Dead Bodies and Disasters: Principles of Mortuary Services Painting: “Muertos Recogidos” Goya 1810 to 1815, published in 1863 Amado Alejandro Baez MD MSc EMT-P Brigham and Women’s Hospital / Harvard Medical School aabaez@partners.org Senior Advisor National Directorate of Emergencies and Disasters Dominican Republic State Secretary of Public Health and Social 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

Objectives At the end of this lecture the participant will be able to: Understand the basic principles of the management of dead bodies in disasters. Review important epidemiological issues related to mass dead bodies. Understand principles of cadaver identification. Review techniques of dead body disposal in disasters.

Cadaver Recuperation Process Coordination and Communication Search Localize Transport Temporary deposit and Analysis * Final Disposition Release to relatives EVENT Follow Up * The analysis process involves investigation, identification and determination of cause of death Stages of the Process

Equipment for mortuary services in major disasters Stainless steel postmortem tables covered with plastic Wheeled trolleys for transportation within the mortuary. Plastic sheeting for the floor. Heavy-duty black plastic sheeting for temporary screens. Refuse bins and bags. Cleaning materials – mops, buckets, cloths, soap, towels. Disinfectant and deodorizer. Protective clothing and heavy-duty rubber gloves. Translucent plastic body bags 0.1 mm thick and labels. Wall charts to record progress or large poster boards if there are no walls. Wisner and Adams (2002).

Coordination & Support Body Recovery Communities, volunteers, NGOs, police, military Identification Doctors, medical staff, forensic specialists, foreign embassies, INTERPOL, NGOs Death certification Coroners, police Disposal Military, police, local authorities

Body Recovery Initial element in the cadaver management process. Can be initially chaotic and extremely distressful. Need to involve search and rescue groups. Need for tagging bodies (name location etc..) to allow further identification. Equipment can be diverse Basic usually in the initial phase Volunteers, wheel barrels Advanced after improved resources Trucks, planes buses

Storage and Body Preservation In Sri Lanka bodies taken to the local hospital had a negative effect on hospital operations disrupting medical care and leading to a storage problem.

Storage Issues Without proper storage, bodies may began to decompose early depending on environmental temperature. Storage Options: Refrigeration Ice and Dry ice Temporary burial

Body preservation measures Body preservation measures are required on arrival. Anticipate need for refrigerated holding areas. Mobile or portable refrigeration units (refrigerated containers or trucks) The morgue’s refrigeration capacity will most likely be exceeded during a disaster. Keep refrigerated trucks close to holding site. Need for use of other preservative measures: Calcium hydroxide, formol and zeolite

Identification of Bodies

Methods of Identification Personal effects: Identity cards Rings, necklaces Telephone memory cards Location of body. Internet sites. Message boards with photos of missing. Red Cross.

Viewing and photographing Should be arranged quickly. Decomposition may be too advanced after 24-48hrs Arranged locally when possible. Logistically very difficult . Distressing for relatives. Photographs – face & body. Soon after death Possibly the best postmortem information available in mass fatality incident

Disaster Forensic Methods Standard methods Dental analysis Limited by: Lack of comparison elements Availability of resources DNA techniques Limited by costs and availability of expertise and resources A common myth is related to concerns about availability of DNA methods in underdeveloped regions, currently DNA technologies are considered the standard of care and assistance from countries with this technology and resources is frequently available

DNA analysis Consideration of established techniques. Choice of most informative and valid technique. Application of analysis techniques for DNA according to necessity and availability of each sample. Need for reference materials and conclusive samples.

