for Strategic Preparedness and Response Disaster Mortuary Operational Response Teams (DMORTs).
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Virginia Department of Health, Office of the Chief Medical Examiner Mass Fatality Planning.
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This ASPR TRACIE Topic Collection was refreshed in October 2022. It was comprehensively reviewed in June 2015 by the following subject matter experts (listed in alphabetical order): Cynthia S. Gavin, MS, PMP, CCP, Biochem Sciences and Security Manager, Computer Sciences Corporation; John Hick, MD, HHS ASPR and Hennepin County Medical Center; Edward M. Kilbane, MD, JD, MPH, Fatalities Management, National Disaster Medical System, Office of Emergency Management; and Victor Weedn, MD, JD, Professor and Chair, George Washington University, Department of Forensic Sciences.

Additional assistance provided by Anthony M. Flood, Senior Functional Analyst (National Security), Computer Sciences Corporation; Alicia Livinski, Biomedical Librarian, HHS National Institutes of Health; John T. Nesler, MS, CEM, Senior Functional Analyst, Computer Sciences Corporation; and James Paturas, Director, Center for Emergency Preparedness and Disaster Response, Yale New Haven Heath System.
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