Management of mass fatalities: Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector
Guidelines for the Management of Mass Fatalities During an Influenza Pandemic
Table of Contents
- 1.0 Preamble
- 2.0 Planning for a Surge in Deaths
- 3.0 Other Technical Considerations
- 4.0 Social/Religious Considerations
- Appendix 1: List of Current Suppliers
During a pandemic, local authorities will have to be prepared to manage additional deaths due to influenza, over and above the number of fatalities from all causes currently expected during the inter-pandemic period. Within any locality, the total number of fatalities (including those resulting from influenza and all other causes) occurring during a 6- to 8-week pandemic wave is estimated to be similar to that which typically occurs over 6 months in the inter-pandemic period. This guideline aims to assist local planners and funeral directors in preparing to cope with the surge in deaths due to an influenza pandemic. A number of issues have been identified, which should be reviewed with coroners/medical examiners, local authorities, funeral directors, and religious groups/authorities.
Note: This annex is intended to provide general guidance. Planners should be aware of the specific requirements and terminology of legislation in their jurisdiction regarding management of the dead (such as coroners’ acts, emergency management) and will need to customize pandemic planning for their jurisdiction accordingly.
2.0 Planning for a Surge in Deaths
In order to identify planning needs for the management of a surge in deaths during a pandemic, it is important to examine each step in the management of a corpse under normal circumstances and then to identify what the limiting factors will be when the number of deceased persons increase over a short period of time. The following table identifies the usual steps. Possible solutions or planning requirements are discussed in further detail in the sections that follow this table.
Planning for Possible Solutions/Expediting Steps
Transportation to the morgue
Autopsy if required/ requested
1) CremationTable 1 - Footnote 1 *
2)EmbalmingTable 1 - Footnote 2 **
2a) Transportation to temporary vault or burial site
2b) Temporary vault storage
2.1 General Planning Considerations
In order to develop guidelines or adjust existing plans to suit the pandemic situation, local pandemic planners should ensure that the following persons are involved in death surge planning:
- the Coroner/Medical Examiner's Office/Branch,
- the Medical Officer of Health,
- the Emergency Response Team,
- representatives of the FSAC and/or the local funeral director,
- representatives from local health care facilities, and
- representatives of local religious and ethnic groups.
Existing disaster plans may include provisions for mass fatalities but should be reviewed and tested regularly, to determine whether these plans are appropriate for the relatively long period of increased demand that may occur in a pandemic, as compared with the shorter response period required for most disaster plans. There are currently no plans to recommend mass burials or mass cremations. This would only be considered in the most extreme circumstances.
Since it is expected that most fatal influenza cases will seek medical services prior to death, hospitals, nursing homes and other institutions (including non-traditional sites) must plan for more rapid processing of human remains. These institutions should work with the pandemic planners, funeral directors and coroner/medical examiner’s office to ensure that they have access to the additional supplies (e.g. body bags) and can expedite the steps, including the completion of required documents, necessary for efficient management of human remains during a pandemic.
In order to deal with the increase in fatalities, some municipalities will find it necessary to establish temporary morgues. Plans should be based on the capacity of existing facilities compared with the projected demand for each municipality. Local planners should make note of all facilities available, including those owned by religious organizations. Some religious groups maintain facilities including small morgues, crematoriums and other facilities, that are generally operated by volunteers. Access to such resources should be discussed with these groups as part of the planning process during the interpandemic period.
If local funeral directors are unable to handle the increased numbers of deceased and their funerals, it will be the responsibility of municipalities to make appropriate arrangements. Individual municipalities should work with local funeral directors to plan alternative arrangements.
Planning should also include a review of death documentation requirements and regulatory requirements that may affect the timely management of corpses.
