Mass Fatality Events Research Articles

Victim identification from the September 11, 2001 attack on the World Trade Center: Past trends and future projections

Victim identification following mass fatality events is critically important. Extensive traumatic injuries and body fragmentation add complexity to this process. World Trade Center (WTC) identification efforts have been ongoing for over 20 years and this study tracks identification trends from the 2753 known WTC victims and the 21,905 recovered remains. For identified victims, data include the number of remains identified, date(s) of the identification(s), and identification modalities. Results show a heavy reliance on DNA due to body fragmentation. Other modalities played an important role initially, but DNA eventually became the singular identification modality. For large-scale disasters involving significant body fragmentation, aggressive DNA testing strategies are critical for victim identification. Over time, the number of linked remains (portions of previously identified individuals) will greatly outnumber the new identifications (first-time identifications). A novel approach using statistical modeling from ecology studies was applied to estimate future WTC identification rates using Identification Accumulation Curve extrapolation with the Good-Toulmin estimator. Projections indicate there will be 76 first-time identifications (95% CI: 49–117) through the successful DNA testing of 3404 unidentified, fragmentary remains. The remainder of the identifications would be additional portions of previously identified victims. These results may be instructional for management of other large-scale, protracted victim identification efforts.

The Public Health Role of Medical Examiner Offices During COVID-19 and Other Mass Fatality Events.

The public health role of a medical examiner office (MEO) in a pandemic is largely undefined; however, death data may be useful in strategic planning. Deaths reportable to MEO are defined in statute, with discretion as to the assumption of jurisdiction. We analyzed the daily reported death numbers (DRDNs) in our jurisdiction from March 1, 2020, to March 31, 2021, and compared them with hospital admission and COVID-19 fatality data over the same period. The DRDN from an MEO is easily obtained and may be useful as a supplemental and surrogate metric in certain pandemic mass casualty decisions. Hospital admission data were analyzed in real time and with a 2-week time-shift, as deaths lag hospital admissions as a disease surveillance metric. Moderate correlation was observed between DRDN and hospital admissions (r = 0.570), and this improved to strong correlation (0.645) when the 2-week time-shift was incorporated into the analysis. Both evaluations were statistically significant (P < 0.0001). The DRDN also moderately correlated (r = 0.412) with the number of COVID-19 deaths. Because death certification and hospital diagnosis may be delayed, real-time trend recognition in a pandemic may benefit from use of DRDN from MEO.

Ergonomic exposures and control measures associated with mass fatality decedent handling in morgues and body collection points in a New York healthcare system during COVID-19: A case series

IntroductionIn April 2020, novel coronavirus SARS-CoV-2 (COVID-19) produced an ongoing mass fatality event in New York. This overwhelmed hospital morgues necessitating emergent expansion of capacity in the form of refrigerated trucks, trailers, and shipping containers referred to as body collection points (BCPs). The risks for musculoskeletal injury during routine and mass fatality mortuary operations and experiences of decedent handlers throughout the "first wave" of COVID-19 are presented along with mitigation strategies MethodsAwareness of the high rates of musculoskeletal injury among health care workers due to ergonomic exposures from patient handling, including heavy and repetitive manual lifting, prompted safety walkthroughs of mortuary operations at multiple hospitals within a health system in New York State by workforce safety specialists. Site visits sought to identify ergonomic exposures and ameliorate risk for injury associated with decedent handling by implementing engineering, work practice, and administrative controls. ResultsMusculoskeletal exposures included manual lifting of decedents to high and low surfaces, non-neutral postures, maneuvering of heavy equipment, and push/pull forces associated with the transport of decedents DiscussionRisk mitigation strategies through participatory ergonomics, education on body mechanics, development of novel handling techniques implementing friction-reducing aides, procurement of specialized equipment, optimizing BCP design, and facilitation of communication between hospital and system-wide departments are presented along with lessons learned. After-action review of health system workers' compensation data found over four thousand lost workdays due to decedent handling related incidents, which illuminates the magnitude of musculoskeletal injury risk to decedent handlers.

The effect of chemical compromise on the recovery of DNA from skeletonized human remains: A study of three World War II era incidents recovered from tropical locations.

