Dead Bodies and Disasters: Dead Bodies and Disasters: Principles of Mortuary Principles of Mortuary

ServicesServices

Amado Alejandro Baez MD MSc EMT-PAmado Alejandro Baez MD MSc EMT-P Brigham and Women’s Hospital / Harvard Medical Brigham and Women’s Hospital / Harvard Medical

SchoolSchoolaabaez@partners.orgaabaez@partners.org

Senior Advisor National Directorate of Emergencies and Senior Advisor National Directorate of Emergencies and DisastersDisasters

Dominican Republic State Secretary of Public Health and Dominican Republic State Secretary of Public Health and Social AssistanceSocial Assistance

"We were working for the living, and now we are working for the dead and the living," "It's pretty tough, pulling out dead bodies." A Louisiana State Medical officer referring to the devastating aftermath of the August 2005 hurricane Katrina

ObjectivesObjectives

At the end of this lecture the participant At the end of this lecture the participant will be able to:will be able to:

Understand the basic principles of the Understand the basic principles of the management of dead bodies in disasters.management of dead bodies in disasters.

Review important epidemiological issues Review important epidemiological issues related to mass dead bodies.related to mass dead bodies.

Understand principles of cadaver Understand principles of cadaver identification.identification.

Review techniques of dead body disposal Review techniques of dead body disposal in disasters.in disasters.

Cadaver Recuperation Process Cadaver Recuperation Process

SearchLocalize

Transport

Temporary deposit

and Analysis *

Final Disposition

Release to relativesE

VE

NT

Fo

llow

Up

Coordination and Communication

Stages of the Process

Equipment for mortuary Equipment for mortuary services in major disastersservices in major disasters

Stainless steel postmortem tables covered with plastic Stainless steel postmortem tables covered with plastic Wheeled trolleys for transportation within the mortuary.Wheeled trolleys for transportation within the mortuary. Plastic sheeting for the floor.Plastic sheeting for the floor. Heavy-duty black plastic sheeting for temporary screens.Heavy-duty black plastic sheeting for temporary screens. Refuse bins and bags.Refuse bins and bags. Cleaning materials – mops, buckets, cloths, soap, towels.Cleaning materials – mops, buckets, cloths, soap, towels. Disinfectant and deodorizer.Disinfectant and deodorizer. Protective clothing and heavy-duty rubber gloves.Protective clothing and heavy-duty rubber gloves. Translucent plastic body bags 0.1 mm thick and labels. Translucent plastic body bags 0.1 mm thick and labels. Wall charts to record progress or large poster boards Wall charts to record progress or large poster boards

if there are no walls. if there are no walls.

Coordination & Coordination & SupportSupport

Body Recovery

Communities, volunteers, NGOs, police, military

IdentificationDoctors, medical staff, forensic specialists,

foreign embassies, INTERPOL, NGOs

Death certification

Coroners, police

Disposal Military, police, local authorities

Body RecoveryBody Recovery Initial element in the cadaver management Initial element in the cadaver management

process.process. Can be initially chaotic and extremely Can be initially chaotic and extremely

distressful.distressful. Need to involve search and rescue groups. Need to involve search and rescue groups. Need for tagging bodies (name location Need for tagging bodies (name location

etc..) to allow further identification.etc..) to allow further identification.

Equipment can be diverseEquipment can be diverse– Basic usually in the initial phaseBasic usually in the initial phase

Volunteers, wheel barrelsVolunteers, wheel barrels– Advanced after improved resourcesAdvanced after improved resources

Trucks, planes busesTrucks, planes buses

Storage and Body Preservation

Storage IssuesStorage Issues

Without proper storage, Without proper storage, bodies may began to bodies may began to decompose early depending on decompose early depending on environmental temperature.environmental temperature.

Storage Options:Storage Options:– RefrigerationRefrigeration– Ice and Dry iceIce and Dry ice– Temporary burial Temporary burial

Body preservation Body preservation measuresmeasures

Body preservation measures are required on Body preservation measures are required on arrival.arrival.

