Background

Horrific disasters are memorialized by the number of dead left in their wake. Large numbers of deceased overwhelm the collective psyche and dislodge the civil infrastructure of society. Acts of terrorism—such as the 2001 attacks on the Pentagon and the World Trade Center in the United States and subsequent bombings in Madrid, London, and Bali—killed more than 3,000 people over the course of four years. Nations were gripped with fear, resulting in new policies and systems of detection and protection that impacted every segment of society.

Clusters of natural disasters and hazards emanating from global and ecological changes have included heat waves, floods and mudslides, hurricanes and tsunamis, and earthquakes claiming catastrophic numbers of lives lost. The 2004 Southeast Asian tsunami resulted in the death of over 200,000 people, with millions more missing and displaced. The Kashmir earthquake in 2005 killed over 75,000 people. As a direct result of Hurricane Katrina, which hit the Gulf shore of the United States in 2005, over 1,400 people perished.¹ The large numbers of casualties associated with Katrina overwhelmed local forensics teams that continued to find bodies in the region nearly 6 months following landfall.² A record heat wave that hit seven countries throughout Western Europe over the course of two weeks in the summer of 2003 claimed an estimated 35,000 lives.³ Three years later, though on a much smaller scale, a two-week heat wave throughout California was blamed for as many as 141 deaths; coroners struggled to keep up with the large jump in the number of bodies that were stuffed, some piled on top of others, into the freezers at the Fresno County morgue.⁴

Plagues and outbreaks of communicable disease also contribute to the mass-fatality burden. The 1918 Spanish influenza pandemic stands out as a sentinel event that literally stopped armies. Spreading around the globe in three distinct waves, this pandemic claimed the lives of 50 million to 100 million people worldwide.⁵ Estimates place the death toll in the United States at over 675,000.⁶ The numbers of dead in cities most affected, such as Philadelphia, surpassed the average number of deaths per week from all causes.⁷ Hospital capacities were overwhelmed as medical practitioners died in large numbers.⁸ The number of bodies rapidly exceeded the number of coffins, and bodies overflowed from hospitals, city morgues, and people’s homes.⁹ The military commandeered entire trains to transport dead soldiers.¹⁰

The H5N1virus, first identified in 1997,¹¹ has rekindled fears and led to dire forecasts of the potential for global dissemination of a highly pathogenic influenza. Thus far, over 140 million flocks have been culled in over 50 countries,¹² and bird-to-human transmission has yielded a 60% case fatality rate in humans.¹³ Extrapolating the effects of this novel virus probabilistically on morbidity and mortality rates from the 1918 Spanish flu, experts have hypothesized that as many as 90 million Americans would contract the H5N1 influenza strain, resulting in 1.9 million deaths.¹⁴ The global death toll from an influenza pandemic on the scale of the 1918 pandemic is estimated at approximately 62 million people.¹⁵

The fatality management infrastructure, comprising disaster workers, medical examiners/coroners (ME/Cs), physicians and hospitals, funeral services directors, faith-based groups, mortuary affairs, and others, is highly vulnerable to such overwhelming events. Recent tragedies have heightened awareness regarding the limited capabilities within this sector to comprehensively and swiftly meet the spectrum of its fatality-related responsibilities to families, communities, and governments.

The National Response Plan (NRP), issued in December 2004 by the Department of Homeland Security, is an all-discipline, all-hazards plan intended to establish a single, comprehensive framework for managing domestic incidents.¹⁶ The NRP provides a framework for federal interaction with and support to state, local, and tribal governments, the private sector, and nongovernmental organizations. Its premise is that while the combined expertise and capabilities of all levels of government will likely be required in the prevention of, preparedness for, and response to domestic incidents, the primary management of an incident should occur at the lowest possible geographic, organizational, and jurisdictional level.¹⁷ In general, federal support will be implemented through the activation of Emergency Support Functions (ESFs) at the request of the governor when an individual state’s resources and capabilities are overwhelmed by an incident of national significance. ESFs identify primary and support agencies that are assigned to head the federal response based on authorities, resources, and capabilities best suited to each specific functional area.¹⁸

ESF 8—the Public Health and Medical Services Annex—provides the mechanism for coordinated federal assistance to supplement state, local, and tribal resources in response to public health and medical care needs.¹⁹ ESF 8 is coordinated by the Secretary of Health and Human Services and acknowledges a number of civilian and military entities as playing a critical role in meeting the public health and medical needs of victims following an incident of national significance.²⁰ Within ESF 8, the Department of Defense has been identified as a support agency in managing human remains, including victim identification and mortuary affairs.²¹

Large-scale fatality management requires robust planning, broad-based technical expertise, and enormous logistical capabilities and resources. Comprehensive planning for a mass-fatality event also requires acknowledging the complexity and diversity of America’s cultures, religions, socio-demographics, communities of faith, and legal and regulatory systems.