The use of DNA extracted from skeletonized human remains is a common challenge for those working in human identification. Thermal age and chemical compromise should be considered prior to performing DNA testing on skeletonized remains. Both heat and chemical contamination may cause damage to the DNA present in the osseous materials and a subsequent increase in both the difficulty and expense of DNA testing. For this study, three World War II era mass fatality events involving the US military, the USS Oklahoma, the Battle of Tarawa, and the Cabanatuan Prison Camps, were examined for the overall success of DNA testing using five DNA modalities: Sanger sequencing of mitochondrial DNA, AmpFlSTR® MiniFiler™; PowerPlex® Fusion; a modified AmpFlSTR® Yfiler™; and a Next Generation Sequencing (NGS) protocol. Decedents from the three chosen incidents were buried in tropical environments and have the same approximate post mortem interval of 75years, however, the chemical conditions that decedents were exposed to at each of the incidents vary. Remains from the USS Oklahoma were soaked in fuel oil and salt water immediately post-mortem; Cabanatuan Prison Camp remains were treated with a 'hardening' compound; and those from the Battle of Tarawa were not treated. Skeletal elements from each incident were compared across the 5 tested DNA modalities for success. Chemical insult to skeletal materials appears to have the greatest impact on every modality of DNA testing examined.

Dental identification using 3D printed teeth following a mass fatality incident

• Forensic odontology remains at the forefront of the disaster victim identification (DVI) process following mass fatality incidents. • Post-mortem CT scanning has become established as part of the DVI process, and the scan data can be used in a variety of ways including 3D printing. • A case is presented where a 3D printed model of the dentition of a deceased individual enabled successful identification without resorting to disfiguring facial incisions in a charred body. Following a mass fatality event there is a requirement to establish the identities of the deceased individuals as quickly as possible, but with sufficient certainty. Comparison of post-mortem dentition with ante-mortem records remains one of the most cost-effective methods of achieving this reliably and in a timely manner. The relatively recent introduction of post-mortem CT scanning into the Disaster Victim Identification (DVI) environment has brought with it an abundance of additional detailed information that can be used in a variety of novel ways. Here we present a case where 3D printing was used to produce a model of a victim's dentition, enabling confident odontological identification without resorting to disfiguring incisions in a charred body. On-site access to a 3D printer of sufficient quality meant that there was no significant delay in the identification process, and the cost of consumables used to manufacture the model totalled less than £1.

The comparison of DNA extraction techniques in human bone and tooth samples exposed to high heat

In the identification of forensic cases, it is critical to obtain information to identify the victimÂ’s identity from burnt bone and tooth remains. When bone and tooth are burned, both their physical and chemical properties change significantly, which prevents anthropological evaluations and successful DNA profiling for identification purposes. Heat causes difficulties in the identification techniques in which bones and teeth are used, depending on the degree of heat exposure. For this reason, with the changes occurring in bone and tooth during combustion, it is necessary to evaluate the results of observation and analysis, and to be used the information obtained in a certain order. It is very difficult to extract DNA from the samples obtained from fire, explosion, motor vehicle and aircraft accidents and other traumatic events by traditional methods. The only biological material available to determine the typing and the identification of missing persons or unknown remains in different situations, such as mass fatality events, wars or socio-political events, is often only human remains. Effective DNA extraction procedures are critical steps in successful DNA analysis of skeletal remains. Due to variations in DNA and heterogeneity within the bone, unfortunately, the only reliable method for obtaining DNA from overly degraded specimens such as burnt bones and teeth in the literature, is still not available. In the study, present extraction methods are compared and as a result it was suggested that phenol-chloroform and Qiagen DNA Mini Kit could be used in routine with a newly developed modified procedure in order to increase efficiency and efficiency in forensic genetic identification.

