Best practices of highly infectious decedent management: Consensus recommendations from an international expert workshop

Abstract

With the increasing number of highly infectious disease incidents, outbreaks, and pandemics in our society (e.g., Ebola virus disease, Lassa fever, coronavirus diseases), the need for consensus and best practices on highly infectious decedent management is critical. In January 2020, a workshop of subject matter experts from across the world convened to discuss highly infectious live patient transport and highly infectious decedent management best practices. This commentary focuses on the highly infectious decedent management component of the workshop. The absence of guidance or disparate guidance on highly infectious decedent management can increase occupational safety and health risks for death care sector workers. To address this issue, the authorship presents these consensus recommendations on best practices in highly infectious decedent management, including discussion of what is considered a highly infectious decedent; scalability and storage for casualty events; integration of key stakeholders; infection control and facility considerations; transport; care and autopsy; psychological, ethical, and cultural considerations as well as multi-national care perspectives. These consensus recommendations are not intended to be exhaustive but rather to underscore this overlooked area and serve as a starting point for much-needed conversations.

Keywords:

• Death care
• decedents
• fatality management
• highly infectious
• human remains
• transport

Background

The global community has faced a steady cadence of highly infectious disease (HID) events in recent years, many of which have required careful planning for and intensive response to fatality management needs. For example, viral hemorrhagic fever occurrences, such as the 2014–2016 West Africa Ebola outbreak, underscored the critical need to have coordinated decedent management to prevent further transmission. Similarly, the infection of a German funeral home worker handling a Lassa fever decedent highlighted the value of proper training for such scenarios (Shuaib et al. 2014; Ehlkes et al. 2017). Over the last decade, other outbreaks (e.g., Nipah virus) have presented similar, though smaller-scale, challenges around highly infectious decedent management (HIDM).

Planning for HIDM is challenging and complicated by the patchwork of decedent management approaches, varying regulations within and between nations, and literature gaps describing best practices for such management activities—particularly as they apply to developed nations for high-decedent-volume public health emergencies. The major gap in current practice is the lack of standardization in training, education, or continuing education for those in HIDM, which results in limited uniformity in response across localities, nations, and worldwide. At the most basic level, there is no clear consensus on what constitutes a highly infectious decedent or how a certain infection at the time of death affects that classification. There is also little information regarding how HIDM should best be conducted as it relates to integration with academic, military, and civilian medical system preparedness; facility and community capacity for safely storing and transporting bodies; performance of autopsies; and maintenance of rigorous public, occupational safety and health (OSH), and environmental health protections as well as ethical standards during all such activities.

To address this gap and the ofttimes disparate recommendations in HIDM, an international consensus workshop was convened with experts in the fields of death care and highly infectious diseases (HIDs). Capitalizing on the international knowledge, experience, and expertise represented at the workshop, experts from the United States and Europe developed recommendations on varying facets of HIDM.

Workshop logistics

The workshop was held on January 8, 2020. Participants included 54 international academics, healthcare and public health practitioners, government officials, and other HID subject matter experts (SMEs) (e.g., high-level isolation units (HLIUs), laboratory biocontainment, aeromedical evacuation) as well as experts from stakeholder organizations (e.g., Centers for Disease Control and Prevention (CDC), Assistant Secretary for Preparedness and Response (ASPR), Occupational Safety and Health Administration (OSHA), centers, military). Not all invited were able to attend, and not all attendees opted to participate in this commentary. This workshop occurred nine days after the first report to the World Health Organization (WHO) Country Office in China of a cluster of viral pneumonia cases in Wuhan City of unknown etiology that would later be known as SARS-CoV-2 and COVID-19 (WHO 2020). Thus, SARS-CoV-2 was not discussed at this workshop.