2.2 Role of the FSAC
It is recommended that all funeral directors contact their Medical Officer of Health to become involved in disaster and pandemic planning activities with respect to the management of a surge in deaths at the local level. The national mass fatalities subgroup for pandemic influenza planning has recommended that funeral directors consider it a part of their professional standards to make contingency plans for what would happen if they were incapacitated or overwhelmed. This recommendation is being taken forward to the Association, which has an established disaster planning committee. It is expected that this committee will put forward a recommendation to the provincial/territorial associations to set up disaster plans.
Members of the FSAC board are on the Funeral Supply Coalition Council of Canada. FSAC is likely to take a role in supply management (e.g. of fluids, body bags and caskets) for a death surge related to a pandemic.
The FSAC has produced a booklet as well as a series of articles regarding specific preparations that funeral homes can make in order to be prepared at the time of a pandemic and will continue to update information regarding health concerns and funeral service issues; this information will be available through a publicly accessible web site.
Many deaths in a pandemic would not require autopsies since autopsies are not indicated for the confirmation of influenza as the cause of death. However, for the purpose of public health surveillance (e.g. confirmation of the first cases at the start of the pandemic), respiratory tract specimens or lung tissue for culture or direct antigen testing could be collected after death. Serological testing is not optimal but could be performed if 8-10 mL of blood could be collected from a subclavian puncture. Permission will be required from next-of-kin for this purpose, unless the post-mortem examinations are carried out under the authority of a coroner’s warrant/medical examiner. In the early stages of a pandemic it is likely that coroners/medical examiners would be providing this assistance to the public health surveillance process.
If a physician requires an autopsy to be performed, normal protocols will be followed, such as obtaining permission from the next-of-kin. In cases in which the death is reportable to and accepted for investigation by a medical examiner or coroner, the usual protocols prevail according to provincial legislation.
Any changes to regular practices pertaining to the management of human remains and autopsy requirements during pandemics would require the authorization of the Chief Medical Examiner or Coroner.
2.4 Preparations for Funeral Homes and Crematoriums
In a pandemic, each individual funeral home could expect to have to handle about 6 months' work within a 6- to 8-week period. That may not be a problem in some communities, but funeral homes in larger cities may not be able to cope with the increased demand.
Individual funeral homes should be encouraged to make specific plans during the interpandemic period regarding the need for additional human resources during a pandemic: for example, collaboration with other funeral homes, utilizing part-time or retired funeral providers or accessing volunteers from local service clubs or churches who may be able to take on tasks such as digging graves under the direction of current staff.
Crematoriums will also need to look at the surge capacity within their facilities. Most crematoriums can handle about one body every 4 hours and could probably be run over 24 hours to cope with increased demand. Cremations have fewer resource requirements than burials and, where acceptable, this may be an expedient and efficient way of managing large numbers of deceased during a pandemic.
2.5 Planning for Temporary Morgues
Additional temporary cold storage facilities may be required during a pandemic for the storage of human remains before their transfer to funeral homes. A temporary morgue must be maintained at 4°-8°C. However, human remains will begin to decompose in a few days when stored at this temperature. If the remains are not going to be cremated, plans to expedite the embalming process should be developed since, in the case of a pandemic, remains may have to be stored for an extended period of time. In jurisdictions where a timely burial is not possible because of frozen ground or lack of facilities, remains may need to be stored for the duration of the pandemic wave (6 to 8 weeks).
Each municipality should make pre-arrangements for temporary morgues according to local availability and requirements. The resource needs (e.g. body bags) and supply management for temporary morgues should also be addressed. The types of temporary cold storage to be considered may include refrigerated trucks, cold storage lockers or arenas.
Refrigerated trucks can generally hold 25-30 bodies without additional shelving. To increase storage capacity, temporary wooden shelves can be constructed of sufficient strength to hold the bodies. Shelves should be constructed in such a way that allows for safe movement and removal of bodies (e.g. storage of bodies above waist height is not recommended). To reduce any liability for business losses, municipalities should avoid using trucks with markings of a supermarket chain or other companies, as the use of such trucks for the storage of remains may result in negative implications for business.