Anticipate need for refrigerated holding Anticipate need for refrigerated holding areas. areas. – Mobile or portable refrigeration units Mobile or portable refrigeration units

(refrigerated containers or trucks)(refrigerated containers or trucks) The morgue’s refrigeration capacity will most The morgue’s refrigeration capacity will most

likely be exceeded during a disaster.likely be exceeded during a disaster. Keep refrigerated trucks close to holding site.Keep refrigerated trucks close to holding site. Need for use of other preservative measures:Need for use of other preservative measures:

Calcium hydroxide, formol and zeoliteCalcium hydroxide, formol and zeolite

Identification of Identification of BodiesBodies

Methods of Methods of IdentificationIdentification

Personal effects:Personal effects:– Identity cardsIdentity cards– Rings, necklacesRings, necklaces– Telephone memory cardsTelephone memory cards

Location of body.Location of body. Internet sites.Internet sites. Message boards with photos of Message boards with photos of

missing. missing. Red Cross.Red Cross.

Viewing and Viewing and photographingphotographing

Should be arranged quickly.Should be arranged quickly.– Decomposition may be too advanced after Decomposition may be too advanced after

24-48hrs24-48hrs Arranged locally when possible.Arranged locally when possible. Logistically very difficult .Logistically very difficult . Distressing for relatives.Distressing for relatives. Photographs – face & body. Photographs – face & body.

– Soon after deathSoon after death– Possibly the best postmortem information Possibly the best postmortem information

available in mass fatality incidentavailable in mass fatality incident

Disaster Forensic MethodsDisaster Forensic Methods

Standard methodsStandard methods Dental analysisDental analysis

– Limited by:Limited by: Lack of comparison elementsLack of comparison elements Availability of resourcesAvailability of resources

DNA techniquesDNA techniques– Limited by costs and availability of Limited by costs and availability of

expertise and resourcesexpertise and resources

DNA analysisDNA analysis

Consideration of established Consideration of established techniques.techniques.

Choice of most informative and Choice of most informative and valid technique.valid technique.

Application of analysis techniques Application of analysis techniques for DNA according to necessity for DNA according to necessity and availability of each sample.and availability of each sample.

Need for reference materials and Need for reference materials and conclusive samples.conclusive samples.

Identification of bodies: Key PointsIdentification of bodies: Key Points Records of deaths kept to monitor mortality rates Records of deaths kept to monitor mortality rates

and the incidence of disease.and the incidence of disease. Displaying bodies for identification requires space Displaying bodies for identification requires space

– 1000 bodies require over 2000m2. 1000 bodies require over 2000m2. When possible avoid relatives viewing many When possible avoid relatives viewing many

bodies.bodies. Separate location for identification and grieving.Separate location for identification and grieving. Once identified, a death certificate should be Once identified, a death certificate should be

issued and body tagged.issued and body tagged. With violent deaths, record the cause of death for With violent deaths, record the cause of death for

possible future investigation.possible future investigation.

“There is no evidence that, following a natural disaster, dead bodies pose a risk of epidemics. “Epidemic-causing” acute diseases are unlikely to be more common among disaster victims than among the general population, suggesting that the risk to the general public is negligible”

Categories and examples of Categories and examples of infectious hazards associated infectious hazards associated with cadavers after a natural with cadavers after a natural disasterdisaster

BloodborneBloodborne– Hepatitis BHepatitis B– Hepatitis CHepatitis C– HIV HIV

RespiratoryRespiratory– TuberculosisTuberculosis

GastrointestinalGastrointestinal– Rotavirus diarrheaRotavirus diarrhea– Campylobacter Campylobacter

enteritisenteritis– SalmonellosisSalmonellosis– Enteric fevers (typhoid Enteric fevers (typhoid

and paratyphoid)and paratyphoid)– Escherichia coliEscherichia coli– Hepatitis AHepatitis A– ShigellosisShigellosis– CholeraCholera

Burial ServicesBurial Services Burial is the preferred Burial is the preferred

method of body disposal. method of body disposal. Attention to ground Attention to ground

conditions.conditions.– Groundwater drinking Groundwater drinking

sources should be a sources should be a least 50m away least 50m away

An area of at least An area of at least 1500m2 per 10,000 1500m2 per 10,000 population is required. population is required.

