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Information Requirements for Disaster Victim Identification and Emergency Medical Services: Hajj Crowd Disaster Case Study.

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Disturbing crowd disaster incidents have been witnessed in every corner of the planet, which often lead to extensive difficulties, especially when they involve mass multi-nation casualties. When conducting Disaster Victim Identification (DVI) tasks, starting from finding the missing, curing the injured, and identifying the deceased, the challenge in such disasters is the lack of information to provide Emergency Medical Services (EMS) and conduct DVI in a timely manner. The literature presents fragmented solutions that can equip either post-mortem DVI or EMS with solutions to facilitate data collection and dissemination, but they do not consider a holistic solution that allows access to the victims’ right information when needed. In this paper, we analyze information needs across multi-disciplines, as well as the requirements for technical support that can help manage the identification process. Recommendations should lay a sound foundation for future multi-disciplinary research in the areas of DVI, EMS, crowd disaster, health informatics, information security and software engineering in the health sphere.
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Alsalamah, S. A. et. al
Information Requirements for Disaster Victim Identification
and Emergency
CoRe Paper Community Engineering & Healthcare Systems
Proceedings of the 15th ISCRAM Conference Rochester, NY, USA May 2018
Kees Boersma and Brian Tomaszewski, eds.
Information Requirements for Disaster
Victim Identification and Emergency
Medical Services: Hajj Crowd Disaster
Case Study
Shada Alsalamah
College of Computer and Information
Sciences, King Saud University (KSU),
Saalsalamah@ksu.edu.sa
MIT Media Lab, MIT, Shada@mit.edu
Hessah Alsalamah
College of Computer and Information
Sciences, KSU,
Halsalamah@ksu.edu.sa
Jaziar Radianti
Centre of Emergency Management, University
of Agder, Jaziar.radianti@uia.no
Sakher Alqahtani
College of Dentistry, KSU,
Asakher@ksu.edu.sa
Thamer Nouh
Trauma and Acute Care Surgery Unit,
Department of Surgery, College of Medicine,
KSU, Tnouh@ksu.edu.sa
Mohamed Abomhara
Department of Information and
Communication Technology,
University of Agder,
Mohamed.abomhara@uia.no
Ibrahim Alyahya
Emergency Medical Services,, Saudi Red Crescent Authority, Imyahya@srca.org.sa
ABSTRACT
Disturbing crowd disaster incidents have been witnessed in every corner of the planet, which often lead to
extensive difficulties, especially when they involve mass multi-nation casualties. When conducting Disaster
Victim Identification (DVI) tasks, starting from finding the missing, curing the injured, and identifying the
deceased, the challenge in such disasters is the lack of information to provide Emergency Medical Services
(EMS) and conduct DVI in a timely manner. The literature presents fragmented solutions that can equip either
post-mortem DVI or EMS with solutions to facilitate data collection and dissemination, but they do not consider
a holistic solution that allows access to the victims right information when needed. In this paper, we analyze
information needs across multi-disciplines, as well as the requirements for technical support that can help
manage the identification process. Recommendations should lay a sound foundation for future multi-disciplinary
research in the areas of DVI, EMS, crowd disaster, health informatics, information security and software
engineering in the health sphere.
KEYWORDS
Crowd disaster, Disaster victim identification, Emergency medical services, Hajj stampede, Information
security.
Alsalamah, S. A. et. al
Information Requirements for Disaster Victim Identification
and Emergency
CoRe Paper Community Engineering & Healthcare Systems
Proceedings of the 15th ISCRAM Conference Rochester, NY, USA May 2018
Kees Boersma and Brian Tomaszewski, eds.
INTRODUCTION
As the worlds largest gathering (Ministry of Health (MoH), 2017), approximately 4 million pilgrims from more
than 50 countries around the world travel to the holy city of Mecca to complete the Hajj rituals (i.e. Islamic
Pilgrimage to Mecca). In these overcrowded conditions, human stampedes can occur, resulting in many injured
people. Over the years, crowd incidents have happened on both a small and large scale during Hajj
(Manoochehry and Rasouli, 2017). Moreover, being in a crowd is a situation that often cannot be avoided in our
daily life. Some types of crowds are ad-hoc, such as riots or crowd attacks, but another type of crowd is
voluntary, such as when someone is attending a football match or political event, during transportation or a
funeral procession of famous people, or concerts in a large hall. Identifying the injured, dead or missing people
in a crowd disaster is an elusive, complicated and time-consuming task. Many crowd studies have recognized
that the forces of a massive gathering are almost impossible to control; fatal incidents occasionally occur, and
the emergency response has been challenging (Ngai, et al., 2009; Santos-Reyes and Olmos-Peña, 2017).