An economical and efficient method for postmortem DNA sampling in mass fatalities

In mass fatality events, the need to identify large numbers of deceased persons using DNA can be a significant drain on already overburdened forensic practitioners, both in the field setting and the laboratory. The laboratory may be required to extract DNA from a variety of postmortem sample types, family or direct reference samples related to the missing, and perform matching of these results in a short period of time. While most forensic institutions are well equipped to handle both family and direct reference samples, postmortem samples such as bone or heterogeneous tissue samples can be difficult for labs to analyze.We have devised an easily deployable, efficient, and inexpensive method for collecting postmortem DNA samples on commercially available DNA preservation cards (“FTA®” cards). FTA® cards are already widely used in forensic labs and are convenient for shipping due to their small volume and stability at room temperature. We evaluated the suitability of a protocol involving swabbing of incisions made on cadavers and sample deposition onto FTA® cards over various postmortem intervals and under different environmental conditions. Each trial took place during a different point in the calendar year to evaluate the effects of seasonal weather patterns and temperature on decomposition, DNA yield, and rates of DNA degradation. To further account for the effects of seasonality (temperature and humidity), the progression of body decomposition was recorded following the Total Body Score (TBS) method [1].DNA degradation was assessed either through STR amplification of 1.2 mm FTA punches or DNA extraction from 3.0 mm punches followed by real-time PCR quantification and STR amplification and genotyping. No consistent relationship was observed between postmortem interval and DNA degradation. Instead, the TBS score, which captures the stage of body decomposition, was shown to correlate well with DNA quantity. A TBS of 15 and below consistently yielded strong partial or full profiles (20 STR loci and Amelogenin using the PowerPlex 21 System) from all individuals from either 1.2 mm or 3.0 mm punches.Transfer of sample swabs to FTA cards is shown to be a simple and effective method for both field and laboratory operations over a range of conditions that can be evaluated by field forensic practitioners based on a body decomposition score. The approach could be beneficially integrated into mass fatality response plans.

Forensic odontology

Abstract: Forensic Odontology (or Forensic Dentistry) can be defined as the branch of dentistry that addresses the proper handling and examination of dental evidence and the evaluation and presentation of dental findings in the interests of justice. In the UK, this usually involves solicitors, barristers, coroners, coroner's officers and the police, and can require appearances and/or presentations and/or formal reports to Crown Courts, Magistrate's Courts, Coroner's Courts and occasionally Civil Courts. Forensic odontologists often work abroad and therefore must be adaptable to the demands and limitations of foreign jurisdictions in relation to international criminal proceedings, suspicious deaths and mass fatality events. CPD/Clinical Relevance: Forensic odontology depends on meticulous record-keeping and accuracy.

Trends in United States Mass Fatality Incidents and Recommendations for Medical Examiners and Coroners.

It is imperative that medicolegal jurisdictions prepare for the occurrence of a mass fatality incident. Despite the trend to plan for catastrophic and complicated incidents, this analysis of recent mass fatality events seeks to better inform authorities regarding the scale and types of incidents that could potentially impact their jurisdiction. The guidance provided by this study serves as a tool to guide the development of plans, acquisition of appropriate resources, and training of staff. To perform this analysis, data were collected from mass fatality incidents occurring in the United States from January 1, 2000 to December 31, 2016 that resulted in ten or more fatalities. Specific data points were collected for each incident including the date, location, number of fatalities, incident type (e.g., man-made or natural), incident subtype, and description (e.g., mass shooting, hurricane, aviation). A total of 137 incidents fit the criteria for inclusion in the analysis, resulting in a total of 8462 fatalities. The average number of incidents was eight per year during the study period. The analysis demonstrates that most mass fatality incidents (88.8%) result in between ten and 50 fatalities and are variable based on incident type and geographic location. This study includes several large-scale incidents, which as outliers have influenced fatality management operations and preparedness efforts on a national level. In particular, the World Trade Center attack of September 11, 2001 and subsequent remains recovery and identification operations have served to inform the New York City Office of Chief Medical Examiner of the capabilities required to manage a complex, protracted victim identification process involving extensive body fragmentation and commingling. While the World Trade Center attack has been shown to be outside the normal trends of mass fatality incidents, it has nonetheless offered the medicolegal community several invaluable lessons.

