PMC:7148714 / 23630-46414 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7148714","sourcedb":"PMC","sourceid":"7148714","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7148714","text":"3 Protracted response to increased deaths from COVID-19: A Preparatory Guideline for mass fatality response plan\nThere is a likely probability in some context for a significant increase over a very short period of time in the number of fatalities from COVID-19. This can easily overwhelm local capacities available to mange the deceased, with the subsequent additional pressure on the health and medico legal systems as well as on other service providers involved in the Management of the Dead (MotD).\nThis section provides guidance/advice for decision makers and managers of concerned structures in their preparation and planning a response to an increase in deceased individuals that may overwhelm their normal capacities. It contains essential elements that should be considered by the highest Government authorities and Ministries as part of a Mass Fatality Response Plan (MFRP) for the COVID-19 crisis. Normally a crisis management coordination centre should be activated to coordinate the emergency response including the MotD. In the absence of a crisis management coordination centre, or in case the centre has not incorporated the MotD in their response, a coordination group should be established with main focal points from relevant institutions. This section focuses on elements unique to mass fatalities or excess deaths caused by infectious diseases such as the COVID-19. Most of the following recommendations should ideally be part of an existing mass fatality response plan (see the ongoing efforts from various countries and regions to create specific guidelines for the dead as a part of their directives [[10], [11], [12], [13], [14], [15], [22]]).\nIn the absence of a contingency plan, the following provides general guidance on essential elements for such a plan. Concrete steps/measures are also presented to address in a quick manner and with an integrated and comprehensive response, the increased number of deaths.\nGeneral recommendations of a MFRP;• A National Disaster Contingency plan should always include a MFRP drafted with input from all actors with the relevant mandates to deliver proper management of the dead, ensure the dignity of and respect to the deceased individuals and their families and to undertake investigations where appropriate. The plan is a coordination framework that identifies key actors, their roles and responsibilities. These plans are supplemented with operational guidelines with specific actions that need to be conducted along the continuum of a legal death enquiry/investigation.\n• The MFRP should describe a multi-agency communication and coordination strategy for all actors involved in the process. This will allow the different actors to understand their responsibilities with full knowledge of an agreed upon set of standardized and complementary activities and practices that respect the interests of all actors and the public.\n• A MFRP describes the activation criteria and mechanism for mass fatality management. This includes the legislation on response by the different authorities, the hierarchy of delivery and command and control structure for the response. It facilitates reporting conduits that are followed at all levels and by all actors to meet all complementary mandates.\n• Routine death enquiries/investigations should confirm the identity and where, when, how and by what means the person died. These investigations are for all sudden, unexpected or unexplained deaths, including unexpected deaths from infectious disease outbreak such as COVID-19.\n• Not all deaths from COVID-19 will occur in a medical facility. Therefore, proper training and supervision must be provided to first or emergency responders attending a reported death to ensure safe management of the death scene.\n• Basic management of the dead practices should be followed and are essential in all cases. These procedures are particularly important when the volume of deaths increases sharply, exerting stress on both human resource and facility capacity.\n• Adequate attention to families of the deceased is also part of the response.\n• A public communication and media strategy, delivered through designated communication centres and/or broadly accessible networks, should provide regular, reliable and transparent public communication. This conduit should represent the plans and operational aspects of the consortium of actors participating in the response and offer regular updates and progress reports. Protection of personal information legislation must be complied and SOPs must be implemented to ensure protection.\n• The MFRP does not merely provide direction for the adequate mass handling and/or disposal of bodies. On the contrary, the plan describes operational practices, the supporting financial, administrative and logistical systems that allows for the professional and dignified search for, recovery, examination, identification, storage and return of bodies to the families for burial. All these steps should be generating standardized documentation which contains important information that should be protected and centralized to support not only investigative aspects of case management, but it is also required for planning, operations, logistics, administration and finance, and reporting. It also describes policies and procedures in relation to managing unclaimed and unidentified bodies, documentation of identification features for future comparison, and their temporary disposition. All these phases require a thorough understanding of existing capacities, capabilities, and prior acknowledgement of the gaps where solutions are needed.