The major challenge facing DVI and EMS teams in multi-national situations is the collection of the right
information about the victims to find those missing, cure those found, and identify the deceased. Due to victims’
demographics and the involvement of multiple stakeholders, governments are left with no option but to request
help from external intergovernmental organizations, such as Interpol, to manage multi-DVI and EMS teams for
each nation with victims involved. First and foremost, Interpol, as well as local police investigators, follow a
traditional approach towards identifying missing persons in such open disasters, where families and friends
report missing people by completing lengthy forms with fine-grained details about any identifiable information
they can possibly record to help find them; examples in (Interpol, 2013a, 2017a). Some researchers have
proposed a solution to address missing persons list identification and generation. Manoochehry and Rasouli
(2017) suggested an early warning deployment of computerized software systems and camera monitoring,
which can identify lost pilgrims, update their locations, and alert their group guide. However, those solutions are
limited to the number they can manage at once. In addition, they are more victim rather than disaster-oriented,
which renders them effective to search for a particular victim and it does not automatically generate a missing
persons list for a particular disaster. Second, EMS provision for injured victimsneeds to be done in a timely
manner as time is critical. Therefore, paramedic teams need to access victim-related medical information
immediately to provide healthcare services to victims; without these details, informed decisions (as simple as
blood transfusion) cannot be made to decide the best way to save the victims life. Therefore, several articles
have suggested the enhancement of health and management approaches, such as an intervention (Salamati and
Rahimi-Movaghar, 2016), health responses (Shujaa and Alhamid, 2015), and management of injured victims
(Ganjeh and Einollahi, 2016). Third, DVI is “the formal process whereby multiple individuals who have died as
a result of a single incident have their identity established through the application of scientifically proven
techniques (Victoria Institute of Forensic Medicine, 2014). Therefore, DVI plays a significant role!in
identifying deceased victims, where experts with different backgrounds and specialties need to collaborate in the
case of a disaster.
When a major disaster occurs with mass fatalities, such as the Hajj stampede, the process of identifying victims
is rarely possible by visual recognition (Interpol, 2017a), and thus often requires obtaining a conclusive
identification through fingerprints, dental records, facial recognition, or DNA samples comparison with ones
already stored in databases or taken from victims’ personal belonging reference (Interpol, 2017a) and biological
samples from the victims’ families (Ritter, 2007). However, research is limited regarding DVI needs, and how
to find information promptly on victims of Hajj crowd incidents. Currently ante and post-mortem information is,
to a certain degree, still performed manually, and solutions in the literature mostly focus on helping post-
mortem DVI teams in recording data collected from deceased victimsremains, such as in (Colville-Ebeling et
al., 2014), but no research so far has focused on how to collect ante-mortem data and automate the comparison
for the identification. Furthermore, some solutions are limited to a specific number of victims and are neither
fast nor accurate, which renders them ill-equipped for investigations of mass fatalities incidents (Levinson and
Domb, 2016). Finally, the lack of comprehensive solutions that would allow the availability of the right
information for the DVI and EMS hampers them from achieving their tasks. Technology is one of the solutions
that can mitigate the risk of deadly crowd incidents during Hajj, but the existing technology solutions are
fragmented to focus on one team’s needs, and lack a holistic solution that would equip DVI and EMS with the
technology needed to achieve their goals in a timely manner.
In this paper, we use Hajj as a case study to investigate the information, as well as the technical needs for DVI
and EMS teams to find the missing disaster-victims, cure the injured, and identify the deceased. The
contribution of this paper is threefold. First, it identifies victims associated with a disaster, and classifies them
into victims identification status lists. Second, it defines the set of information criteria required by the DVI and
EMS teams for each victim status; Third, it identifies a set of required features of alternative technology to
Alsalamah, S. A. et. al
Information Requirements for Disaster Victim Identification
and Emergency
CoRe Paper Community Engineering & Healthcare Systems
Proceedings of the 15th ISCRAM Conference Rochester, NY, USA May 2018
Kees Boersma and Brian Tomaszewski, eds.
accelerate the DVI and EMS tasks and minimizes casualties and loss and it assesses security and privacy risks
that may arise due to the collection, processing and usage of the victim’s data. The remainder of this paper is
organized as follows. The Hajj Ritual section explains the basic information of Hajj rituals and common crowd
disaster risks. The following section summarizes the literature review and methodology. The DVI current
practices section presents the analysis of the information needs. The methodology section defines the research
approach, following which, the results section presents the results from the analysis and lists the set of
recommendations for future research. The following section, technical challenges, discusses in detail the
opportunities proposed by seamless sharing, suggests information security risks, and raises privacy concerns at
the same time. Finally, a conclusion is drawn in the last section along with suggestions for future research.
