dead body disaster
TRANSCRIPT
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
[email protected]@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
ReferencesReferences Harvey, P., Baghri, S. and Reed, R.A. (2002) Emergency Sanitation, Harvey, P., Baghri, S. and Reed, R.A. (2002) Emergency Sanitation,
Assessment and Programme Design. WEDC, Loughborough, UK.Assessment and Programme Design. WEDC, Loughborough, UK. Davis, J. and Lambert, R. (2002) Engineering in Emergencies: a Practical Davis, J. and Lambert, R. (2002) Engineering in Emergencies: a Practical
Guide for Relief Workers, (2nd. Edn.) ITDG Publishing, London. Wisner, B. and Guide for Relief Workers, (2nd. Edn.) ITDG Publishing, London. Wisner, B. and Adams, J. (eds.) (2002) EnvironmentalAdams, J. (eds.) (2002) Environmental
Health in Emergencies and Disasters. WHO, Geneva. Pan American Health Health in Emergencies and Disasters. WHO, Geneva. Pan American Health Organization (PAHO) (2003) ‘Unseating the Myths Surrounding the Organization (PAHO) (2003) ‘Unseating the Myths Surrounding the Management of Cadavers’, Disaster newsletter, No. 93, October 2003. PAHO, Management of Cadavers’, Disaster newsletter, No. 93, October 2003. PAHO, USA.USA.
http://www.pitt.edu/~super1/lecture/lec18941/index.htmhttp://www.pitt.edu/~super1/lecture/lec18941/index.htm Oliver Morgan Egbert Sondorp Management of the dead following the South Oliver Morgan Egbert Sondorp Management of the dead following the South
Asian tsunami disaster.January 2005. retrieved from the web at: Asian tsunami disaster.January 2005. retrieved from the web at: http://www.omorgan.info/download/projects/Study%20Protocol%20%20Dead%20bodieshttp://www.omorgan.info/download/projects/Study%20Protocol%20%20Dead%20bodies%20after%20the%20Tsunami.pdf%20after%20the%20Tsunami.pdf
Morgan O. Infectious disease risk of dead bodies following natural disasters. Morgan O. Infectious disease risk of dead bodies following natural disasters. Rev Panam Salud Rev Panam Salud 2004;15(5):307-312.2004;15(5):307-312.
Pan American Health Organization. Pan American Health Organization. Management of Dead Bodies in Disaster Management of Dead Bodies in Disaster SituationsSituations. Washington DC: PAHO, 2004.. Washington DC: PAHO, 2004.
Yin R. Yin R. Case Study Research. Design and MethodsCase Study Research. Design and Methods. London: Sage . London: Sage Publications,2003.Publications,2003.