Marked decline of sudden mass fatality events in New Zealand 1900 to 2015: the basic epidemiology

Objective:To describe the basic epidemiology of sudden mass fatality events for the 1900 to 2015 period in New Zealand (NZ). Methods:Official lists and internet searches were used to identify the events. Events were categorised, rates calculated and time trends analysed. Results:A total of 56 sudden mass fatality events with 10 or more fatalities between 1900 and 2015 in NZ were identified. There were 1,896 deaths in total, with the worst event being the Hawke’s Bay earthquake (258 deaths). Events were classified as transportation‐related (64%), natural causes (11%), industrial (9%), war (9%) and infrastructure (5%). There were marked declines in the rate of events per person‐years of exposure and the associated mortality rate (both p<0.0001). Knowledge gaps were identified around: i) the basic epidemiology, e.g. non‐fatal injuries and numbers of survivors; ii) the role of subsequent official inquiries in guiding preventive measures; and iii) the likely cost‐effectiveness of measures to prevent harm from such events. Conclusions:The occurrence and health burden of sudden mass fatality events have markedly declined in NZ over time. Implications for public health:There remains large scope for addressing the knowledge gaps in the basic epidemiology and societal responses to these events to guide primary prevention and appropriate disaster response.

Naming the dead: DNA-based identification of historical remains as an act of care

Empirical knowledge of how DNA matching for identifications following mass fatality events is used, and how it interacts with existing social practices and values, is important not only to enlarge our understanding of the technology but also to inform normative thinking about its use. This paper draws on preliminary empirical material from a study of World War I dead at Fromelles to consider DNA matching as an act of care. Family members' involvement in the process of identifying historical human remains may be a way to demonstrate care toward a vulnerable subject, or toward the past and present family, as much as it is a way to confirm an individual's death. Framing DNA donation as an act of care enables it to be analyzed from the perspective of the ethics of care, thereby highlighting ethical issues of relationality, power, and obligation, which have relevance to the normative evaluation of the technology.

Disaster victim identification: quality management from an odontology perspective

The desired outcome of the victim identification component of a mass fatality event is correct identification of deceased persons in a timely manner allowing legal and social closure for relatives of the victims. Quality Management across all aspects of the Disaster Victim Identification (DVI) structure facilitates this process. Quality Management in forensic odontology is the understanding and implementation of a methodology that ensures collection, collation and preservation of the maximum amount of available dental data and the appropriate interpretation of that data to achieve outcomes to a standard expected by the DVI instructing authority, impacted parties and the forensic odontology specialist community. Managerial pre-event planning responsibility, via an odontology coordinator, includes setting a chain of command, developing and reviewing standard operating procedures (SOP), ensuring use of current scientific methodologies and staff training. During a DVI managerial responsibility includes tailoring SOP to the specific situation, ensuring member accreditation, encouraging inter-disciplinary cooperation and ensuring security of odontology data and work site. Individual responsibilities include the ability to work within a team, accept peer review, and share individual members' skill sets to achieve the best outcome. These responsibilities also include adherence to chain of command and the SOP, maintenance of currency of knowledge and recognition of professional boundaries of expertise. This article highlights issues of Quality Management pertaining particularly to forensic odontology but can also be extrapolated to all DVI actions.