BACKGROUND AND LITERATURE REVIEW
Hajj Ritual Pathway
Hajj ritual involves ten tasks to be completed by all pilgrims in about four consecutive days in five different
geographical locations (most of them are limited in terms of their space) representing a pathway: Migat, The
Holy Mosque (also known as Al-Masjid Al-Haram), Mina, Arafat, and Muzdalifah. In order to illustrate the Hajj
ritual process followed by pilgrims, we modeled their journey using Business Process Modeling Notation
(BPMN). Figure 1 shows the Hajj ritual journey including: different sites, processes, order, and time restrictions
for each move. Tasks are described in detail based on each day as follows:
Figure 1 Hajj Ritual Journey
Day One
Hajj is initiated by reaching the Miqat before entering the holy city, Mecca. It is one of the points where the
state of Hajj starts. Once pilgrims are ready, they head next to Al-Masjid Al-Haram to perform three tasks:
Tawaf, (i.e. going around Kabah seven times in a defined manner), a prayer, and Sai (i.e. walking quickly
between two small hills, Safa and Marwah). Thereafter, the pilgrims travel to Mina where they spend the night
on this first day.
Alsalamah, S. A. et. al
Information Requirements for Disaster Victim Identification
and Emergency
CoRe Paper Community Engineering & Healthcare Systems
Proceedings of the 15th ISCRAM Conference Rochester, NY, USA May 2018
Kees Boersma and Brian Tomaszewski, eds.
Day Two
Pilgrims travel 20 km by public transportation from Mina to the mountain of Arafat where they keep praying
until sundown. After sunset, they leave for Muzdalifah and stay overnight to collect stones for their next tasks.
Days Three and Four
Pilgrims return to Mina to perform the symbolic throwing of stones at the first pillar representing the
temptations of the Devil. Afterwards, the pilgrims return to Mecca to conduct the second Tawaf, return to Mina
to spend the third and fourth days stoning the second and third pillar consequently, repeating the symbolic
throwing of stones, and then return to Mecca for bidding farewell to Tawaf, before finally leaving Mecca.
During the Hajj, pilgrims are exposed to many risks and incidents, as a large number of pilgrims need to strictly
follow the Hajj ritual journey at the same time. Risks and incidents include: fire incidents, crushes, injuries and
stampedes, as well as infectious disease outbreaks (MoH, 2017). Two of the most prominent Hajj crowd
incidents occurred in July 1990 and September 2015 (Ganjeh and Einollahi, 2016). In 2015, the whole world
witnessed the deadly stampede incident which occurred in Mina when the pilgrims were conducting the stoning
of the pillars; this killed a total number of 1,849 pilgrims (The_Guardian, 2015a), and that was not the first time
Hajj had been marred by crowd-related accidents and tragedies (The_Guardian, 2006; 2015b). In 1990, a
stampede happened inside a pedestrian tunnel leading out from Mecca towards Mina.
Religious Events and Crowd Incidents
Disasters during mass gatherings have repeatedly occurred throughout history. Soemaroo and Murray (2012)
examine mass gathering disasters that occurred between 1971-2011. There were some major disaster crowds
with mass casualties, such as a crush between fans entering and exiting an event venue; crowd surge and
crushing; fireworks causing a fire; stairways fires in front of emergency exits; overcrowding of fans leading to a
stampede. Crowd disasters frequently occurred in large events such as football matches, Olympic games, music
festivals, firework events, and religious events, such as Hajj. The reasons for the mass casualties were various,
but Soemaroo and Murray (2012) conclude that there are five categories of the causes of crowd disasters:
overcrowding and crowd control, event access point, inadequate fire safety measures, medical unpreparedness
and slow emergency response. Overcrowding could happen because of tickets being oversold for big events,
such as football matches and music festivals, poor estimation of crowd numbers, and efforts to control crowds
using tear gas leading to panic and human stampedes. Sometimes, crowd disasters are caused by a lack of safety
measures, such as fire protocols or delays in emergency response (Soemaroo and Murray, 2012). At times, EMS
could not access the disaster site causing response delay, such as in the Ramstein airshow disaster (Martin TE.,
1990), or there were no routes available for the responders to reach the stampede location.
Religious events and crowd incidents such as Hajj crowd disasters have been the subject of scientific
investigation related to crisis management (Helbing et al., 2007), which is considered equally as important as
other crowd research on religious gatherings, such as the stampede case in the Kumbh Mela (Greenough, 2013),
or examples of various human stampede cases during religious festivals in India (Illiyas et al., 2013). The Hajj
disaster in 1990, causing the death of 1,426 pilgrims, occurred when they spontaneously rushed to leave Mecca
via one exit. Such major crowd disasters have occurred many times and there are similarities in these major
events, i.e. missing people or fatalities.