The burial site can be The burial site can be divided to accommodate divided to accommodate different religious different religious groups.groups.

Burial depth should Burial depth should be at least 1.5m be at least 1.5m above the above the groundwater table, groundwater table, with at least a 1m with at least a 1m covering of soil.covering of soil.

Burial in individual Burial in individual graves is preferred graves is preferred

If coffins are not If coffins are not available, corpses available, corpses should be wrapped should be wrapped in plastic sheeting.in plastic sheeting.

BurialBurial

Preserve evidence.Preserve evidence. Location of suitable grave sites difficultLocation of suitable grave sites difficult

– Local communitiesLocal communities– Environmental health concernsEnvironmental health concerns

Operational difficultiesOperational difficulties– Lack of suitable documentation Lack of suitable documentation – Single graves or trench graves?Single graves or trench graves?– Clearly marked, not a ‘hole in the Clearly marked, not a ‘hole in the

ground’ground’– Minimum burial depth, distance from Minimum burial depth, distance from

water sources etc.water sources etc.

CremationCremation

There are no health advantages There are no health advantages of cremation over burial.of cremation over burial.

Some communities may prefer it Some communities may prefer it for religious or cultural reasons. for religious or cultural reasons.

Factors against it:Factors against it:– The amount of fuel required by a The amount of fuel required by a

single cremation (approx 300kg single cremation (approx 300kg wood) wood)

– Smoke pollution caused.Smoke pollution caused.

Suggestions for burialSuggestions for burial

Trench graves.Trench graves. One layer of bodiesOne layer of bodies Location of each body clearly marked, Location of each body clearly marked,

corresponding with identification corresponding with identification datadata

Grave construction Grave construction – Water table at least 2.5m deepWater table at least 2.5m deep– Bodies buried at least 1.5m deepBodies buried at least 1.5m deep– 30m from springs & watercourses30m from springs & watercourses– 250m from wells & drinking water 250m from wells & drinking water

sourcessources

Burials in common graves and Burials in common graves and mass cremations are rarely mass cremations are rarely warranted and should be warranted and should be avoided.avoided.

Pan American Health Organization. Management of Dead Bodies Pan American Health Organization. Management of Dead Bodies in Disaster Situations. Washington DC: PAHO, 2004.in Disaster Situations. Washington DC: PAHO, 2004.

Recommendations for managingRecommendations for managingthe dead following natural the dead following natural disastersdisasters

Universal precautions for blood and body fluids.Universal precautions for blood and body fluids. Time for action is short.Time for action is short.

– Decomposition 24-72 hrsDecomposition 24-72 hrs– Body recovery begins immediatelyBody recovery begins immediately

Avoiding cross-contamination of personal items.Avoiding cross-contamination of personal items. Washing hands after handling bodies and before Washing hands after handling bodies and before

eating.eating. Disinfection of vehicles and equipment.Disinfection of vehicles and equipment. Use of body bags.Use of body bags. Hepatitis B and tetanus vaccination.Hepatitis B and tetanus vaccination. No special arrangements, such as disinfection with No special arrangements, such as disinfection with

disposal of bodies.disposal of bodies. New burial areas site at least 250 m away from New burial areas site at least 250 m away from

drinking water sources, and with at least 0.7 m of drinking water sources, and with at least 0.7 m of distance above the saturated zone.distance above the saturated zone.

Important principlesImportant principles Give priority to the living over the dead.Give priority to the living over the dead. Dispel myths about health risks posed by Dispel myths about health risks posed by

corpses.corpses. Identify and tag corpses.Identify and tag corpses. Provide appropriate mortuary services.Provide appropriate mortuary services. Reject unceremonious and mass disposal of Reject unceremonious and mass disposal of

unidentified corpses.unidentified corpses. Respond to the wishes of the family.Respond to the wishes of the family. Respect cultural and religious observances.Respect cultural and religious observances. Protect communities from the transmission of Protect communities from the transmission of

medical epidemics.medical epidemics.

Disposal of dead bodies in emergency conditionsWorld Health Organization http://www.who.int

http://www.paho.org/english/dd/ped/ManejoCadaveres.htm

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