Concerns regarding deliberate attacks using biological, chemical, radiological, or other weapons of mass destruction and natural disasters and pandemics necessitate enhanced thought and planning regarding mass-fatality management. Many experts have expressed concern that ESF 8 lacks the depth, breadth, and precision necessary to adequately address future mass-fatality events and operations.²² The civilian community and critical support entities such as the National Guard and the Department of Defense should collectively understand and undertake measures to narrow the gap between current and required capabilities to cope under the most exigent of circumstances.

Methods

A two-day working group conference was convened in March 2006 at the Joint Task Force Civil Support (JTF-CS) headquarters in Fort Monroe, Virginia, by U.S. Northern Command in cooperation with the Department of Health and Human Services. The participants who were invited, assembled, and empanelled under the direction of a mortuary affairs planner at JTF-CS were intended to comprehensively represent all aspects of the civilian and military mass-fatality community. Experts included medical examiners, health care workers, law enforcement, casket manufacturers, funeral directors, and others from local, state, federal, and private agencies. Although participants were encouraged to express the broadest base of their experience and expertise, the focus throughout this meeting was specifically applied to mass-fatality planning and response within the context of a pandemic influenza.

Over two days, the participants met in plenary session and smaller working groups aggregated by theme and subject matter expertise. Oral presentations expanded the knowledge base of the group and allowed multiple opportunities for debate and discussion. By the conclusion of the conference, each working group had completed and presented a summary oral report highlighting specific findings and recommendations. A written report by each working group was submitted to the meeting conveners within several months of the conference. This consensus paper summarizes the findings of each working group and presents all-embracing recommendations to improve mass-fatality capabilities for a pandemic influenza. The following key areas were addressed during this meeting: scene operations, body identification, and medico-legal investigation protocol; command and control of a mass-fatality event; funeral services and final disposition of mass fatalities; and family assistance and behavioral health services provision.

Working Group Recommendations

Scene Operations, Body Identification, and Medico-Legal Investigation Protocol²³

Assumptions

Medico-legal death investigations in the United States mostly comprise ME/C systems established by state, county, or city codes (some jurisdictions have the Office of Attending Physician or the Justice of the Peace fill this role). In all U.S. jurisdictions, licensed treating or primary-care physicians are authorized to certify death from natural disease occurring under natural circumstances for the state in which they are licensed. ME/Cs typically certify homicidal, accidental, suicidal, undetermined, or otherwise non-natural manners of death. On average, 10% to 12% of deaths in the United States are ME/C cases.

Most ME/Cs are governed by codes that require a medico-legal investigation for sudden and unexplained deaths to validate potential disease epidemics and for all deaths without an attending physician or medical professional authorized to certify death. In addition, there may be requirements for ME/Cs to assume jurisdiction when situations present atypically large numbers of bodies.

In some jurisdictions, the ME/C is required to pronounce and investigate all deaths outside of medical treatment facilities. Depending on the circumstances, the ME/C may investigate and turn over the certification procedures to the primary-care physicians. In some jurisdictions, deaths within a medical treatment facility that occur within a certain time frame (for example, 24 or 48 hours) must be reported to the local ME/C, who may investigate further, depending on the circumstances.

A typical ME/C’s investigation includes scene documentation, the appropriate medico-legal examination (which may include a forensic autopsy), witness statements, and investigative notes and studies of the event.

Almost all ME/Cs are required to assume jurisdiction over deaths of persons in correctional custody, deaths in mental institutions, and sometimes nursing care facilities, irrespective of the circumstances. Some state and local codes also require the law enforcement agencies to investigate deaths within their jurisdictions with or without coordination with the ME/C.