Numerous studies suggest the use of technical solutions to improve the management of Hajj or to better prepare
in case of disaster, such as: crowd-sourced data collection and context aware services, big data cloud computing,
intelligent shelter allotment for evacuation planning, pilgrimage tracking using both RFID and mobile
systems/wireless devices, and multimedia surveillance event detection. Ahmad et al. (2014), for instance,
suggest a spatio-temporal ritual service HajjNUmrah framework that exploits smartphone sensors to locate
pilgrims, sense the environment, geo-tag people with severe health issues and social networks tailored to the
Hajj ritual. In a normal situation, such applications may enable people stay connected and allow them to call in
case of emergency, but they are not at all effective in identifying the injured or deceased in a crowd disaster.
SmartCrowd (Ali et al., 2015) is a mobile cloud computing system that offers information and communication
services during the Hajj. The data from pilgrims’ smartphones can be used for locating high-density
concentration points to be analyzed and mapped. However, there is no further information on the
implementation part of SmartCrowd. Similarly, multimedia surveillance event detection is suggested as an
alternative technology by Al-Salhie et al. (2014). A smartphone-based Hajjlocator (Mantoro et al., 2011) is
proposed to solve the issue of missing pilgrims. The prototype of the mobile application is designed in such
way that one can track and monitor individuals in a crowd. Both SmartCrowd and multimedia surveillance are
useful features that allow EMS to remain alerted regarding potential crowd disasters from different areas with
Alsalamah, S. A. et. al
Information Requirements for Disaster Victim Identification
and Emergency
CoRe Paper Community Engineering & Healthcare Systems
Proceedings of the 15th ISCRAM Conference Rochester, NY, USA May 2018
Kees Boersma and Brian Tomaszewski, eds.
high-density locations. Likewise, tracking people is possible through Hlocator and this is mostly useful for
groups conducting Hajj together. Other solutions focus on wireless communication sensor networks to provide
assistance to pilgrimages (Alwakeel et al., 2014). A crowd controller has been proposed (Yamin and Albugami,
2014) for monitoring transportation, health care services, ritual services, security services and improvement of
Hajj management. Meanwhile, intelligent shelter allotment for emergency evacuation has been proposed (Yang
et al., 2015) for pre-planning under various evacuation scenarios, which will contribute significantly towards
improved emergency management. However, in the literature, how to improve victim identification when
disasters actually occur remains unsolved.
DVI, Forensic Practices and Technologies
Although there is extensive literature focusing on how to improve crowd Hajj management, there is very limited
research dedicated to DVI on large-scale crowd tragedies such as in Hajj or other religious gatherings, even
though both issues are equally important. DVI is part of humanitarian and legal responsibility where
investigators should identify every individual, when possible, so that the victims can be returned to their family
to help with their grief (Interpol, 2017b). Victim identification is, indeed, part of forensic medicine and crime
investigation. However, there were variations from time to time regarding how victim identification should be
conducted, as explained by De Alwis (2011). There was a period where the post-mortem identification was not
performed in the field, and should only be performed by a medical officer. Later, on-scene investigation was
introduced where the expert (a medical officer) would observe the scene, take notes and photographs, and carry
out basic medico-legal investigations, but not carry out the post-mortem examination. Afterwards, the first
personnel to arrive at the scene where a dead body is lying are specially trained police officers to preserve the
scene and conduct relevant investigations until the arrival of senior police investigators, the magistrate, medical
officer and forensic scientist. Most of these techniques are valid for individual forensic investigations. The DVI
for mass causalities was introduced later, which means that in previous mass tragedies involving numerous
victims, such as tsunami disasters, airplane crashes, and crowd tragedies, the majority of victims were not
identified.
Modern technology introduced new techniques, such as photographic evidence, X-ray for mortuary, DNA
technology and other means for identification, such as fingerprint, eye print, handprint, leg-print. Post Mortem
Computed Tomography (PMCT) scanner (Morgan et al., 2014), radiography and fluoroscopy (Viner et al.,
2015) are used for mass casualties. Dental radiographs/forensic odontology is a robust alternative for human
forensic identification (Rindhe and Shaikh, 2013), used when other information is not available. In forensic
odontology, the victim identification is performed based on dental features, as teeth are parts of the human body
that are not easily damaged, and this is considered as a reliable tool for DVI. There are numerous suggestions
introduced to improve forensic odontology. Debbarma and Nath (2014), for instance, suggest a contour and
skeleton-based shape extraction used in matching algorithms for dental radiographs. The DVI has recently
gained more attention as part of forensic techniques. However, in the existing literature, how resource and time
intensive DVI can be applied during mass fatalities such as the Hajj crowd disaster remains unresolved. In the
following sections, we briefly introduce the development of DVI and existing standards and regulations.
DVI Current Practice
The Hajj stampede, similar to many other large-scale crowd disasters, is a subject of international investigation
as the victims are often citizens from multiple countries. The International Criminal Police Organization (ICPO)
or Interpol, is an intergovernmental organization facilitating international police cooperation, making it the
world’s largest international police organization, bringing 192 members to represent their countries under its
umbrella (Interpol, 2017c). When a major disaster occurs, one country alone may not have sufficient resources
to deal with mass casualties. In some cases, the incident may have damaged or destroyed the country’s existing
emergency-response infrastructure, making the task of victim identification even more difficult. Therefore,
Interpol established the first working party on DVI in 1982 to tackle this challenging issue (Interpol, 2017a).
