Measuring Mass Fatality Preparedness – How Does Public Health Stand Up?

chemicalresponseMany of the catastrophic hazards that LHDs plan for have serious potential to become mass fatality events. Even in the most well-prepared communities, events such as pandemics, chemical spills, radiation releases, mass shootings, and acts of terrorism can still result in extremely high death tolls. Moreover, it doesn’t necessarily take a large number of deaths for a mass fatality event to be declared. The threshold for what constitutes a mass fatality event varies by jurisdiction; whenever the number of deaths exceeds local response capabilities, it is considered a mass fatality event.

Because by definition mass fatality exceeds normal response capacity, advance planning is critical to ensure the ability to manage surge when needed. Expedient, safe, and sensitive handling of a mass fatality event requires extensive coordination between the many partners that make up a jurisdiction’s mass fatality infrastructure, including medical examiners/coroners; the death care industry (funeral homes, cemeteries, crematories, and funeral industry suppliers); departments of health; faith-based organizations; offices of emergency management; and Disaster Mortuary Operational Response Teams (DMORT).[1]

A recent University of California, San Francisco study, led by Dr. Robyn Gershon, and funded by the National Science Foundation, sought to assess the level of preparedness of the US mass fatality infrastructure.[2] Researchers developed and tested metrics for three components of preparedness: organizational, operational, and resource-sharing networks (i.e. established partnerships). They then administered an online survey to representatives of state and local health departments and representatives of other sectors of the mass fatality infrastructure, including state and local offices of emergency management, faith-based voluntary organizations, and death care organizations.

While public health performed well compared to other sectors, the study demonstrates a clear need for the entire infrastructure to enhance its level of mass fatality planning. A composite estimate of national preparedness of the mass fatality infrastructure was found to be 51%. In other words, the US mass fatality management infrastructure has about 50% of the capability to manage large scale or complex mass fatality incident.

In terms of organizational capacity for mass fatality preparedness, health departments ranked second highest among respondents, behind offices of emergency management. Approximately 80% of health departments had mutual aid agreements with partners, but only about half were participating in drills and exercises with their partners with respect to mass fatality planning. While more than 71% of respondents from health departments indicated that they were willing and able to respond to a mass fatality incident, those percentages dropped precipitously, as did the percentages of other sectors, when the incident involved chemical, biological, radiological, nuclear, and explosive (CBRNE) agents.

With regard to operational capabilities, upwards of 90% of health departments indicated that their mass fatality plans cover continuity of operations, dissemination of public information, and guidance on health and safety for the public. However, only slightly more than half indicated that their plans included operating a family assistance center and plans for the storage of human remains. On the topic of resource-sharing relationships, departments of health and medical examiners/coroners reported reciprocal ties much more frequently, though overall numbers were not high. About 60% of health departments indicated reciprocal ties with local first response organizations, other local/state health departments, and law enforcement partners. Only 22% indicated reciprocal ties with faith-based organizations and around 35% had reciprocal ties with medical examiners and volunteer groups.

Mass fatality planning is clearly a challenging topic across the board. However, the high stakes make it imperative to develop plans and build partnerships that will help to minimize the adverse effects of mass fatality events. Public health may be ahead of the curve, but much work remains to be done to ensure that all health departments are prepared to respond in an efficient and respectful way. Health departments must continue to lead the way in this critical area of preparedness.

The full study has been published in Disaster Medicine and Public Health Preparedness and is available online to subscribers here. To obtain a copy of the study questionnaire or research paper, email


[1] Gershon RRM, Orr M, Zhi Q, Merrill JA, Chen DY, Riley HEM, Sherman MF. Mass Fatality Preparedness among Medical Examiner/Coroners in United States: A cross-sectional study. BMC Public Health. 2014 Dec 15;14(1):1275. PMID:25511819.

[2] Merrill, JA, Orr M, Chen, DY, Zhi, Q, Gershon RR. Are We Ready for Mass Fatality Incidents? Preparedness of the US Mass Fatality Infrastructure Disaster Medicine and Public Health Preparedness DOI:

About Rachel Schulman

Rachel Schulman is a Senior Program Analyst for Public Health Preparedness at NACCHO. Her work includes enhancing and recognizing local public health preparedness planning efforts through Project Public Health Ready and building collaborations between public health and emergency management. Twitter: @rms_ph

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