All human remains require proper identification before a death certificate is issued. If hospital admissions personnel secure patient identification with government-issued photographic documentation, that will ease identification of patients who die in hospitals. This process will be more labor intensive during unattended death investigations, where reliable witnesses or data are not available.

During any mass-fatality event, a surge in deaths will overwhelm the resources, personnel, funds, and planning efforts of the medical care community, law enforcement investigations units, and the funeral and disposition care community, as well as the ME/C system. Routine exposure to potentially infectious remains and a possible absence of protective equipment may result in physicians and members of the ME/C community themselves being overcome by the same illness that is contributing to the high death rate.

In a mass-fatality incident associated with a communicable disease, the location of the bodies will not be restricted to one geographic area. Since hospitals will be admitting only the sickest patients and using public health’s isolation and quarantining procedures for other ill individuals, as many as 75% of deaths may occur outside a hospital, additionally straining both workers in the field and the coordination of activities and information. Morgue space will be quickly overwhelmed.

Customary identification of the body may be limited by the condition of the remains when found in the field. The lack of reliable witnesses to visually identify the deceased or inform staff of the location of dental or medical records will adversely impact the identification process. Further complicating the identification issues, fewer than 10% of the U.S. population has fingerprints on file, and DNA is on file only for the Defense Department’s uniformed service personnel. These and other issues may extend the time needed to complete fatality management responsibilities during a pandemic influenza to 6 months, 12 months, or even more.

Recommendations

• Improve death reporting and tracking by establishing dispatch systems separate from emergency medical services and 911 systems that can be managed through family assistance and patient tracking centers. Facilitate use of these systems by private citizens as well as first responders, physicians, and treatment facilities to ensure that a complete patient tracking and case management database is available for families, ME/C offices, and law enforcement.
• Explore strategies that facilitate and provide oversight to the process of pronouncing death, determining cause and manner of death, completing death certificates, and establishing victim identity. Solutions may include amending the Health Insurance Portability and Accountability Act of 1996, other regulations, and codes for use by trained and credentialed non-ME/C personnel (such as police, fire, and emergency medical services) and retired physicians to assist with these responsibilities during a large-scale emergency.
• Explore strategies to augment transportation of human remains during a mass-fatality event. Solutions may include amending codes regarding the use of volunteers and access to other resources.
• Ensure proper identification of bodies and avoid insurance fraud and wrongful-death cases. Solutions may include implementing standardized methodology for collecting samples of human remains such as a right thumbprint, DNA, and a facial photograph. In the case of decomposed bodies, this may also include anthropological markers, dental impressions, and, if possible, fingerprints.
• Augment existing morgue space. Solutions may include expanding hospital morgues and securing additional facilities, including refrigerated trailers or containers with diesel or electrical power supplies.

Morgue Operations and Command and Control of a Mass-Fatality Event²⁴

Assumptions

A pandemic influenza will result in a shortage of personnel, supplies, equipment, and storage: there is little expectation of assistance from neighboring communities as, most likely, the nation at large will be similarly taxed. Delays and disruption will occur throughout the spectrum of the death and transitional care industry. Decomposition slows once a body is sufficiently cooled (at 34° to 37° F); at these temperatures, bodies can be stored for up to 6 months.

Recommendations

• Shift resources to the most vital public health functions, including body recovery, abbreviated processing, temporary storage, and tracking. At the designated collection point, trained personnel should sort bodies by cause and manner of death to ease subsequent processing (victim identification and issuing a death certificate).
• Pre-identify community-based collection points and morgues that meet temperature requirements.
• Ensure that the Strategic National Stockpile is sufficiently stocked with critical morgue supplies.
• Improve the time required for processing and the capabilities to track decedents during a mass-fatality event. Solutions may include developing a national, uniform method for numbering, such as state abbreviation and zip code followed by case number.
• Employ a strategy of batch processing to administer the issuance of death certificates during a pandemic.
• Organize and train volunteers from the public and private sectors to assist with and support the mass-fatality functions within their communities.
• ME/Cs should stockpile sufficient critical supplies to support operations for 10 days and put in place contracts and memoranda of agreement to ensure that they receive priority distribution of water, generators, and gasoline.
• Local and state governments should establish simple, uniform procedures forms for requesting critical assistance from the federal government to expedite obtaining people, supplies, equipment, and/or operational assistance.