The first Interpol DVI Guide was issued in 1984 and was subsequently revised over several years, and the most
recent one was published in 2014 (Interpol, 2017a).
DVI is the formal process whereby multiple individuals who have died as a result of a single incident have their
identity established through the application of scientifically proven techniques (Hallam et al., 2005). Therefore,
DVI plays a crucial role in law enforcement criminal investigations and interrogations. When a major disaster
occurs with mass fatalities, the process of identifying victims is rarely possible by visual recognition (Hallam et
al., 2005), and thus DVI often requires obtaining a conclusive identification. Furthermore, DVI teams work
collaboratively, in an interdisciplinary manner, engaging the services of experts in various disciplines towards
the identification of victims. DVI teams are encouraged to cooperate with other national DVI teams. Currently,
Alsalamah, S. A. et. al
Information Requirements for Disaster Victim Identification
and Emergency
CoRe Paper Community Engineering & Healthcare Systems
Proceedings of the 15th ISCRAM Conference Rochester, NY, USA May 2018
Kees Boersma and Brian Tomaszewski, eds.
the basis for coordination and response that require DVI includes: first, Legislation, Jurisdiction and National
Conventions; second, Interpol DVI Standards; and finally, Command and Control arrangements. The DVI
process consists of four phases (see Figure 2):
Phase 1- Scene
The team investigates the human remains and property at the disaster site.
Phase 2- Post-Mortem (Victim Data)
The team conducts a detailed examination of human remains in the mortuary. It collects detailed data, such as
fingerprints and skeleton sketches, in addition to the data that are collected during Phase 3 (See Ante-Mortem
data).
Phase 3- Ante-Mortem (Missing Person Data)
The team collects missing person data from various sources. This task is initiated with collecting and recording
all information related to individuals who may be regarded as potential disaster victims (Interpol, 2013). This
process starts only when a victim has been identified as missing. The data can be collected from the missing
person’s family, relatives, and/or friends.
Phase 4- Recognition
The DVI teams match/cross reference post-mortem and ante-mortem data. The combination of Victim Data and
Missing Person Data will lead to Identification, and conducting recognition. Victim Identification is done by
preparing a list of special Ante-Mortem and Post-Mortem key markers for bodies using only particularly
noteworthy features of a missing person or body recorded in a list.
DVI teams consist of the following experts:
Photographers, Radiologists and Interview Teams
Property Managers
Scene and Post-Mortem Recorders and Quality Assurance Teams
Evidence Collection and Management Teams,
Mortuary Managers
Investigators, Logistics, Liaison and Missing Persons Officers
Information Technology Specialists
According to Interpol (2014), disasters can naturally be classified as open or closed, looking at it from the DVI’s
perspective. On the one hand, an open disaster is a catastrophic event resulting in the death of unknown
individuals for whom no prior records or descriptive data are available. The Hajj stampede is an example of an
open disaster. A closed disaster, on the other hand, is an event where there has been the death of a number of
individuals belonging to a fixed, identifiable group (e.g. aircraft crash with a registered passenger list). DVI in
an open disaster is more challenging and requires both technology and expertssupport.
In Europe, the FP7 EU funded project FASTID has introduced an international Missing Persons and
Unidentified Dead Bodies (MPUB) database in Interpol secretariat (Interpol, 2013b). FASTID was created due
to the unavailability of a centralized database at both regional and international level. Even if the data existed in
Figure 2. The DVI Process (Interpol, 2017a)
Alsalamah, S. A. et. al
Information Requirements for Disaster Victim Identification
and Emergency
CoRe Paper Community Engineering & Healthcare Systems
Proceedings of the 15th ISCRAM Conference Rochester, NY, USA May 2018
Kees Boersma and Brian Tomaszewski, eds.
some regions, the database was not interlinked. MPUB database allows for searching of items such as DNA and
dental records. It also integrates its interface with other databases, such as fingerprints (Interpol, 2013b), which
greatly supports the DVI tasks. However, in crowd incidents such as the Hajj, the situation is more complicated
as there are many nationalities involved, and thus the biometric data is not always available in such databases
for all countries. Also, the victims could be from countries that have no link to MPUB.
Current Forensic Practice in Saudi Arabia
Concerning the legislation related to forensic identification process in Saudi Arabia, Alqahtani et al. (2017)
identify that there are two relevant government agencies involved in such cases, i.e. The MoH and The Ministry
of Interior (MoI). The MoH, on the one hand, is the main regulator of forensic issues and the party responsible
for the technical supervision of forensic activities in the country. The Ministry issues a set of instructions and
procedures to guide the doctors performing forensic duties. On the other hand, the MoI conducts the
investigations, arrests the perpetrators, and establishes the claims before the courts. However, they work
exclusively, where each department establishes its own protocol in dealing with the forensic investigation.