\n• A MFRP describes occupational health, safety requirements that protect responders and practitioners. It lays out risk assessment criteria and establishes a dissemination mechanism to educate responders about reducing their risk of infection during infectious disease outbreaks. Equally, it addresses the need for skills training on safety control mechanisms, safety tools and equipment to first responders, mortuary personnel, laboratory technicians, and other individuals involved with body and human remains handling. This would also include the importance of safety bulletins communicated to families and communities where COVID-19 infected bodies were recovered to reduce their further contamination.\n• Mass graves are highly discouraged. They are often a demonstration of poor planning by authorities, shows a disregard for the wishes, cultural/religious rites of families and communities. Single graves are respectful and dignified, they promote the traceability of human remains. This can only be accomplished, however, by collaborative planning between authorities and other relevant industries, such as funeral homes, crematoriums and cemeteries and most importantly the families.\n• Mass fatality events often include deaths of both nationals and foreigners. Internationally accepted best practices and procedures that promote the dignified and professional management of the dead and respectful engagement with people of different backgrounds, cultures and religions must be upheld. This will facilitate the sometimes complex administrative and legal procedures of foreign governments when seeking repatriation of bodies to the country of residence or requesting assistance with notifications of death to relatives living abroad. Shipment of bodies across international boundaries may be delayed until the infection is deemed no longer transmissible. Planning should include participation of airline companies expected to provide the shipment of bodies.\nWe list hereafter essential practical questions that will help in the rapid assessment of the existing health and medico legal systems to respond to increased deaths. These questions are also applicable in the assessment of the response in place by detention centres in case of sudden increase of number of deaths in custody related to the pandemic:• Does a MFRP or Annex related to death management exist to guide a multiagency response to an increase in deaths from COVID-19?\n• Do you have the support of the Ministry of Health, Ministry of Justice, Ministry of Interior, Cabinet of Ministers, directly through the Office of the President’s Disaster Management Department to activate the existing contingency mass fatality plan -as part of a National Disaster Management Plan or develop an emergency option?\n• What agencies have a mandate to respond to multiple deaths in a large scale or protracted event and who would be the primary lead agency to work towards a coordinated approach to delivering a plan and implementing it?\n• What is the current capacities and capabilities of all agencies involved in the management of deaths?\n• What percentage of increased case load would overwhelm agencies at their current capacity and trigger the activation of the plan?\n• Are the current personnel adequately trained in safety precautions and equipped with appropriate personal protective equipment to handle a surge in infectious disease cases? Are they insured against injury and death?\n• Have arrangements been made with non-government groups and the corporate sector to secure additional support as well as to procure additional equipment?\n• Does the plan insist on dignified and professional management of deceased persons and respect in terms of engagement and complying with the wishes of the families and communities affected?\n• Do the law enforcement community and medicolegal practitioners have the additional resources to ensure that all sudden and unexpected deaths are thoroughly investigated even during an infection outbreak?\n• Does the plan provide guidance towards compliance with protection of personal information legislation and regulations?\n• Will the families and communities (and media) be able to rely on regular, reliable and transparent communication from competent source that represents all response agencies and groups? Where will they go to receive updates and status reports on the response?\n• Who will recover deceased persons from their homes and what training and equipment will they receive to protect themselves and the bereaved families in an infectious disease outbreak?\n• What additional refrigerated storage space is available for a surge in deceased persons?\n• What labelling, and body tracking methods are conducted to effectively manage large numbers of bodies accumulating in mortuaries?\n• Is there a standardized file management (including standardized forms) process to ensure all facilities and agencies involved work coherently and collaboratively in one system that allows for centralization of all data related to the management of the death?\n• How will caseload information be centralized to assist with further planning and targeted deployment of additional resources and equipment?\n• Are there sufficient cemetery spaces and/or crematorium operations to receive and respond sin a timely manner to the increase in deaths?\n• What is the short- and long-term approach to managing unclaimed and unidentified bodies?\n• What administrative processes and additional support will ensure that families receive medical certificates of death, burial permits, autopsy reports and other important documentation to resolve financial affairs, estates, etc.?