Funeral Services and Final Disposition of Mass Fatalities²⁵

Assumptions

The availability of state, federal, and military assistance during a catastrophe resulting in mass fatalities is unpredictable. Local communities and businesses will bear the burden of body disposition, which will rapidly exceed existing capacity and storage for human remains. Levels of cooperation across funeral service providers, suppliers, and others may become strained and result in difficulty implementing a standard disposition process.

Recommendations

• Ensure smooth fatality planning and management by implementing clear lines of communication and authority at the local, state, and national levels
• Address the expected surge in morgue and funeral capacity by defining standard protocols for handling, processing, securing, and disposing of large numbers of remains in a respectful and dignified manner.
• Ensure the funeral industry’s priority access to labor, supplies, personal protective equipment, vaccines, fuel, raw materials, communication bandwidth, transportation, and security and other resources. Consider the mortality management sector a first responder.
• Implement reciprocal licensing of mortuary services personnel to overcome variations in state licensing of funeral directors, embalmers, cemetery and crematory operations, and unionized labor.

Providing Family Assistance and Behavioral Health Services²⁶

Assumptions

A typical family assistance center is a secure facility established at a centralized location serving a wide spectrum of missions. Among its responsibilities are providing facts about missing persons who may be victims of a disaster, serving as a gathering point for information exchange to facilitate the identification of a body, reunifying the remains of loved ones with next of kin, collecting of DNA, and offering a safe harbor for spiritual and emotional support. Family assistance centers also provide supportive services relating to housing, insurance, and legal assistance.

The use of a family assistance center or similar communal gathering place is not feasible during a communicable disease outbreak, as the center would serve as a locus of exposure and further spread the disease. Unlike a point-source event, such as an explosion or natural disaster, a communicable disease will result in waves of illness and affect multiple family and community members in succession. In such a situation, the family assistance center will have a greater responsibility to distribute information to the community rather than to gather information from individuals regarding potential fatalities. Outlets for educational information distribution should include the Internet, television, and the press.

Recommendations

• Develop supportive capabilities for families and communities that are flexible and appropriate to the circumstance. For example, during a communicable disease event such as a pandemic, institute a family information center (virtual, not tangible) rather than a family assistance center.
• Build a national database (similar to that of the National Crime Information Center), operated by the Department of Justice, to coordinate inquiries and reports regarding missing persons. Expand this internationally through the World Health Organization or the U.S. Department of State.
• Establish a fatality and missing-person information telephone number to report unidentified fatalities, similar to the National Find Family Hotline model.
• Establish a national voluntary registry of next of kin so families can register information before a disaster.
• Collect and prepare, from reliable sources such as the Department of Health and Human Services, emergency public information and educational information. Such information should be ready to disseminate and appropriately presented (sensitive to reading levels, languages, and cultures) to reduce disease exposure and protect families.
• Identify strategies to expand subject matter expertise and bolster the ME/C and public health sectors during an emergency. Consider the use of related professions (such as Justices of the Peace) or retired workers.
• Explore interventions and strategies regarding special populations, such as those with mental and behavioral illness or disabilities, as well as non-documented aliens.

Discussion

The recommendations reflect the opinions and expertise of the working group members assembled for this meeting. While they may not reflect a national consensus, these recommendations are informed by knowledgeable and nationally recognized professionals who have experience handling mass-fatality events.

A number of themes pervaded the conference and working groups. The following should be considered priority strategy and policy areas in planning for pandemics and catastrophic health events:

1. Although mass-fatality events have remained relatively rare in the United States, the current threat environment and forecasts of pandemic influenza require revised strategy by government and industry and modified expectations by the public. Most people assume that the remains of a loved one will be treated with care and will be expeditiously returned to the next of kin for customary interment. Therefore, government leaders and public information officers must prepare now to deliver honest and timely information to the community. These leaders must be ready to deal proactively with heightened levels of frustration and anger in order to restore confidence and maintain public trust during periods of massive social and economic dislocation.
2. A mass-fatality event due to a communicable disease will present opportunities for disease exposure to the members of the death and transitional care industry and to the volunteers whose assistance will become invaluable across the multiple components of the fatality management process. Both prior education and event-specific training will be essential. Sufficient quantities of personal protective equipment must be available to offer individuals an incentive to fulfill their job commitment or provide assistance.
3. A pandemic, and its consequent mass mortality, will be enormously disruptive to all sectors of society. Fatality management across the United States comprises a wide diversity of codes, regulations, and practices, entailing cumbersome processes and hindering seamless support through mutual aid or assistance from neighboring communities. Efforts should be made to develop uniform procedures, forms, and databases and to employ strategies that can bring national consistency to fatality management.
4. Support and assistance through the federal government are unpredictable and may be insufficiently proficient to address the complexity and provide the precision of skills required during a mass-fatality event. The working group overwhelmingly supported instituting a separate Emergency Support Function within the National Response Plan to comprehensively plan for and respond to mass-fatality events. This would bring to bear greater levels of expertise clearly identified within one lead federal agency and bring about necessary training, planning, and exercises from the Defense Department, the National Guard, and other federal agencies to provide support during events that require mass-fatality management.

