A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters (2020) / Chapter Skim
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As a disaster unfolds, these data are crucial in guiding response and recovery priorities, ensuring a common operating picture and real-time situational awareness across stakeholders, and protecting vulnerable populations and settings at heightened risk. Public health messaging shaped by accurate morbidity and mortality data is critical for communicating vital information to the public, protecting them from ongoing and future hazards, and prompting protective actions from policy makers and other leaders.
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Whether explicit or inadvertent, this can lead to controversy and confusion. Avoiding these problems requires improving processes for vital statistics, public health, emergency management and emergency response data systems; integrating these data sources with other sources of health data, including indicators of the social determinants of health (especially where morbidity data are concerned)
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• Incorporate both individual counts and population estimates to better understand a disaster's true effect. • Leverage morbidity data and mortality data to support response, recov ery, mitigation, and preparedness.
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Leadership at the federal and SLTT levels must buy-in as champions to drive lasting changes across multiple systems and overcome fragmentation. Throughout the disaster management cycle, cross-agency responsibilities will need to be adapted to meet this mission for domestic action.
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The second basic approach to estimating mortality and morbidity is to use statistical methods, such as survey, sampling, or excess mortality methods. These methods typically generate more comprehensive data than the individual counting approach -- because they inherently include both direct and indirect deaths, injuries, or illness -- and produce results that are generalizable to the population level.
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Estimates based on individual counts of deaths recorded in administrative systems are valuable for understanding the immediate impact of disasters, but their accuracy depends on the completeness with which individual cases are recorded and reported. The individual counting methods within this approach often fail to capture certain types of disaster-related deaths including individuals who would not have died but for the disaster (e.g., carbon monoxide poisoning from a poorly placed generator or a fatal heart attack during disaster cleanup)
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entities; public health agencies; and death investiga tion and registration systems. To implement this uniform framework nationally, the National Center for Health Statistics in conjunction with state and local vital records offices, medical examiners and coroners, medical certifiers, and all relevant professional associations should jointly adopt and apply this framework to practice, including the rou tine use of uniform case definitions and data collection, recording, and reporting practices.
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State and federal reporting of total mortality and morbidity estimates following disasters should use both individual counts of direct and indirect deaths and population estimates of mortality and morbidity as these data become available following a disaster. Individual count data should be referred to as reported cases or reported deaths and should not be referred to as reflecting total mortality or a death toll.
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Mortality data are currently collected and reported through a byzantine process that spans a disjointed network of federal and SLTT-level systems for death investigation and registration. No federal or nationally standardized system exists for death investigations; instead, these are carried out through a patchwork of different medicolegal death investigation systems that are governed at the SLTT level and thus vary by jurisdiction.
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Because of the variation in the types of medicolegal death investigation systems that exist throughout the United States, the qualifications of these certifiers vary from being a registered voter with a high school diploma and free of a felony conviction in some coroner systems to forensic pathologists with 4–6 years of postgraduate medical training and board certification working in medical examiner systems as autopsy physicians and public health officers (see Chapter 3 for discussion of variation in the medicolegal death investigation system)
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, should lead an enterprise-wide initiative to strengthen existing death registration sys tems to improve the quality of disaster-related mortality data at state, local, tribal, and territorial levels. These efforts should prioritize the standardization of methods for data reporting and recording and to improve the capacity of death investigation and registration systems to capture more detail on contributing causes of death following disasters.
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To promote uniformity in definitions and practices for collecting and recording disaster-related mortality data and enhance the quality and comparability of these data, NCHS should revise the Model State Vital Statistics Act to provide clear guidance and data stan dards to state vital records offices and medical certifiers. These changes should include the use of automated flags, prompts, and drop-down options to collect data on the relationship of a death to a recent disaster and provide decision-making support for medical certifiers.
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. For end users in the field of disaster management, in particular, estimates of morbidity resulting from a disaster may actually be of more value than mortality data in informing life-saving recovery, mitigation, and preparedness activities; enhancing real-time response; and providing information on health care utilization.
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, in assessing the impacts of disasters, the committee recognizes the importance of both counting individuals who die and estimating the morbidity and mortality impacts of disasters on the entire population at risk using statistical methods. Accurate counts of individual deaths can provide timely information on the scale of an event and is critical for assigning individual-level benefits, but individual counts rarely provide an adequate picture of a disaster's impact on the mortality and morbidity of the population as a whole.
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. Recommendation 4-1: Fund and Conduct Research on Analytical Methods for Population Estimates The Centers for Disease Control and Prevention, the National Institutes of Health, and the National Science Foundation should es tablish a national research program to advance analytical methods for conducting population-level estimates of mortality and morbidity related to disasters.
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• CDC and the Federal Emergency Management Agency should integrate frontline public health practitioners (e.g., epidemiolo gists and others) in the disaster response teams to help gather data and begin detailed analyses of mortality and morbidity data early in the disaster.
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• The following immediate actions should be undertaken to en sure SLTT access to and use of mortality and morbidity data: o The National Center for Health Statistics (NCHS) should code and automatically provide, with the assistance of FEMA and ASPR, location-specific, baseline mortality data and up-to-date data on disaster deaths following a declared disaster and upon request, as well as offer ready to-use tools within a set time frame following disasters to states and localities.
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Major barriers identified by the committee include the ongoing siloing of death investigation and registration systems from the disaster management enterprise, disparate levels of professional training and expertise across medical certifiers, and poor continuing education regarding attribution and recording of disaster-related deaths. Cumulatively, these shortcomings hinder the ability of the nation to procure accurate and complete individual counts of reported deaths following a disaster.
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• The National Association of Medical Examiners, the Inter national Association of Coroners & Medical Examiners, the American Board of Medicolegal Death Investigators, and state based medical examiner and coroner professional organiza tions should support the proposed framework for collecting and recording uniform mortality and morbidity data, encour age the use of existing CDC tools and guidance by all profes sionals, and provide continuing education courses for their members that reflect this guidance. • CDC, through the National Center for Health Statistics, along with appropriate licensing bodies should provide standardized training and materials designed for medical certifiers (physi cians, nurse practitioners, physician assistants, and others as applicable by state)
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Recommendation 3-5: Strengthen the Role of the Medicolegal Death Investigation and State Death Registration Systems in the Disaster Management Enterprise State, local, tribal, and territorial public health and emergency management departments should integrate the professionals and agen cies from the medicolegal death investigation and death registration systems in all aspects of preparedness and planning. This should involve the consideration of moving mortality management out of Emergency Support Function #8 (ESF8)
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3. Update of the Model State Vital Statistics Act and Regulations to facili tate more robust and uniform mortality data collection across the nation (Recommendation 3-2)
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