Advances in forensic age estimation

The ability to assign accurate age estimates to human remains and living individuals is becoming an increasingly important element of forensic practice. In mass fatality events, where many people lose their lives and are often unable to be visually identified, being able to separate individuals based on their age as determined by skeletal and/or dental development is a vital part of the Disaster Victim Identification (DVI) operation. For example, in the tragic bushfire disaster which struck Victoria in February 2009, of the 164 victims who lost their lives and were subject to the DVI process, 25 were under the age of 20 years, and many of these were located in commingled circumstances [1, 2]. Due to the severity of the fires and the condition of many of the remains it was only possible to identify a number of these by assessment of their age using dental and skeletal development [3]. Forensic age estimation also plays an increasingly important role in the assessment of living individuals of unknown age who have entered a foreign jurisdiction without identification papers, or with suspect identification documents. It is necessary to be able to determine the age status of these individuals for a number of reasons, including school entry and year level age requirements, and also for assessment of legal adulthood or childhood. Determination of an unknown age individual’s status as either an adult or a child is vital in terms of how that person will be treated by the law in not only criminal prosecutions, but also in immigration hearings, licensing applications and, increasingly importantly, determination of refugee status. Age assessment of living individuals is conducted by using various medical imaging modalities, such as conventional X-ray and CT scanning, in order to capture images of the developing skeleton and the dentition. The anatomical sites most commonly imaged are the hand/wrist region for assessment of skeletal development, the dentition for assessment of dental age, and more recently the use of CT scanning to capture images of the developing clavicle and the dentition [4, 5]. This imaging necessarily involves the use of ionising radiation with concomitant exposure to various tissues. This exposure is not at a level sufficient to cause immediate harm, but does raise the total lifetime dose of radiation experienced by the individual concerned. There are medical ethical and legal considerations involved in conducting radiological procedures on living people, with no definite medical need, that are yet to be properly addressed. In Australia and New Zealand, forensic odontologists and anthropologists have been using various age estimation methods for many decades, the majority of these developed from population studies originating in the United States, Canada, and Europe [6–9]. These methods were developed from research conducted many decades ago and on populations which geographically, environmentally, and nutritionally do not accurately reflect current population demographics. For juveniles, that is, those individuals under the age of 15 years, these systems, especially those describing dental development, have proven to be quite adequate and have served the profession well. Recent research, however, would suggest that for dental ageing at least, these older methods may not be as accurate as was once thought for young individuals [10], and it is suspected that they may be substantially more inaccurate for individuals older than 15 years of age. R. B. Bassed (&) Department of Forensic Medicine, Victorian Institute of Forensic Medicine, Monash University, 57-83 Kavanagh St, Southbank, Melbourne, Australia e-mail: richardb@vifm.org

Population Substructure Can Significantly Affect Reliability of a DNA‐led Process of Identification of Mass Fatality Victims

Aiming to evaluate the effects of population substructure on the reliability of a DNA correspondence in the process of human identification, we used the model of "in silico" constructed populations with and without substructure. Effects of population substructure were evaluated at the level of locus heterozygosity, Hardy-Weinberg equilibrium and mini-haplotype distribution. Inbreeding in a subpopulation of 100 individuals through 10 generations did not significantly alter the level of heterozygosity and Hardy-Weinberg equilibrium. However, analysis of mini-haplotype distribution revealed a significant homogenization in separated subpopulations. Average observed mini-haplotype frequency (f(o)) increased to threefold from expected values (f(e)), and the number of mini-haplotypes with f(o)/f(e) above 10 increased over sixfold, suggesting that the effects of population substructure on calculated likelihood ratios (LR) might be larger than previously estimated. In most criminal cases, this would not represent a problem, whereas for identifications in large-scale mass fatality events, population substructure might considerably increase the risk of false identification.

Granular detergent composition with reduced perfume leakage

In April 2020, novel coronavirus SARS-CoV-2 (COVID-19) produced an ongoing mass fatality event in New York. This overwhelmed hospital morgues necessitating emergent expansion of capacity in the form of refrigerated trucks, trailers, and shipping containers referred to as body collection points (BCPs). The risks for musculoskeletal injury during routine and mass fatality mortuary operations and experiences of decedent handlers throughout the "first wave" of COVID-19 are presented along with mitigation strategiesAwareness of the high rates of musculoskeletal injury among health care workers due to ergonomic exposures from patient handling, including heavy and repetitive manual lifting, prompted safety walkthroughs of mortuary operations at multiple hospitals within a health system in New York State by workforce safety specialists. Site visits sought to identify ergonomic exposures and ameliorate risk for injury associated with decedent handling by implementing engineering, work practice, and administrative controls.Musculoskeletal exposures included manual lifting of decedents to high and low surfaces, non-neutral postures, maneuvering of heavy equipment, and push/pull forces associated with the transport of decedentsRisk mitigation strategies through participatory ergonomics, education on body mechanics, development of novel handling techniques implementing friction-reducing aides, procurement of specialized equipment, optimizing BCP design, and facilitation of communication between hospital and system-wide departments are presented along with lessons learned. After-action review of health system workers' compensation data found over four thousand lost workdays due to decedent handling related incidents, which illuminates the magnitude of musculoskeletal injury risk to decedent handlers.