Workshop participants were invited based upon their extensive experience in protocol design for and participation in HIDM, including for Ebola virus disease (EVD), severe acute respiratory syndrome (SARS), and other globally present HIDS. Workshop participants from the U.S., United Kingdom, Germany, Italy, Norway, Japan, Singapore, and South Korea shared their experiences in transportation and HIDM, including lessons learned from events and exercises. Prior to the workshop, a team of SMEs aggregated a list of key HIDM issues used to initiate discussion on topics including management of human remains; equipment and supplies for management; transportation of human remains; regulations and guidelines specific to handling human remains in the U.S.; and recommendations to address gaps in knowledge and skills for those in the government, academic, and civilian sectors involved in HIDM. The online supplemental materials contain the workshop agenda (Appendix A) and country-specific HIDM summaries (Appendix B).

MeetingSphere (MeetingSphere Inc, 2020, Norfolk, VA) interactive meeting software was used during the workshop. Small breakout groups discussed the agenda topics and reconvened with the larger group to reach consensus. MeetingSphere also enabled attendees to discuss issues over chat; chat text was exported. Additionally, three notetakers transcribed live conversations to capture all discussions. Dialogue from the chat and notes was integrated into the consensus recommendations. This authorship group refined the final versions of the recommendations.

Consensus recommendations

Definition of highly infectious remains

Human remains include the entire body, parts, or prostheses that have been permanently attached or implanted in the body. Although systems for classifying pathogens vary by country, decedents are considered highly infectious if remains are suspected or confirmed to be infected with or contaminated by pathogens listed in the United Nations Category A list (UN 2019a) (online supplemental Appendix C has examples). It is recognized these lists are not all-encompassing, and there could be other criteria and/or pathogens that might be considered highly infectious in specific environments. Workshop participants discussed differences in general terminology. In the U.S., the term “HID” or “highly hazardous communicable disease” are primarily used whereas in Europe (e.g., UK, Germany) the term “high consequence infectious disease” is used because the term “infectious” does not alone relate the transmissibility nor the effects of any infection in terms of outcome (e.g., case fatality). It is important to note that distinction and differences between nations and how that has resulted in varying guidelines. There needs to be an international consensus conference that solely addresses the following gap: Clearly defining an HID vs. high consequence infectious disease vs. highly infectious communicable disease vs. a pathogen of concern; furthermore, determining which causal organisms are associated with what term.

Scalability and storage

Whether a disease event is deemed mass casualty—“an event that overwhelms the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short period of time” (DeNolf and Kahwaji 2019)—or not, scalability and decedent storage need to be addressed. If capabilities and capacity for highly infectious decedent transport and care at the state, tribal, local, and territorial level (STLT) are overwhelmed, it is recommended that advanced consideration and external partnerships be established to assist with HIDM.

In the U.S., there are entities trained to respond to disasters and public health emergencies including but not limited to: U.S. Public Health Service Commissioned Corps, Medical Reserve Corps, Federal Emergency Management Agency, and the National Disaster Medical System (NDMS) under the Departments of Health and Human Services (DHHS). Specifically, NDMS is a federally coordinated healthcare system and partnership of the DHHS, Departments of Homeland Security, Defense, and Veterans Affairs (VA) (DHHS n.d.a.). The mission of NDMS is to support federal and STLT authorities following disasters and emergencies by supplementing health, medical systems, and response capabilities. NDMS also supports the military and VA healthcare systems for combat casualties. The NDMS is predominantly staffed by trained intermittent federal employees capable of responding to varying public health, medical and veterinary crises. Uniquely, NDMS has Disaster Mortuary Operational Response Teams (DMORT). DMORTs are trained and deployed to track and document human remains and personal effects; establish temporary morgue facilities; assist in the determination of cause and manner of death; collect ante- and postmortem data (e.g., DNA); aid in victim identification; perform forensic dental pathology and forensic anthropology methods; process and re-inter disinterred remains; and assist in highly infectious decedent transport (DHHS 2020).