Arenas and curling rinks, where the required temperature of 4°-8°C can be maintained, are other options for temporary morgues. Using local businesses for the storage of human remains is not recommended and should only be considered as a last resort. The post-pandemic implications of storing human remains at these sites can be very serious, and may result in negative impacts on business with ensuing liabilities.
2.6 Capacity of and Access to Vaults
A vault is a non-insulated storage facility for remains that have already been embalmed, put into caskets and are awaiting burial. In most places in Canada extra corpse storage facilities already exist, as they are often needed from January to April when the ground is frozen and burials are difficult to perform. Although larger cities may be able to open burial plots in winter, smaller communities do not have the equipment or permanent staff to do this.
The accessibility of vaults during the winter should be assessed. A vault may be situated in the back of cemeteries, with entrances that are partially below ground level or in close proximity to headstones, so that a snow blower or plough would have difficulty creating a path of access without damaging some headstones.
In preparation for a pandemic each community should identify the capacity of existing vaults and address access issues for temporary storage. In addition, the need for the creation of new temporary vaults to meet the increased demand during a pandemic should be addressed. This temporary vault should be non-insulated and have some security features such as covered windows and locks on doors.
3.0 Other Technical Considerations
3.1 Death Registration
Death registration is a provincial/territorial (P/T) responsibility and each jurisdiction has its own laws, regulations and administrative practices to register a death. Moreover, there is a distinction between the practices of pronouncing and of certifying a death. For example, physicians, nurses and, in some circumstances, police and ambulance attendants in Ontario may pronounce a person dead. Only physicians and a small group of designated nurses in narrowly defined circumstances may certify death.
In a pandemic, with the increased number of deaths, each jurisdiction must have a collection plan in place to ensure that there is no unnecessary delay in moving remains of a deceased to the (temporary) morgue. If the person's death does not meet any of the criteria needed for reporting to a coroner, then the remains could be moved to a holding area soon after death has been pronounced. Then, presumably on a daily basis, a physician could be designated to complete the death certificate.
Funeral directors generally have standing administrative policies that prohibit them from collecting remains from the community or an institution until there is a completed certificate of death. In the event of a pandemic with many decedents, it seems likely that funeral directors could work out a more flexible practice if directed to do so by some central authority (e.g. the provincial Attorney General, Registrar of Vital Statistics). These special arrangements must be planned in advance of the pandemic and should include consideration of the regional differences in resources, geography and population.
3.2 Infection Control
The Infection Control and Occupational Health Guidelines (Annex F of the Canadian Influenza Pandemic Plan) provide general recommendations on infection control for health care facilities and non-traditional sites during a pandemic. However, special infection control measures are not required for the handling of persons who died from influenza, as the body is not “contagious” after death. Funeral homes should use normal body fluid precautions with deaths from influenza as with all cases. Training in the routine infection control practice and additional precautions is available through the FSAC (www.fsac.ca).
Visitations could be a concern in terms of influenza transmission among attendees, particularly in smaller communities. For example, in Prince Edward Island, the average attendance at a visitation is 1,000 to 1,400 people; visitations in larger centres are typically a fraction of that size. The Infection Control and Occupational Health Guidelines (Annex F), lists several recommendations regarding public gatherings. It is the responsibility of the medical officers of health to place restrictions on the type and size of public gatherings if this seems necessary to reduce the spread of disease. This may apply to funerals and religious services. Medical officers of health should plan in advance how such restrictions would be enacted and enforced, and how to establish consistency and equitability in the application of any bans.
No special vehicle or driver licence is needed for transportation of the deceased. Therefore, there are no restrictions on families transporting bodies of family members if they have a death certificate. Transportation of bodies from their place of death to their place of burial in northern and isolated communities may become an issue, especially if this requires air transport. Local pandemic planners should consult existing plans for these communities and determine what changes can be made to meet the increased demand during a pandemic.