Alqahtani et al. (2017) list several issues regarding current forensic practice in Saudi Arabia:
No clear national guidelines or protocols for personnel dealing with forensic cases (photographs,
radiographs, descriptive report or methods to be used).
No protocols in the hospitals on reporting or documenting cases that arrive during the emergency.
No standardized report forms to describe the detailed cases to the court and typically they are sent
directly to the judge without the need for the expert witness to attend.
No references and limited accuracy.
No minimum and maximum range of age estimation reports or the method used to reach that
estimation.
In addition, when applying forensic odontology techniques, official forensic forms that document oral findings
are available in Arabic only, and do not include the complete dental status. Tooth abbreviations, color
distinction, supplementary examination, types of radiographs taken and methods used in the analysis are not
documented. In brief, there are huge challenges in handling mass fatalities as DVI is not fully supported by
current legal practice, and can lead to inefficiency in the DVI workflows.
Finally, this section clearly identifies the number of fragmented solutions that can equip post-mortem DVI to
help with the data collection and dissemination. It also identifies the gap in the literature that needs to be bridged
with a holistic solution that allows for victimsappropriate information to be accessed by the right team member
at the right time.
METHODOLOGY
Initially, the information requirements identification for DVI and EMS followed the requirement elicitation and
analysis cycle in Figure 3 (Sommerville, 2016). This requirement elicitation and analysis cycle involved
stakeholders with different areas of expertise to discover, classify, organize, prioritize, negotiate and specify
these requirements.
Figure 3. Requirement Elicitation and Analysis Cycle (Sommerville, 2016).
The methodology involved the following key phases:
Alsalamah, S. A. et. al
Information Requirements for Disaster Victim Identification
and Emergency
CoRe Paper Community Engineering & Healthcare Systems
Proceedings of the 15th ISCRAM Conference Rochester, NY, USA May 2018
Kees Boersma and Brian Tomaszewski, eds.
Define the complete Hajj process in terms of activities, locations, users, and information requirements.
Design and model the scenario of the Hajj ritual using BPMN to illustrate the process and the
challenges it includes (see Figure 1).
Classify victims in a disaster into four scenarios based on the identification stage lists: Alive and Well,
Alive and Injured, Indirect Confirmation through an emergency contact, and Missing person.
Discuss and revise challenges for each class of victims as seen by DVI and EMS teams in worse case
scenarios.
Identify the gap.
Validate the requirements.
Within discussion groups, the initial requirements were refined to generate the requirement specifications. A
total of at least sixty-seven hours of brainstorming sessions were conducted jointly and individually with experts
in thirty-three fields over the course of sixteen months distributed as listed in Table 1 and 2:
Table 1 Fields of Expertise
Total Fields of
Expertise
Team Member Expertise
Total number
33
Physicians
2
Health informatics experts
2
Information security experts
4
Computer scientists
8
Saudi Red Crescent authority representatives
7
DVI Dentals team members from Saudi Arabia,
Italy, Australia, and Brazil.
4
Disaster Mortuary Operational Response Team
(DMORT) members from USA
2
Members of Interpol and one forensic
deontologist.
4
Table 2 Contact Hours with Discussion Groups
Discussion Groups
Total hours
Specific hours
Specific Team
67 h
34 h
EMS
33 h
DVI
These results include a set of information requirements for DVI and EMS to allow them to find the missing,
rescue the injured, and identify the deceased.
RESULTS
This section summarizes the results from the analysis and synthesis we performed on the primary and secondary
data collected from the experts in eight different fields. The results present the classification of victims, as well
as the classification of information required by the DVI and EMS teams in Hajj crowd incidents and discusses
the technical challenges.
Victims Identification Lists
According to the Interpol guide (Interpol, 2017a), missing persons’ lists cannot be confirmed until forty-eight
hours from when the disaster happens. Therefore, and in order to generate a final missing persons list for DVI
teams, a list of victims in an identified disaster must be added to one and only one of the following four lists
shown in Table 3 below.
Alsalamah, S. A. et. al
Information Requirements for Disaster Victim Identification
and Emergency
CoRe Paper Community Engineering & Healthcare Systems
Proceedings of the 15th ISCRAM Conference Rochester, NY, USA May 2018
Kees Boersma and Brian Tomaszewski, eds.
Table 3 Victims' Lists and Descriptions
No.
List Name
List Description
1
Alive and Well List
Victims who are found alive within the first 24 hours and do not need any
medical attention.
2
Alive and Injured List
Victims who placed an S.O.S. call within the first 24 hours and need medical
treatment.