Decedent storage considerations need to be evaluated in unideal scenarios, such as if mutual aid and decedent processing capabilities are exceeded or fatality management occurs outdoors. Preplanning and identification by STLT authorities of temporarily repurposed cold storage assets (e.g., refrigerated trucks, ice rink) are critical. With outdoor fatality management, available deployable morgue processing units (DPMU) can serve as a temporary morgue with a cache of supplies to assist in decedent management (FEMA 2016). Items in a DPMU cache include but are not limited to: administrative supplies (e.g., pens, labels), instrument kits (e.g., scalpel, scissors), documentation technology (e.g., digital cameras fingerprinting), communication equipment, decontamination supplies, human remain bags/pouches, general tools, and appropriate personal protective equipment (PPE) for workers.

Integration of highly infectious decedent care into academic centers, military, and civilian preparedness stakeholders

It is recommended that academic mortuary care training programs expand infection control curriculum beyond bloodborne pathogens to HIDM practice considerations (Le et al. 2019). Those in active practice of decedent management are often not provided continuing education (CE) opportunities that involve HIDM. Several professional training programs and international health authorities have begun incorporating HIDM education based on emerging science, evidence, and practice (CDC 2015; NETEC 2021; WHO 2022). Standardizing academic HIDM curriculum, that use both online learning and hands-on skill demonstration, would provide a basis for CE and reduce knowledge and practice gaps between military, government, and civilian mortuary practitioners. Additionally, too often HIDM is not integrated into training exercises. These trainings and exercise activities will be critical to identify those willing and capable to provide HIDM and refine gaps or issues in HIDM plans. Lastly, incorporation of HIDM curriculum into academic programs should include ethical and religious considerations for HIDM care (WHO 2017) (detailed below).

It is recommended that national authorities work with STLT authorities and key stakeholders to prepare a HIDM curriculum that can be widely shared and adopted not only for civilian mortuary care training (e.g., accredited programs) but also can be adapted for military operations (e.g., U.S. Army’s Mortuary Affairs Specialist Advanced Individual Training). Since many military standard operating procedures (SOPs) are not publicly available, questions remain about translation of use in military operations.

Currently, HIDM is not routinely addressed within many initial training or CE programs associated with mortuary education and apprenticeship. Moreover, when civilian training is completed, it is normally a locally developed training that is not able to take full advantage of the breadth of information and experiences available. Leveraging partnerships with national associations related to decedent care (e.g., National Funeral Directors Association, American Board of Medicolegal Death Investigators) to establish competencies, communicate critical HIDM knowledge, CE opportunities, and training would be beneficial (Le, Witter et al. 2017; Le et al. 2019).

Whether in academic, military, or civilian settings, it should be noted that providing the respective training and technology for HIDM is one part of the planning process, but it is also critical to have the people that are willing to train and do this work under potential biocontainment conditions.

Infection control and facility considerations

The following considerations detailed are based on the Hierarchy of Controls to reduce worker exposures to hazards that cause occupational illness or injury but are applied to HIDM scenarios (NIOSH 2015).

Engineering

A multi-pronged engineering control strategy should be implemented within HIDM scenarios, and these can be adapted based on fixed- or deployable field-based capabilities. Negative pressure and high-efficiency particulate air (HEPA) filtered handling systems, that achieve acceptable numbers of air changes per hour, can be implemented to reduce exposures if aerosol generating procedures are needed. When available, downdraft ventilation tables should be used. Autopsy is not recommended for HIDM unless deemed necessary for diagnostics. In this event, autopsy should be performed in negative pressure rooms in HLIUs/biocontainment units in coordination between highly trained clinicians and autopsy personnel (Herstein et al. 2017). These rooms are designed with minimum air flow and pressure requirements that better protect personnel from potential pathogen exposure. Barrier containment vessels in for remains can also be used. General facility design must also consider: (1) incorporation of effective engineering controls (e.g., systems to exhaust building air away from people), (2) additional security associated with highly infectious remains, (3) enhanced decontamination and SOPs, and (4) unidirectional flow through the facility, including PPE donning and doffing areas. Due to the enhanced engineering controls required for HIDM, personnel should be trained to validate, operate, and maintain all controls.