3.4 Supply Management
FSAC is recommending to funeral directors that they not order excessive amounts of supplies such as embalming fluids, body bags, etc., but that they have enough on hand in a rotating inventory to handle the first wave of the pandemic (that is enough for 6 months of normal operation). Fluids and body bags may be stored for years, but body bags and other supplies have a limited shelf life. A supply list for temporary morgues will be accessible through FSAC. Cremations generally require fewer supplies since embalming is not required.
A list of current suppliers is provided in Appendix 1.
Families having multiple deaths are unlikely to be able to afford multiple higher-end products or arrangements. Funeral homes could quickly run out of lower-cost items (e.g. inexpensive caskets made of cloth and some wooden caskets) and should be prepared to provide alternatives.
4.0 Social/Religious Considerations
4.1 Special Populations
A number of religious and ethnic groups have specific directives about how bodies are managed after death, and such needs must be considered as a part of pandemic planning. First Nations, Inuit, Jews, Hindus and Muslims all have specific directives for the treatment of bodies and for funerals.
The wishes of the family will provide guidance, however, if no family member is available local religious or ethnic communities can be contacted for information. For example, in the case of First Nations peoples, mechanisms currently exist to communicate with band councils for this purpose (established to deal with archeological issues) and medical examiners/coroners should contact the band council of the individual where this is possible. (Note: this would only apply if the medical examiner/coroner was investigating the death. In other circumstances, the medical examiner/coroner may be directing the local municipality to arrange for disposition, for example, as occurs under the Anatomy Act in Ontario.)
As a result of these special requirements, some religious groups maintain facilities such as small morgues, crematoriums, and other facilities, which are generally operated by volunteers. Religious groups should be contacted to ensure that these facilities and volunteers are prepared to deal with pandemic issues.
Religious leaders should be involved in planning for funeral management, bereavement counselling and communications, particularly in ethnic communities with large numbers of people who do not speak the official languages.
4.2 Northern and Isolated Communities
Northern and isolated communities face particular issues in dealing with large numbers of fatalities. The following factors make the preparation, storage and burial/disposal of large numbers of human remains very challenging in such communities:
- The lack of funeral service personnel and other resources poses a problem.
- The extreme cold weather and heavy snowfalls in winter result in difficulties with burials and in difficulties with the transportation of remains.
- In remote areas where families live vast distances apart, remains may have to be transported a long way for burial/disposal. This may be challenging for areas with few plane flights and no road access or with poor road surface conditions. The large distances also pose a challenge for the transportation of funeral directors and funeral supplies.
- Permafrost, boggy land and other geographical features also pose a challenge to transportation and burial.
Planners responsible for these jurisdictions should ensure that local pandemic plans address such issues.
Appendix 1: List of Current Suppliers
Embalming fluids suppliers:
- H.S Eckels and Company, Guelph, Ontario
- Esco of Rexdale, Ontario
- Les Fournitures, J.C.R. Inc., Vanier, Quebec
- Dodge Chemical, Mississauga, Ontario
- Alton Caskets
- J.I. Astley & Associates
- Batesville Canada
- Bernier Caskets Inc./Cercueils Bernier Inc.
- Classic Casket Distributors, Limited
- Colonial Caskets Limited
- Cercueils Concept Inc/Concept Caskets Inc.
- Cormier & Gaudet
- Exquisite Enterprises, Inc.
- Imperial Evergreen Casket Corporation
- Imperial Casket (Calgary) Limited
- Imperial Casket (Saskatchewan) Limited
- Imperial Casket (Manitoba) Limited
- Imperial Legacy Caskets Limited
- Industries Maximel Inc.
- Cercueils Magog Caskets
- Northern Casket (1976) Limited
- Cercueils South Curham Caskets
- St. Lawrence Casket Co. Inc.
- Trans-Global Casket
- Victoriaville Funeral Supplies, Inc.
- Winkler Caskets Co. Limited
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