3
Pending Confirmation List
Victims who did not place an S.O.S call within 24 hours, and before the
following 48 hours pass, an emergency contact is contacted to request the
whereabouts of the identified victim and his/her health status. If the
emergency contact has already responded and supplied updated information
about the targeted victim, this is listed in this list.
4
Missing Persons List
Victims who were neither reached within the first 48 hours nor their
emergency contact reached, are considered missing.
Information Requirements for DVI and EMS Teams
For each victim in any of the three lists, specific information needs to be accessed by either the DVI team or
EMS team. This information is classified based on the task needed for the victim’s case, whether because he/she
is missing, injured, or deceased. This is shown below in Table 4.
Table 4 Summary of Information Requirements for DVI and EMS Teams and Access Control Rights
Information Required
Victim’s case task
Task Purpose
Access
Control
Rights
Cure the
found
Find
the
missing
Identify
the
deceased
Medical records
Medical treatment, first aid
EMS teams
Blood type
Medical treatment, first aid
Family members
Help find victim and/or return them to
the family
Affected person lists
Medical treatment, first aid
Alive/injured list
Help responding to victims within
24h
Pending confirmation lists
Contact next kin if no response after
24h-48h
DVI teams:
law
enforcement
officials,
deontologists,
DNA and
fingerprint
specialists
Missing person list
If no response from victim and next
of kin after 24-48h, missing person
will be listed as missing
Victim’s registered
information (dental x-ray,
dental work, fingerprints)
Post/Ante-Mortem
Basic information of the
victims
Ante-Mortem
Body description (weight,
height, eye colors)
Post/Ante-Mortem
Pathology
Post-Mortem
DNA (blood from the core of
the body, deep muscle tissues,
bones or teeth)
Post-Mortem
Skeleton sketch
Post-Mortem
Original medical/dental
record, medical practitioners
and dentists consulted by
missing person
Ante-Mortem
Blood samples from
parents/children of missing
persons
Ante-Mortem
Alsalamah, S. A. et. al
Information Requirements for Disaster Victim Identification
and Emergency
CoRe Paper Community Engineering & Healthcare Systems
Proceedings of the 15th ISCRAM Conference Rochester, NY, USA May 2018
Kees Boersma and Brian Tomaszewski, eds.
Technical challenges: Security and Privacy Risks
Table 4 shows the information criteria required and the access rights for the EMS and DVI teams which could
be used as guidelines for the list of features required, including functional and non-functional requirements for
software and technical solutions of mobile applications on mobile or wearable devices to connect victims with
DVI, EMS, and rescue teams in real time to allow them to find the missing, cure the injured, and identify the
deceased. For the different actors, the tasks and information needs are as follows:
Victims; place an S.O.S emergency call in the event of an incident.
Rescue teams; access a list of injured victims and share their geo-location and medical information
with the local rescue team to prepare for EMS who provides medical treatment.
DVI teams; access a list of victims “last seen” within a close range of the identified disaster and share it
along with their geo-location with the local DVI teams to try to find them and have access to their
essential identifiable information to speed up the identification of victims.
EMS teams; access list of injured victims and their medical information.
Access Vs. Privacy
Although the above solution encourages openness and seamless sharing to paint a full picture that would allow
each team to perform their tasks, it nevertheless raises information security and privacy concerns that could
hinder its adoption. As mentioned above, different teams require specific victim-related information at various
victim identification stages. Even though the need for personal identifiable information may improve the quality
of DVI work, the digitization of such information poses new privacy and security threats. Such threats include,
among others, first, improper disclosure of sensitive information by privileged DVI professionals. Second, there
is the threat of unauthorized access to personal information by persons taking advantage of the DVI
environment, and finally, cyber criminals could gain access to valuable data such as health information.
Information security and privacy are major concerns for individuals and DVI team members worldwide. For
instance, if we consider the medical information of victims (shown in Table 2), Vodicka et al. (2013) carried out
a survey on online access to patient records and found that approximately one-third of participants were
concerned about the security and privacy of their health records, particularly regarding who should have access
to which item of health information. Furthermore, according to a survey by IBM and the Ponemon Institute in
2017 (US Department of Health and Human Services, 2017), many breaches involve personal information, such
as protected health information theft, loss or improper disposal of medical records, and unauthorized access to,
or disclosure of, health information. The above-mentioned findings demonstrate that it is essential to address
security and privacy concerns regarding personal information. Furthermore, there is global governing legislation
with which such a solution must comply. Such legislation has defined access restrictions to protect patient
privacy and means of processing health records securely. Moreover, the Health Insurance Portability and
Accountability Act” (HIPAA) is an American legislation to ensure that health information is protected
adequately while allowing the necessary flow of health information for providing and promoting high-quality
healthcare (Nosowsky and Giordano, 2006, U.S. Department of Health and Human Services, 1996).