Administrative

An OSH biosafety program should be established in consultation with SMEs prior to handling highly infectious decedents. This should include, but not be limited to, critical decisions around: if and when autopsy will be performed; how to manage containment breaches; contingency plans for scenarios warranting deviation from SOPs; specimen collection; internal and external communications; transportation plans; surveillance program for worker exposure; scenarios where a worker passes out or loses mobility; and maintenance of recommended vaccinations and prophylaxis for providing decedent care. Moreover, competencies for CE and training should occur regularly (e.g., quarterly); be standardized based on job description and level of involvement in decedent management; and address critical topics such as sharps injury prevention, hand hygiene, and adherence to other workplace controls. Routine training programs should include drills/exercises with detailed after-action reports and improvement plans as part of a comprehensive OSH program.

Sites where HIDM occurs should plan for appropriate cleaning and environmental disinfection, as well as management of residuals (e.g., contaminated water, cleaning products, body fluids). While mortuary care routinely utilizes well-established disinfection approaches for the elimination of bloodborne pathogens, many facilities are not designed for the implementation of a broader gaseous or vapor-based environmental decontamination strategy that may be required for certain pathogens (Brickhouse et al. 2009; Lowe et al. 2013a, 2013b; Jelden et al. 2015). Facility design should consider a more intensive environmental decontamination process with consideration for material compatibility, degradation, and gas containment (e.g., gaseous chlorine dioxide) (Lowe et al. 2012, 2013a, 2013b).

Personal protective equipment (PPE)

While PPE is considered the least effective element of the Hierarchy of Controls, it will be imperative in HIDM. The selection, training, and use of PPE (e.g., disposable gloves, disposable gowns, National Institute for Occupational Safety and Health (NIOSH)-approved respirators, eye protection) should be determined based on risk assessments for the pathogen(s) suspected or confirmed in decedents. Respirator use among employees providing HIDM should include medical clearance, training, and fit testing in accordance with federal and STLT regulations (e.g., OSHA’s 29 CFR 1910.134). Employers of workers conducting HIDM activities should ensure PPE offer appropriate protection for potential types of hazards encountered. HIDM personnel should have ample exercise experience in how to conduct tasks while in various PPE ensembles. Existing PPE selection matrices for managing decedents for certain Category A pathogens should be referenced in addition to consultation with HIDM expert personnel (OSHA 2014; Brown et al. 2019).

Decedent transportation and ultimate disposition considerations

Safety and security need to also be considered if highly infectious decedents are being transported. A transportation plan and SOPs should be established delineating the ability to transport decedents from the point of origin to the appropriate facilities for management or ultimate disposition. Depending on the origin and destination of remains, the plan may need to address regulatory compliance and legal considerations for movement across jurisdictions (e.g., internationally). Plans should also address decontamination of vehicles and management of waste generated during transportation. All remains transported should be properly packaged in leak-proof body bags and appropriate transport containers (Jelden et al. 2015). For enhanced security, a law enforcement vehicle can serve as an escort for vehicles transporting decedents. Routes also need to be taken into consideration, as the shortest or quickest route may not always be ideal (e.g., great public visibility, jurisdiction prohibiting transport) or if interstate restrictions are placed (KSLA 2014).

For ultimate disposition of the remains, the facility or organization should have a memorandum of understanding (MOU), or procedure established with a designated cremation facility (e.g., local funeral home). If cremation is not possible, interment without embalming may be an alternative. If the remains are interred, a security plan should be developed to ensure bad actors are not able to disinter the remains (e.g., to cause panic, potentially accessing the pathogen). It is of the utmost importance HIDM personnel communicate with mortuary personnel for seamless handoff.