Source: www.paho.org

Source: www.paho.org

Identification of bodies: Key Points Records of deaths kept to monitor mortality rates and the incidence of disease. Displaying bodies for identification requires space 1000 bodies require over 2000m2. When possible avoid relatives viewing many bodies. Separate location for identification and grieving. Once identified, a death certificate should be issued and body tagged. With violent deaths, record the cause of death for 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” O Morgan. Rev Panam Salud Publica. 2004;15(5);307-12

Categories and examples of infectious hazards associated with cadavers after a natural disaster Gastrointestinal Rotavirus diarrhea Campylobacter enteritis Salmonellosis Enteric fevers (typhoid and paratyphoid) Escherichia coli Hepatitis A Shigellosis Cholera Bloodborne Hepatitis B Hepatitis C HIV Respiratory Tuberculosis

Burial Services Burial is the preferred method of body disposal. Attention to ground conditions. Groundwater drinking sources should be a least 50m away An area of at least 1500m2 per 10,000 population is required. The burial site can be divided to accommodate different religious groups. Burial depth should be at least 1.5m above the groundwater table, with at least a 1m covering of soil. Burial in individual graves is preferred If coffins are not available, corpses should be wrapped in plastic sheeting.

Burial Preserve evidence. Location of suitable grave sites difficult Local communities Environmental health concerns Operational difficulties Lack of suitable documentation Single graves or trench graves? Clearly marked, not a ‘hole in the ground’ Minimum burial depth, distance from water sources etc. Burial should be done in a way that preserves evidence for identification

Cremation There are no health advantages of cremation over burial. Some communities may prefer it for religious or cultural reasons. Factors against it: The amount of fuel required by a single cremation (approx 300kg wood) Smoke pollution caused.

Suggestions for burial Trench graves. One layer of bodies Location of each body clearly marked, corresponding with identification data Grave construction Water table at least 2.5m deep Bodies buried at least 1.5m deep 30m from springs & watercourses 250m from wells & drinking water sources O Morgan. Rev Panam Salud Publica. 2004;15(5);307-12

Burials in common graves and mass cremations are rarely warranted and should be avoided. Pan American Health Organization. Management of Dead Bodies in Disaster Situations. Washington DC: PAHO, 2004.

Recommendations for managing the dead following natural disasters Universal precautions for blood and body fluids. Time for action is short. Decomposition 24-72 hrs Body recovery begins immediately Avoiding cross-contamination of personal items. Washing hands after handling bodies and before eating. Disinfection of vehicles and equipment. Use of body bags. Hepatitis B and tetanus vaccination. No special arrangements, such as disinfection with disposal of bodies. New burial areas site at least 250 m away from drinking water sources, and with at least 0.7 m of distance above the saturated zone. Source www.paho.org

Important principles Give priority to the living over the dead. Dispel myths about health risks posed by corpses. Identify and tag corpses. Provide appropriate mortuary services. Reject unceremonious and mass disposal of unidentified corpses. Respond to the wishes of the family. Respect cultural and religious observances. Protect communities from the transmission of medical epidemics.

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

Further information can be obtained from the Panamerican Health Organization (PAHO) http://www.paho.org/english/dd/ped/ManejoCadaveres.htm

References Harvey, P., Baghri, S. and Reed, R.A. (2002) Emergency Sanitation, Assessment and Programme Design. WEDC, Loughborough, UK. Davis, J. and Lambert, R. (2002) Engineering in Emergencies: a Practical Guide for Relief Workers, (2nd. Edn.) ITDG Publishing, London. Wisner, B. and Adams, J. (eds.) (2002) Environmental Health in Emergencies and Disasters. WHO, Geneva. Pan American Health Organization (PAHO) (2003) ‘Unseating the Myths Surrounding the Management of Cadavers’, Disaster newsletter, No. 93, October 2003. PAHO, USA. http://www.pitt.edu/~super1/lecture/lec18941/index.htm Oliver Morgan Egbert Sondorp Management of the dead following the South Asian tsunami disaster.January 2005. retrieved from the web at: http://www.omorgan.info/download/projects/Study%20Protocol%20%20Dead%20bodies%20after%20the%20Tsunami.pdf Morgan O. Infectious disease risk of dead bodies following natural disasters. Rev Panam Salud 2004;15(5):307-312. Pan American Health Organization. Management of Dead Bodies in Disaster Situations. Washington DC: PAHO, 2004. Yin R. Case Study Research. Design and Methods. London: Sage Publications,2003.