The country’s ability to effectively manage a mass-fatality event is limited. During a pandemic or other catastrophe resulting in unusually high levels of mortality, fear and possibly panic will be pervasive. To some degree this can be mitigated by government leaders who demonstrate skill, forethought, and planning for the dignified and expeditious treatment of the dead. The working group stands ready to assist national leaders in all aspects of policy making and implementation to move mass-fatality efforts forward.

Acknowledgment

The Working Group extends its grateful appreciation to John Nesler for convening experts to address the critical issue of mass fatality. The group also thanks Sweta Batni and Phi Vu for their research assistance.

The Joint Task Force Civil Support Mass Fatality Working Group

Robert Alonzo, Department Head, Contingency Planning–Medical, Naval Medical Center Portsmouth

Richard Alt, Arlington Police Department

Rochelle Altholz, State Administrator, Virginia Office of Chief Medical Examiner

Jason Altieri, President, Commonwealth Institute of Funeral Service

Robert Biggins, President, National Funeral Directors Association

Bob Boetticher, Director of Special Projects, Service Corporation International

Rich Burmood, Senior Doctrine and Plans Analyst, Joint Task Force Civil Support

Barbra Butcher, Director, NYC Office of the Chief Medical Examiner

Ramon Collazo, Mortuary Affairs Planner, Joint Task Force Civil Support

Sherry Daniels, Bioterrorism Preparedness Manager, Public Health, Pima County, AZ

Rick Davis, Director, Emergency Communications, American Red Cross

Frank De Paolo, Deputy Director, NYC Office of the Chief Medical Examiner

Nicolas Demarco, Joint Mortuary Affairs Officer, U.S. Central Command

Suzanne Devlin, Deputy Chief, Fairfax, VA, Police

John Dill, Planner, Standing Joint Force Headquarters North

Bill Ellerman, Instructor, Mortuary Affairs Center

Robert Fells, Chief Operating Officer, International Cemetery and Funeral Association

Marcella Fierro, MD, Chief Medical Examiner, Commonwealth of Virginia

John Fitch, Senior VP, Advocacy, National Funeral Directors Association

John Fudenberg, Deputy Coroner, Clark County, NV

Cynthia Gavin, Principle Research Scientist, Battelle, Military Improved Response Program

Andy Gist, Logistics Planner, Joint Task Force Civil Support

Bob Gordon, Director, Eternal Hills

Jimmy Green, Forensic Pathologist, Armed Forces Medical Examiner Office

Elin Gursky, Principal Deputy for Biodefense, ANSER/Analytic Services, Inc.

Lori Hardin, Statewide Emergency Planner, Virginia Office of Chief Medical Examiner

Buddy Horton, Mortuary Affairs officer, U.S. Air Forces in Europe

Gary Huckabay, Family Assistance Planner, U.S. Northern Command

Pete Hull, Senior Researcher, Homeland Security Institute

Peter Kanis, Deputy Director, Communications, American Red Cross

Don Kautz, Public Health Safety Officer, State of Arizona

Lisa La Due, Director, National Mass Fatality Institute

Babette Lenfant, Director, Communications Directorate, Joint Task Force Civil Support

John Linstrom, Regional Commander, U.S. Public Health Service Disaster Mortuary Operational Response Team

Bruce Lyle, Assistant Chief Deputy Coroner, Orange County, CA, Sheriff-Coroner

Michelle Mack, Chief Investigator, Washington, DC, Office of the Chief Medical Examiner