Care issues and autopsy

The standard recommendation is that highly infectious remains not undergo autopsy and are cremated in a timely fashion. However, situations may arise in which an autopsy is necessary, and, in those situations, should only be done by properly trained and licensed personnel. Generally, the decision to perform an autopsy on a suspected or confirmed highly infectious decedent is made on a case-by-case basis, usually by a physician (e.g., forensic pathologist) or based upon a legal or national security need. Even in cases of determining a diagnosis, a full autopsy is usually not needed. The determination to plug orifices should also be made on a case-by-case basis.

If it is determined that autopsy will be performed, biosafety level (BSL)-3 capabilities or facilities with enhanced engineering controls (e.g., negative pressure rooms, separate rooms from standard autopsy) are ideal for decedents with suspected or confirmed Category A pathogens (UN 2019b). Alternatively, in some cases, virtual autopsy using postmortem multi-slice computed tomography (MSCT) and magnetic resonance imaging can reduce worker exposures since the autopsy can be performed with the body in a decontaminated leak-proof container. It may also be possible to supplement CT angiography and percutaneous needle biopsies as semi-invasive procedures with decreased risk compared to a full autopsy (Bolliger et al. 2008; Bedford and Oesterhelweg 2013; Bolliger and Thali 2015; Filograna et al. 2019; Fusco et al. 2016).

Psychological, cultural, and ethical considerations

Psychological considerations

Anyone working in HIDM may experience high levels of stress. Procedures for mental health screening and availability of mental health services should be assessed well in advance of HIDM deployment. For workers’ psychological considerations, a screening survey should be implemented to determine fitness for duty, especially in the event of mass fatalities. Additionally, pre- and post-monitoring and routine long-term monitoring, including the mental health of responders, should be considered. The Global Assessment Tool used by the U.S. military, or the NIOSH Emergency Responder Health Monitoring and Surveillance Framework are examples of such assessment tools than can be adapted to include mental health (NIOSH 2020; U.S. Army 2009). Psychological and/or emotional resiliency training is also beneficial (Brooks et al. 2020).

In the U.S., many state medical licensure processes for providers require information about whether the individual has a mental health diagnosis, substance use disorder, and whether they are obtaining counseling services. This disincentivizes practitioners to access such services, out of fear it may negatively impact credentialing and licensing (Jones et al. 2018). We highly recommend licensing boards remove these questions, as they only perpetuate stigma in a time where prioritizing mental health should be normalized (NASEM 2016; Galbraith et al. 2021). Additionally for individuals participating in HIDM, an employee assistance program (EAP) should be available. EAPs have proven to be cost-effective and confidential interventions to assist workers in resolving short-term psychological or psychosocial issues (Richmond et al. 2016; Joseph et al. 2018). Worker training and regular staff meetings should also include strategies to enhance resilience, promote open and uniform communication, and identify complex issues that may need to be addressed or planned for with HIDM.

Considerations should also be made to address the psychological needs of the family and loved ones of decedents. If within a HLIU or healthcare facility, behavioral health specialists and workers trained in end-of-life conversations should be available. In a mass casualty event, a pop-up facility should be established (e.g., NDMS’s Victim Information Center) as the centralized location civilians can go to provide or find information about missing loved ones; all information provided should be documented. Lastly, ideally, a joint information line staffed by medical providers, mental health, and public health personnel would be available to answer community questions and provide consistent messaging during an event.

Cultural and ethical considerations

While site security and public safety are critical in HIDM events, cultural and religious considerations for ultimate disposition should also be noted. As an example, consider the 2014 case of a late-stage patient with EVD who, despite evacuation to the Nebraska Biocontainment Unit, died shortly after arrival. Efforts were made to safely contain the remains while respecting cultural and religious requests of the decedent’s family. Last rites were performed over video; the staff in the room were able to serve as proxies for several religious procedures (e.g., holy water) and the family was virtually present prior to cremation (Jelden et al. 2015). As noted previously, cremation is recommended for highly infectious decedents but alternative means of disposition (e.g., burial) may be considered for religious requests. In contrast, during the 2014–2016 EVD events, decedents from dozens of different cultural and religious groups in West Africa were buried together, without regard for specific death care rituals (e.g., touching or shrouding of the body) (Marshall and Smith 2015). Furthermore, tribal nations with indigenous populations should be considered as they may have specific cultural and religious requirements, as well as burial rituals (CDC 2021a, 2021b, 2021c). We recommend that CE in cultural competency training in mortuary affairs to be evaluated for its existence and for just-in-time training to be provided to those responding to an event when specific cultural and religious considerations may be needed.

