Yesterday, it was revealed that New York City Funeral Directors were told by the CDC to prepare for 50,000 to 85,000 deaths due to swine flu. Pixie at PFI_Forum found a document that likely explains where these numbers came from: Pandemic Influenza Surge Plan For Managing In- and Out-of-Hospital Deaths. This document was apparently issued by the City of New York Medical Examiner, Charles S. Hersh. It was last updated in October 2008.
On page 7 of the document, three different pandemic scenarios are described with respect to the case fatality rate: Minimum (1.1%), Most Likely (2.1%) and Maximum (3.5%). Based on the assumption that 30% of New Yorkers will be infected, the document estimates 27,105.7, 51,747.2, and 86,245.3 dead for each of the three case fatality rates, respectively. The last two numbers are very close to the numbers revealed yesterday from the Funeral Directors meeting (50,000 to 85,000 deaths). Although the New York City Medical Examiner’s document was prepared in advance of the current pandemic, the CDC has apparently instructed Funeral Directors in New York to prepare for a medium to maximum event based on numbers taken from this document.
It is worth noting that this document explicitly mentions the role of the Metropolitan Funeral Directors Association (MFDA), the organisation that met last week, during a pandemic. From page 73:
During a PI outbreak, the MFDA will:
• Distribute information regarding infection control measures to funeral directors.
• Distribute information regarding the OCME’s current management of remains, so that funeral directors know where to retrieve bodies, file death certificates (if applicable) and obtain burial permits.
• Coordinate funeral director support at the FAC, by gathering antemortem data and/or assisting those grieving the loss of a loved one and by providing timely information regarding the final disposition process.
The purpose of the meeting of the Metropolitan Funeral Directors Association may have been to prepare funeral directors for their role in a severe pandemic. Note, if the deaths were expected to be no greater than with normal seasonal influenza, there would be no need to make any special preparations. However, in a severe pandemic, the processes for processing the dead are different due to the large number of bodies that must be dealt with.
From page 10 of the document:
• Anticipation of Constraints in the Normal Process — Several variables have the potential to slow down the process of managing decedents. During a PI event, the OCME has identified the following areas where such bottlenecks are likely to occur.
− Signing Death Certificates – Physicians may not be available to sign death certificates, particularly when their patient dies at home, because they will be focused on providing medical care to the living.
− Unidentified Decedents – During a PI event, decedent’s family members may also be ill and therefore unavailable to identify the body. Normal Disaster Victim Identification (DVI) Committee practices may need to be altered to accommodate a protracted response by family members. Potential delays will also affect the OCME process, since it may be difficult to store remains without implementing temporary interment.
− Private Sector Funeral-related Businesses – Private funeral directors, cemeteries and crematoria may not be able to accommodate the large influx of deaths during a PI outbreak.
− Limited Hospital Storage – Hospitals have limited cold storage facilities for decedents. Even in the best of times, they often require the OCME to hold bodies for them due to limited space.
− Decedents Brought to Various City Locations by NOK – During a PI event, it is also possible that NOK will bring their deceased family members to a HCF, fire house, police station or OCME office, for lack of correct information and instruction.
− Death Certificate Registration and Burial/Cremation/Transportation Permit – Typically funeral directors retrieve the deceased from private residences and HCFs, obtain the signed death certificate, go to the Office of Vital Records to register the death certif icate and obtain the burial/cremation/ transportation permit. During a PI event, too many funeral directors would converge on one NYC location, attempting to accomplish these tasks.
− High Death Rate at Alternate HCFs and Prisons – These facilities are likely to experience a greater number of deaths than the general public, due to close living quarters and inability to leave the facility.
− Unattended Deaths – Those who die without family and friends present different challenges, including difficulty establishing decedent identify or locating NOK; the ability to enter a residence, requiring the presence of an NYPD Officer; the management of decedent’s pets; and the management of decedent’s estate.
Many New Yorkers might be surprised to learn of some of the other aspects of the plan that is apparently being readied for this fall. Since funeral homes will not be able to process the large numbers people who will die during a severe pandemic in a timely fashion, the dead will be brought to Body Collection Points (BCPs) and stored in refrigerated trailers. Instructions are provided on how to handle the bodies.
From page 61 of the document:
Maximizing BCP Space
• Bodies must never be stacked.
• Bodies are to be lined up, parallel with the long side of the BCP and placed along each side of the BCP, leaving a center aisle space for staff to walk in and out of the unit.
• The first body is to be placed on the floor parallel to the long wall of the unit, at the farthest end of the BCP; the head of the second body is placed on the abdomen of the first body with the legs placed along side the first body. The third body’s head will be placed on the abdomen of the second body with the legs placed along side the first body. This fishbone positioning will accommodate approximately 9-22 bodies on each side of the BCP (see pictures below).
• Initial BCPs will not have shelving. If the OCME determines shelving is needed, they will work with OEM to obtain a contract to retrofit the BCPs. Replacement BCPs will arrive with one shelving unit on each side to accommodate twice the number of bodies.
The correct body positioning strategy is illustrated with manikins in orange body bags.
I don’t blame the City of New York for having a plan for dealing with the dead in a severe pandemic. Although disturbing to think about, even in the 21st Century, a “bring-out-your-dead” policy is necessary. However, I do object to keeping this information from New Yorkers, especially since the pandemic has already started. If the general public knew what plans were being made for their final disposition during a severe pandemic, they might have second thoughts about sending their kids to schools or spending a lot of time in crowded places.
The New York City authorities and the CDC appear to have two messages, one that it is on a “need to know” basis and a different one for the general public.
Why is that?