Dead Bodies and Disasters: Principles of Mortuary Services

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Dead Bodies and Disasters Principles of Mortuary
Services

• Amado Alejandro Baez MD MSc EMT-P
• Brigham and Womens Hospital / Harvard Medical
  School
• aabaez_at_partners.org
• Senior Advisor National Directorate of
  Emergencies and Disasters
• Dominican Republic State Secretary of Public
  Health and Social Assistance

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"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
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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.

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Cadaver Recuperation Process
Coordination and Communication
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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.

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Coordination Support
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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

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Storage and Body Preservation
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Storage Issues

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

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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 morgues 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

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Identification of Bodies
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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.

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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

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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

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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.

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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.

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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
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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

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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.

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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.

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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.

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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

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• 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.

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Recommendations for managingthe 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.

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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.

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Disposal of dead bodies in emergency
conditions World Health Organization
http//www.who.int
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http//www.paho.org/english/dd/ped/ManejoCadaveres
.htm
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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/Study20
  Protocol2020Dead20bodies20after20the20Tsunam
  i.pdf
• Morgan O. Infectious disease risk of dead bodies
  following natural disasters. Rev Panam Salud
  200415(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.