In addition to ensuring cultural and religious practices are upheld, HIDM may present different ethical issues than highly infectious patient care to be considered. Death care medical ethics should be upheld as medicolegal death investigators may find themselves in unprecedented circumstances while investigating a suspected or confirmed HID death (CDC 2020a, 2020b, 2020c, 2020d). It may be critical for the medicolegal investigator to inform building occupants or the surrounding area of the details of a death to prevent further or additional death. It is imperative that anyone interacting with the death be properly trained on investigation and how to deal with the intricacies of these scenarios (e.g., conducting high-volume death investigations).

Concluding thoughts

With ever-increasing global fluidity and the ease to transport people and goods, it is unlikely that the EVD outbreaks and COVID-19 pandemic will be the last in this lifetime. These events may mark the beginning of an era where infectious diseases will continue to present a need for mass decedent considerations; at the very least they demonstrate the need for readiness. While planning for HIDM is only one facet of preparedness, it is a complex arena that requires consideration and planning at the STLT and federal levels but remains overlooked.

The major strength in current practice highlighted by workshop participants was the existence of DMORT in the U.S. as an exceptionally useful provision for adding surge capacity in mass casualty scenarios. Not all nations have this formal structure in place, and it would be beneficial for other nations to adapt this model. As discussed above, the DMORT model adds a national surge capacity to augment local capabilities and maintaining this national capability does not put undue pressure on local resources to prepare for events that will be rare at the local level.

The lack of standardization in training, education, or CE for those in HIDM, has resulted in disparate responses across all levels of government and infrastructure. The formation of international standards surrounding HIDM (e.g., International Organization for Standardization) could serve as a starting point. Even with the NDMS DMORT model, DMORT responses are not standardized sub-nationally. This results in DMORT and STLT responders needing to familiarize with each other in real time. While there would still be a need to adapt a national training standard to fit particular scenarios, it would promote training and practice consistency, leading to a safer occupational environment.

Unanswered issues still remain. It is unclear which occupations that participate in HIDM will require regular re-training and reeducation. Regular training and hands-on skills exercise is critical for instilling good practices. However, the intervals and depth in which the education and training are being administered remain lacking. Topics discussed where HIDM gaps remain are: safe lifting and lift device use; cohesive communication strategies between the deployed team, levels of government, and media that will inevitably be present; greater understanding of PPE selection in Category A pathogen scenarios; risk assessment knowledge and capabilities prior to transport; equipment management; vehicle preparation; facility requirements to receive highly infectious decedents; and addressing waste generation post-event and how to safely conduct terminal decontamination. Waste generated from HIDM process will likely require specialized handling, packaging, and disposal (Lowe et al. 2014; Le et al. 2018; CDC 2019).

COVID-19 reflections

While not discussed during the workshop due to the timing occurring within a week of WHO and CDC activating responses to what would become the COVID-19 pandemic (CDC 2021a, 2021b, 2021c), this pandemic serves as a prime example of the need for coordinated decedent management. With the information now known about COVID-19, it is not defined as a HID in the U.S. nor in Europe. However, at the start of the pandemic, before more information about the virus was known, it was initially being considered as a Risk Group 4 pathogen (likely to cause serious or lethal human disease, preventative and therapeutic interventions usually not available) but was finally classified into Risk Group 3 (agents associated with serious or lethal human disease, preventive and therapeutic interventions may be available) (Kaufer et al. 2020); a novel pathogen may be classified higher when less is known about its characteristics and downgraded as the body of knowledge expands. It is now known that COVID-19 does not require HIDM, but for a time that was unclear. Fortunately, extra precautions have proven unnecessary given the demonstrated low risk of SARS-CoV-2 spread from decedents if aerosol-generating procedures are minimized (Vasquez-Bonilla et al. 2020; CDC 2020a, 2020b, 2020c, 2020d).