Joanne McGovern, Deputy Surgeon, U.S. Army North

Ed McWilliams, President, Bio-Seal

Luis Molina, Chief Logistics Plans, Joint Force Headquarters–National Capital Region

Terence Murray, Deputy Director, Arlington, VA, Police Office of Emergency Management

John Nesler, Senior Mortuary Affairs Planner, Joint Task Force Civil Support

Mike Nicodemas, Board Member, Cremation Association of North America

Ann Norwood, Senior Advisor, Department of Health & Human Services

Bill Phillips, Assistant Chaplain, U.S. Army North

Paul Rahill, President, Matthews Cremation Division

Elspeth Ritchie, MD, Psychiatry Consultant, U.S. Army

David Roath, Chief, Field Services, 21st Theater Support Command, U.S. Army European Command

Laurel Rutledge, VP of Planning Strategy, Batesville Casket

Lars Skinner, Research Development and Engineering Command Improved Response Program

Gary Smith, Joint Mortuary Affairs Officer, U.S. European Command

Kate Summers, Emergency Planner SSA, U.S. Senate

Jeffrey Timby, Command Surgeon–Medical, Joint Task Force Civil Support

Jean Walters, Medical Planner, Joint Task Force Civil Support

Mark Ward, Senior Policy Advisor, Defense Department

Adrian Winget, Doctrine and Plans Analyst, Joint Task Force Civil Support

Anne Yarbro, Chief, Emergency Plans Analysis Team, Joint Task Force Civil Support

Author Contact Information

Elin A. Gursky
Analytic Services Inc.
2900 South Quincy St., Suite 800
Arlington, VA 22206
(703) 416-3458
Fax: (703) 416-4470
Email: elin.gursky@anser.org

References

Click on an end note number to return to the article.

1. Reuniting the Families of Katrina and Rita: Final Report of the Louisiana Family Assistance Center. Baton Rouge: Louisiana Family Assistance Center, Louisiana Department of Health and Hospitals, 2006.

2. “Handling Mass Fatalities,” Government Technology, April 15, 2006.

3. Janet Larsen, “Record Heat Wave in Europe Takes 35,000 Lives: Far Greater Losses May Lie Ahead,” Earth Policy Institute, Oct. 9, 2003.

4. Michelle Maitre, “Heat Linked to More Than 130 Deaths,” Oakland (CA) Tribune, July 29, 2006.

5. Molly Billings, “The Influenza Pandemic of 1918,” Stanford University, June 1997.

6. World Health Organization, “Avian Influenza: Assessing the Pandemic Threat,” January 2005.

7. John M. Barry, The Great Influenza: The Epic Story of the Deadliest Plague in History (New York: Penguin Books), 2005.

8. Ibid.

9. Ibid.

10. Ibid.

11. World Health Organization, “Avian Influenza: Assessing the Pandemic Threat.”

12. Ibid.

13. Ibid.

14. U.S. Department of Health and Human Services, HHS Pandemic Influenza Plan, November 2005.

15. David Brown, “World Death Toll of a Flu Pandemic Would Be 62 Million: Study Examined 1918-19 Outbreak,” Washington Post, Dec. 22, 2006.

16. U.S. Department of Homeland Security, National Response Plan, December 2004.

17. Ibid.

18. Ibid.

19. Ibid.

20. Ibid.

21. Ibid.

22. Ceci Connolly, “A Grisly but Essential Issue: Pandemic Plan Skims Over How to Deal With Many Corpses,” Washington Post, June 9, 2006.

23. U.S. Northern Command Fatality Management Pandemic Influenza Working Group white paper, “Scene Operations, to Include Identification and Medico-Legal Investigation Protocols and Command and Control of Mass Fatalities Resulting From a Pandemic Influenza (PI) in the United States.”

24. U.S. Northern Command Fatality Management Pandemic Influenza Working Group white paper, “Morgue Operations, Identification, and Command and Control of Mass Fatalities Resulting From a Pandemic Influenza Event in the United States.”

25. U.S. Northern Command Fatality Management Pandemic Influenza Working Group white paper, “Funeral Services and Final Disposition of Mass Fatalities Resulting From a Pandemic Influenza in the United States.”

26. U.S. Northern Command Fatality Management Pandemic Influenza Working Group white paper, “The Provision of Family Assistance and Behavioral Health Services in the Management of Mass Fatalities Resulting From a Pandemic Influenza in the United States.”