1. 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
Senior Advisor National Directorate of Emergencies and Disasters
Dominican Republic State Secretary of Public Health and Social Assistance

3. "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

4. 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.

5. 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

6. 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).

7. 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

8. 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

9. 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.

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

11. 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

12. Identification of Bodies

13. 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.

14. 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

15. 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

16. 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.

17. Source:

18. Source:

19. 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.

20. “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

21. 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

22. 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.

23. 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

24. 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.

25. 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

26. 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.

27. Recommendations for managing the dead following natural disasters
Universal precautions for blood and body fluids.
Time for action is short.
Decomposition 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

28. 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.

29. Disposal of dead bodies in emergency conditions
World Health Organization
Disposal of dead bodies in emergency conditions
World Health Organization

30. Further information can be obtained from the Panamerican Health Organization (PAHO)

31. 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 PAHO, USA.
Oliver Morgan Egbert Sondorp Management of the dead following the South Asian tsunami disaster.January retrieved from the web at:
Morgan O. Infectious disease risk of dead bodies following natural disasters. Rev Panam Salud 2004;15(5):
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.