The fatalities from the COVID-19 pandemic challenged health systems worldwide with an unprecedented volume of decedents requiring storage, transportation, processing, and disposition. In 2020, public health systems, including the death care components, had to manage at least 1.81 million COVID-19-associated fatalities on top of the nearly 60 million who die of all causes worldwide in a normal year (Johns Hopkins University of Medicine 2022; UN 2019a, 2019b). At times, decedent storage capacity was exceeded at many facilities. Los Angeles County, California, U.S.A., for example, had to relax its limits on cremations, as it relates to air quality, due to the volume of bodies needed to be processed (Treisman 2021); some hospitals had to rely on mobile refrigeration units or warehouses for additional storage (Booker 2020; Otterman 2020). The pandemic exposed how quickly local resources became exhausted even when decedent management did not require the precautions and high levels of containment associated with HIDM. Fatality management systems would surely collapse in the face of a similar event requiring HIDM.

Limitations

The consensus recommendations present the opinions of eleven participants. The topics in these recommendations were discussed by the larger group of workshop attendees, but the authorship representing four nations drafted and refined the final recommendations. Moreover, the consensus recommendations are based on the current experiences of the authors—prior to COVID-19—and conclusions derived from scientific data, best practice literature, and infection control guidelines. Additionally, the cost-effectiveness of our recommendations has not been systematically studied.

Four years ago, some of the authorship called for the need to develop a U.S. highly infectious disease care network (Le, Biddinger et al. 2017). Since then, the capabilities and capacity across the nation to address infectious disease outbreaks have greatly varied (Herstein et al. 2016, 2017; HSE 2018). Highly infectious decedent transport and management is only one component of multifaceted preparedness for emerging and reemerging infections, as well as bioterrorism, that needs to be considered in our new reality. Greater attention needs to be dedicated to HIDM, including standards development, investment in training and education, and commitment to establishing global capacity for HIDM. We have entered the “new normal” but that does not mean we have to be unprepared.

Acknowledgments

We would like to thank everyone who prepared for this conference and made this workshop possible including Sarah Dunsmore, Project Manager, for this funding opportunity; the staff at the National Strategic Institute (NSRI) at the University of Nebraska; the staff at the University of Nebraska Medical Center Global Center for Health Security National Training, Simulation and Quarantine Center; and all the participants of the workshop who—some of whom traveled significant distances—contributed to the rich and necessary discussion on HIDM. We would also like to extend our deep appreciation to Theresa Tonozzi, MPH, who served as a contractor on the mortuary affairs and helped us develop all the curriculum materials necessary for the workshop, curate existing literature and evidence-based guidance, as well as organize and analyze key findings from the workshop. Due to confidentiality, we could not list the name of all workshop attendees. However, we would like to extend our deepest gratitude for those who made time to participate in our HIDM workshop to discuss best practices, brainstorm how to best address present and future challenges, and enrich the conversation and quality of the workshop.

Disclosure statement

The findings and conclusions of this report are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Department of Health and Human Services, Assistant Secretary for Preparedness and Response, or U.S. or non-U.S. government position, policy, or decision, unless validated by other documentation. While the grant funding did not contribute to the development and distribution of this consensus statement, the program did highlight the need to explore research in this area.

Additional information

Funding

This workshop was funded as part of the “Training, Simulation, and Quarantine Transportation and Mortuary Training Program” under DHHS/ASPR (HHSO100201700005C/0007). J. Lowe was the co-Principal Investigator of this funding. A. Le and S. Gibbs served as independent contractors under this mechanism. Additionally, we acknowledge the National Institute of Environmental Health Sciences (NIEHS) Worker Training Program (WTP).