\n• Who will pay for the additional personnel, facilities and the activities themselves during a protracted mass fatality event?\nThe following sections outline the key steps in providing a protracted response to increased deaths from COVID-19, from the recovery to the repatriation.\n\n3.1 Management and coordination\n• Identify who has been designated as the lead Ministry/Department responsible to coordinate the Government response.\n• Identify a focal point of each of the agencies, including service providers responsible for the management of the deceased and their families and clarify roles and responsibilities based on the different phases of the MotD such as recovery and transportation of the deceased, post-mortem examinations if required, identification of the deceased, storage and disposal, burial and handover to families, death registration, attention and information to families.\n• Establish a coordination group with a multiagency approach. It is important to include hospital administrators, religious authorities, municipal services, cemeteries and crematoriums for a truly integrated response. While not involved in the process, the private sector are key resources and should be engaged recognizing there might be limitations as per local regulations.\n• Ensure a proper response is in place to cover all those aspects of the management of the dead process, including consider the investigative needs of law enforcement agencies in cases that apply.\n• Local authorities should also ensure that any participation by volunteers or private businesses follow the same procedures.\n• A good understanding of the local capacities for MotD, mainly in relation to transportation, storage and body disposal is a baseline to determine further steps in the multiagency approach.\n• Ensure there is sufficient capacity in terms of infrastructure, human resources, materials and self-protective equipment to respond to the increased number of deaths. If this is not available, the coordination group should resort on alternatives for the required support.\n• Ensure management level or coordination staff at the different entities provide clear procedures and recommendations in relation to the handling of bodies to all those concerned.\n• Additional health and safety issues that could arise from the MotD especially during the transportation of bodies, such as manual handling of bodies (large weight, several times), staff working in cold temperatures for prolonged periods of time, psychological impact, hazardous substances. Ensure support and adequate response to staff working under these conditions.\n• Any activity undertaken in relation to the management of known or suspected COVID-19 fatalities must be preceded by a preliminary evaluation and risk assessment. The evaluation should include determination of the number, location and condition -including COVID-19 status-of the human remains.\n\n3.2 Recovery and transportation of the deceased\nIn the event of increased number of deaths, movement of bodies between homes, hospitals, mortuaries, cemeteries and body storage will require large capacities for manual handling and vehicles. Outline arrangements for transporting the dead bodies considering the following aspects:• Know the legislation and regulations in place, including occupational health and safety\n• Know who is responsible\n• Do they have the capacities?\n• Is there any involvement of police/judicial authorities in these cases?\n• Where should bodies confirmed positive or suspected to be positive cases of COVID-19 be transported? (Specific morgue/mortuary?)\n• When the number of casualties exceeds the capacities for body transportation? Identify the support required in terms of vehicles, infrastructure, materials, human resources. Identify alternatives sources for support and ensure their understanding of their role in the broader response.\n• Do they know/understand the required safety or precautionary actions?\n• Is the necessary insurance coverage provided for these additional resources not routinely deployed in management of the dead?\n\n3.3 Medical certificate, death certificate, death registration\nThe following questions should be considered when preparing a response plan:• What are the regulations in place? Any specific guidance/regulation to consider in pandemic cases? (i.e. normally the physician certifies the death, but if not witnessed such as a death at home with suspicion of COVID 19, who signs? Autopsy mandatory? etc.)\n• In the case of deaths in detention what legislation must be followed? Consider working with legal and ministerial authorities to adapt in the case of a large increase in deaths.\n• Who is responsible for issuing the medical certificate, death certificate, and the death registration?\n• Do they have the capacities in case of exceeding numbers? Measures in place for enough doctors to sign death certificates, for offices to register deaths, etc. -Considering governmental offices not working, reduced activities, social distance, etc.-\n\n3.4 Post-mortem examinations in general and within the medico legal death investigation system (infectious and routine cases)\n• Review existing legislation for infectious diseases (i.e. influenza).\n• Local authorities should take measures to ensure that medico legal services continue to be provided. A contingency plan should be established to properly provide management of the dead services to victims of the pandemic and other non-pandemic related cases, especially when bodies are taken to the same facilities/hospital morgues.\n• Consider ensuring that autopsies can be performed in appropriate forensic facilities and designed rooms with proper ventilation adapted to minimize the risk for transmission of airborne pathogens as much as possible [19].