1. Office of the Chief Medical Examiner (OCME) Flu Issues

2. Objectives Explain OCME jurisdiction Describe OCME responsibilities Explain how OCME works with many partners Discuss unresolved issues for OCME

3. What Part does the OCME Play? §32..1-283 outlines the jurisdiction of the OCME The OCME is charged with the medicolegal investigation of deaths that are sudden and unexpected or violent. Jurisdictional categories are listed

4. Jurisdiction Trauma Violence Poisoning Accident Suicide Unusual Cremation/ burial at sea Deaths in these categories: Homicide (All Terrorism) Unnatural manner Sudden in apparent good health Unattended by physician In jail, prison, in custody State Mental Health patients

5. Natural Death v Natural Event A natural event is a happening such as hurricane or earthquake and may cause unnatural accidental deaths due to drowning, blunt force, CO poisoning from generators, cave-in etc. These are by statute, medical examiner cases A natural death is due to a natural disease process arising out of the ordinary course of an individuals life e.g. diabetes, cancer, ASCVD, COPD Pandemic flu is a natural disease occurring under natural circumstances provided terrorism is excluded.

6. Jurisdiction Under ordinary circumstances, if a disease is naturally occurring, resulting from the normal course of evolution, the deaths are natural deaths and are NOT Medical Examiner cases; the OCME has no jurisdiction over natural deaths even if the numbers are large. E.g. Flu is naturally occurring and deaths are natural E.g. Smallpox is not naturally occurring and deaths are unnatural because it is most likely a bioterrorism agent making smallpox deaths homicides.

7. Jurisdiction However, there are a few special circumstances that may make a death due to a naturally occurring biologic organism, - bacterial or viral -, that might bring the death under the jurisdiction of the OCME

8. OCME - Natural Deaths under Special Circumstances Example: Pandemic flu The OCME would take jurisdiction when –Suspected first native case of pan flu - to establish by culture the first presence of the disease in Virginia –Suspected pan flu death in a poultry worker to prove flu was contracted from poultry –Flu in a poultry workers family to establish person to person transmission of pan flu has occurred

9. OCME - Natural Deaths under Special Circumstances –Pan Flu suspected in a foreign traveler from a place where flu is present –A Virginia native who was at risk for flu because of travel to a place where pan flu is present –If, the first diagnosed case in a hospital needs documentation of the virus in tissue for presence in the community –Otherwise, flu deaths are not ME cases

10. OCME – Unnatural Deaths If the disease is a result of: –a terrorist act - death is a homicide due to a biological bullet –an accidental release from a lab – death is an accident –purposeful suicide by a terrorist in the course of spreading the disease – death is a suicide All of the above are unnatural deaths and subject to ME jurisdiction

11. OCME Missions Determine the cause of death – the disease, injury or poison causing the physiological death of a person Determine the manner of death – the circumstances under which death occurred – Natural, Accident, Suicide, Homicide, Undetermined

12. OCME Missions Collect medical evidence – hairs, fibers, bullets and cultures (under certain circumstances) Reconstruct how injury occurred – body position, distance of GSW etc.

13. OCME Isolation and Quarantine Responsibilities The State Health Commissioner may impose quarantine under §32.1-45 The Medical Examiner does not determine who or how persons are placed in isolation and/or quarantine. However, if a person should die while in a isolation or quarantine situation, the OCME role will be determined by the contagiousness of the agent (smallpox, Ebola v flu), the origin of the agent (terrorism v natural) and the circumstances of its spread (natural, homicide by terrorism, accident, suicide)

14. Management of the Hazardous Body §32.1-288.1 empowers the State Health Commissioner to determine if a body is hazardous to the public health and enables the Commissioner to identify and make a respectful final disposition This section utilized only for bodies too dangerous for anyone to handle in large numbers, e.g. Ebola, other hemorrhagic fevers

15. Who Signs the Certificate of Death? VA Code requires a physician who treated a patient to sign the death certificate for a death due naturally occurring diseases. §32.1-263) within 24 hours of death. The medical certification shall be completed, signed and returned to the funeral director within 24 hours after death by the physician in charge of the patient's care for the illness or condition which resulted in death except when inquiry or investigation by a medical examiner is required by § 32.1-283 or § 32.1-285.1. Certificates filed in Vital Records promptly so families can settle estates and receive benefits.

16. Certification of Death Who signs if there are large numbers of natural deaths? –The attending physician –May be the ER physician who, if after history and physical of a living patient who dies while being treated, is satisfied death is due to flu –An associate physician –Chief medical officer of the institution in which death occurred –Physician who performed an autopsy on the patient

17. Working with Partners – EMS, Law Enforcement OCME relies upon first responders/ receivers to notify ME of cases that are possibly ME cases (including Epi). OCME will work directly with Police forensic and investigative divisions as usual for violent deaths (Unified Command)

18. Working with Partners – Hospitals and Law Enforcement Hospitals/Community resources are tasked with holding bodies locally if deaths are natural until kin claim them Hospitals should notify police if the body is unidentified Police are tasked in cooperation with hospitals to establish identification by usual means – viewing or fingerprints

19. Working with Partners – Hospitals and Law Enforcement If bodies remain unidentified after documented diligent hospital and police search for several days, notify the OCME who will be responsible for further identification efforts OCME will authorize transport to a OCME district office or regional morgue

20. Working with Partners – Medical & Dental Community For longer term unidentified bodies medical/ dental treatment agencies can assist the OCME under HIPAA exclusion with: –Antemortem medical records –Antemortem radiographs –Antemortem dental records –Next of kin information

21. Working with Partners – Law Enforcement If bodies are identified but unclaimed after diligent documented search for next of kin, notify the Sheriff of the jurisdiction of death for final disposition §32.1-288 The identified but unclaimed are not medical examiner cases

22. OCME role in Outbreak Accept & identify and/or determine the first outbreak cases for public health purposes. Certify those who die at home without an attending physician or whose attending is not licensed in Virginia Accept and assist in identification of the dead if the local police cannot do so with investigation and fingerprinting.

23. Unresolved Issues Management of Large Numbers of Bodies Local natural deaths should stay local for the convenience of hospital, family, funeral directors and police Question is surge capacity for holding bodies close to home If number of identified bodies are huge, localities need to integrate local resources

24. Unresolved Issues Management of Large Numbers of Bodies Local hospitals, nursing homes, police, funeral directors, vital records, health departments, social services and others need to work together to: –Augment local hospitals and overworked funeral homes, cemetarians with refrigerated holding capacity –Identify regional locations/refrigerated trucks for storing and cooling bodies until kin can claim –Number bodies. and track release to kin

25. Primary Objectives Primary objectives are to secure remains until funeral homes can catch up with final dispositions on the local natural deaths and until - The OCME can establish an incident morgue to manage its usual caseload of day to day deaths, any bioterrorism deaths, and the unidentified bodies.

26. Summary ME jurisdiction over dead bodies depends on the nature of the infectious agent and the circumstances under which it spread ME accepts suspected index or first cases to establish presence of agent in Virginia ME accepts bodies that are unidentified after diligent local search by hospital and police ME accepts deaths at home with no attending physician