Furthermore, Europe has similar legislation, including the EU directive (EU Directive 95/46/EC) (Directive,
1995) on the protection of individuals with regard to the processing of personal data and the free movement of
such data. The General Data Protection Regulation (GDPR) (European Commission, 2016), adopted in April
2016, will supersede the EU Directive 95/46/EC and will be enforceable from 25 May 2018. Such standards
and legislation also provide security and privacy suggestions to address the need to protect personal information.
However, to establish more secure and readily available services to DVI and EMS teams, there are many
security and privacy challenges to overcome in the technical solution. Among those challenges are:
User privacy and data protection
Authentication and identity management
Trust management and policy integration
Authorization and access control
A number of concerns would be raised by the proposed solution, and so it is important to ensure secure use and
sharing of victims’ personal identifiable information. This is particular to such solutions when diverse
stakeholders need access to fragmented, confidential information in a timely manner to gain a holistic view of
cases under investigation. A major concern would be how to prevent privileged DVI teams from disclosing
sensitive information improperly. A second concern regards to malicious users taking advantage of the DVI
environment by having unauthorized access to personal information such as health information, among others.
Improper disclosure or unauthorized access may occur when someone within the DVI team accesses shared
Alsalamah, S. A. et. al
Information Requirements for Disaster Victim Identification
and Emergency
CoRe Paper Community Engineering & Healthcare Systems
Proceedings of the 15th ISCRAM Conference Rochester, NY, USA May 2018
Kees Boersma and Brian Tomaszewski, eds.
information for unethical reasons, for instance, accessing a victim’s health information for personal gain. In
overcoming authorization and improper access matters associated with DVI, access control models, such as
role-based access control (RBAC) (Ferraiolo, et al., 2001), attribute-based access control (ABAC) (Hu, et al.,
2015) and others, may prove to be the answer. Access control is critical to the successful adoption of this
solution to manage problems related to unauthorized and improper access.
CONCLUSION AND FUTURE WORK
Disaster incidents have been witnessed in every corner of the planet, and the world has mourned for victims
affected by crowd and natural disasters, as well as acts of war and violence. Crowd disasters with mass multi-
nation casualties often lead to vast difficulties and challenges, especially when conducting DVI tasks starting
from finding the missing, curing the injured, and identifying the deceased. Frequently, such mass gatherings
involve multiple citizenships, such as in the largest annual gathering, the Hajj, which is much more complicated
to manage in the case of a disaster. Unlike closed gatherings, such as an airplane crash accident, for instance,
when passengers are mostly well registered and accounted for, the main challenge in crowd disasters is the lack
of medical information for rescue teams to provide EMS in a timely manner, as well as, identifiable information
for ante- and post-mortem DVI teams of police investigators, DNA and fingerprint specialists, and odontologists
to perform their tasks to bring justice to victims and closure to their families. This makes it an elusive,
complicated, and time-consuming task that leads to the increasing number of causalities in such urgent
situations, when time is critical to disaster victims. Practitioners have acknowledged the need for technical
support for victim identification in such multi-nation mass casualties, especially in Hajj.
The literature offers a number of fragmented solutions that can equip either post-mortem DVI or rescue teams
with solutions to assist with data collection and dissemination, but they do not consider a holistic solution that
allows for victimsrelevant information to be accessed by the right team member at the right time. In this paper,
we used requirement engineering and business process modeling notations to analyze information needs across
multi-disciplines, as well as the requirements for technical support that can help manage the identification
process and analyze certain practical challenges that face such solutions with the benefit of insight gained from
the Hajj case study. The requirements were refined with experts in nine specialties to identify: the information
criteria required by DVI and EMS teams from each victim stage, the set of required features of a supportive
technology to speed-up tasks and minimize causalities and loss, and the security and privacy risks. Results show
that victims in the Hajj crowd disaster could be classified into either missing, injured, or deceased. Furthermore,
each of those classifications represents a case which requires specific information that must be granted to a
specific team in order to achieve the goal of that particular case. However, access control is critical to the
successful adoption of this solution as a holistic view is required on each victim under investigation. A set of
features is required by the DVI, EMS and rescue team to operate. For each DVI and EMS team member,
information disclosure should be carefully studied to ensure they only retrieve the required information at the
time they need it. Finally, the set of recommendations outlined in the results should lay a sound foundation for
future multi-disciplinary research in the areas of disaster victim identification, medical emergency services,
crowd disaster, health informatics, and information technology in the health sphere. Suggested future work
includes the use of the requirements identified in this research to develop an alternative technology that can
support faster response? in mass casualties such as the Hajj crowd incidents. With such a tool, the security and
privacy risks could be identified, as a technical concern should also be considered to facilitate the
implementation of a solution and overcome the current technical challenges. The solution should mainly focus
on the technology that can help the EMS and DVI teams to respond faster in terms of finding the missing,
curing the injured, and identifying the deceased.
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