\n• Families of the deceased should be properly informed about any delays, measures taken, etc. Outline plans to properly handle both caseloads.\n• Consider: deploy judicial and forensic resources efficiently to improve decision making in required cases, additional forensic resources that can help in the management of the dead related to the pandemic event, distribution of cases if possible, etc.\n\n3.5 Body storage\n• Body storage refers to the need for temporary storage of the deceased due to an unmanageable surpass in existing storage capacity. Body storage differs from temporary mortuaries that entail the capacity to conduct post-mortem examinations/autopsies.\n• Establish a mechanism to coordinate the procurement, staffing and storage of all bodies, identify potential facilities/premises suitable for body storage.\n• The coordination group should be informed about the existing body storage capacity. Existing facilities may be found within hospitals, public and private funeral homes and forensic services. Consider military assets.\n• In some cases, universities may have additional storage capacities for bodies. Some limitations exist in towns and cities where there is only the public mortuary capacity available.\n• Even if the decision is to bury bodies as soon as possible, or to cremate identified bodies in certain contexts, the body will undoubtedly remain in storage for a period of time before burial while administrative and logistical requirements are satisfied (i.e. while the death certificate is issued, the authorization for cremation or burial, ongoing investigations, awaiting family notification, etc.). Therefore, additional body storage must be addressed in advanced.\n• All phases of the MotD, even when capacities are increased, may incur additional challenges during a pandemic as handling bodies believed to be infectious require additional precautionary measures. A proper storage area allows for continuity of other stages of the process.\n• Be aware of the minimum standards for setting up temporary body storage facilities such as single level facility or establishment with suitable access for loading/unloading, secured premises, permanent access for big capacity vehicles, entrances, exits and windows obscured from media and the public, electricity and plumbing, appropriate height for stacked shelves, identification and body viewing facilities, office spaces, staff amenities, and welfare facilities. Other considerations such as sealed floors, impervious concrete or covered in non-slip waterproof rubber flooring, cleaning of surfaces, appropriate disposal of waste, etc. should be revised considering also local regulations, environmental risk assessments, environmental permits, etc.\n• Prepare a list of equipment to consider for temporary body storage.\n• During the MotD it is especially important in the storage and transportation phases that body identification and labelling is carried out with at least three identifiers including one unique identifier (i.e. body number, date, place of recovery). In storage facilities is imperative to have a proper bay numbering in place to avoid the release of mistaken bodies or cause unnecessary delays in the process.\nAuthorities responsible must ensure operating procedures follow the recommendations for MotD of infectious/contaminated bodies [5].\n\n3.6 Viewing of bodies\nA family viewing area should be facilitated especially if bodies will remain for a certain period of time, or because in line with mitigation of social contact, only few relatives will be permitted access to facilities to complete the required documentation for burial, it is important to allocate an appropriate and comfortable waiting areas for families, following also general recommendations for public spaces in the framework of the pandemic. Minimum requirements: Hygienic rooms, sensitive to the bereaved needs and beliefs, with washing facilities and ensure trained professionals oversee the viewing arrangements.\n\n3.7 Body disposal/burial/cremation\n• Personnel from funeral homes have expertise in the handling and transportation of the dead, though usually without any legal obligation to respond to emergencies, can be considered useful support when capacities are overwhelmed. They can be of timely support to process registrations of the death, permits for burial, etc. They may also offer suitable body storage facilities at their funeral homes should the need arise.\n• Important to review the existing regulations for burial permits and cremation and ensure that the relevant authority issues a decree or instructions to facilitate the burial permits as much as possible.\n• When considering cemeteries for burial of bodies, it is important to consider issues such as permits, land available, etc. Temporary burial of bodies may be necessary [5].\n\n3.8 Repatriation of deceased\nIn the case of repatriation of human remains, is important to be aware of local regulations, procedures, and concerned authorities that go beyond the routine death (such as consulates, border authorities, authorities of the receiving country). A coordination group should establish contact with concerned authorities responsible for issuing repatriation permits in both countries. Generally, a Freedom from Infection or Transmissible Diseases Certificate is required that is normally issued by the forensic practitioner or the attending physician. In the case of COVID-19, it would be important to have a consolidated opinion on procedures based on rules and regulations applicable at the time (consider appropriate ways of solving this in advance in order to help alleviate the time and the burden for respective families in need of repatriation of their deceased loved 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