Maximizing the utilization of resources means that some deaths will be unavoidable, especially in resource-poor situations. When resources are limited, you may have to forego trying to save patients whose deaths are imminent or unavoidable. Considerable improvisation may be required to fashion body bags, equip holding areas, set up a body-identification system, and even embalm a body or perform an autopsy.

The myth that all human and animal corpses pose a public health threat following natural or human-made disasters continues to lead to the misallocation of many scarce resources needed to help the living. Corpses pose only a limited health threat when the person did not die from an infectious disease, because most bacteria and viruses die quickly in a dead body as the internal temperature drops and the body desiccates. This limits any microbe’s ability to transfer to vectors that could infect humans. In fact, corpses pose a much lower risk of infecting people than do the living who are harboring an infection.¹

For those corpses of people who died from infectious diseases, the Centers for Disease Control and Prevention (CDC) guidelines require standard precautions for personnel involved in handling the bodies. These include using a surgical scrub suit, a surgical cap, an impervious gown or apron with full-sleeve coverage, a form of eye protection (e.g., goggles or face shield), shoe covers, and double surgical gloves with an interposed layer of cut-proof synthetic mesh. Those doing autopsies should wear N95 respirators and, if available, consider using powered air-purifying respirators equipped with N95 or high-efficiency particulate air (HEPA) filters. Much of this equipment cannot be easily improvised.²

General Population

Dead bodies from natural disasters do not cause epidemics. Because they do not have infections when they die, they do not spread diseases. Despite the hysteria from the media and politicians, the risk to the public from even masses of corpses is negligible. However, corpses can leak fecal material that can contaminate rivers or other water sources, causing diarrheal illness. Do not drink untreated water that has had dead bodies in it. In reality, routine disinfection of drinking water is sufficient to prevent waterborne illness.

In cases in which people died of an endemic, communicable disease (e.g., cholera, hemorrhagic fevers), see that the populace uses the best hygiene possible. Also, try to prevent direct contact between corpses and family members. One way to do this is to give the family the body in an airtight box for rapid burial.³ Spraying bodies with disinfectant or lime powder does not hasten decomposition or provide any protection to the living against disease.⁴

Body Handlers

Those handling corpses have a small, but real, risk of contracting diseases through the bodies’ blood and feces, particularly when the individual died of an infectious disease. (There is little risk from corpses resulting from natural disasters.) Handlers are especially at risk for contracting hepatitis B and C, human immunodeficiency virus (HIV), tuberculosis (TB), hemorrhagic fevers, and diarrheal diseases. However, the infectious agents responsible for these diseases do not last more than 2 days in a dead body, except for HIV, which may survive up to 6 days, and Ebola virus, which may last even longer.^4,5 Tuberculosis can pose a hazard during an autopsy or for those handling a body when air is expelled from the respiratory tract. To reduce this risk, place a cloth over the corpse’s mouth, ensure adequate ventilation in any temporary morgue, and, if handling hemorrhagic fever bodies, use complete personal protective equipment (PPE).^2,6

Precautions

In austere circumstances, body-recovery workers can wear normal clothing, along with rubber gloves and boots, if available. However, they must adhere to basic hygiene practices, such as washing their hands with soap and water after handling bodies and before eating, and not wiping their face or mouth with their hands. They should wash and disinfect all equipment, clothes, and vehicles used when transporting bodies.

The primary function of facemasks is to lessen the smell from decaying bodies. The smell is unpleasant, but it is not a health risk in well-ventilated areas. There is no danger of contamination through the respiratory tract (unless the patient had TB) because there is no respiratory function in dead bodies. Even though wearing a facemask is not required for health reasons, it may help lessen workers’ anxiety. However, normal facemasks do not filter the air or provide protection against most things (except bad smells) for very long. The problem with wearing masks is that they limit ventilation and increase the work effort.^4,7

If entering potentially hazardous structures, body recovery personnel should use the same protective gear as search and recovery personnel. If recovering bodies from confined, unventilated spaces, first ventilate the area, because after several days of decomposition, potentially hazardous toxic gases can build up. Body recovery teams should also receive priority status for tetanus immunization because of the hazardous locations in which they often work.⁸

Immediately after disasters, rather than prioritizing help for survivors, officials usually expend great efforts and resources collecting corpses. While rapid retrieval helps when trying to identify the dead, this effort should never take priority over or use resources that are needed to care for survivors.

Place recovered bodies and body parts (e.g., limbs) in body bags along with non-perishable personal belongings, such as jewelry. If body bags are unavailable, use plastic sheets, shrouds, bed sheets, or other locally available material. Place personal documents in a plastic bag and keep them with the body.

Transporting Bodies

Generally, take bodies either to a short-term holding area or to a site for long-term storage or final disposition. While mortuary workers normally use specialized mortuary vehicles to transport dead bodies, in major disasters, these may be in short supply or unavailable, so you may need to improvise. (Always check to see if local regulations prohibit using certain vehicles for this purpose.)

While workers often collect bodies using open flatbed trucks, it is preferable to use closed trucks or vans and to cover the floors with plastic. If possible, use refrigerated trucks normally used to transport perishable items. Try to cover any lettering or symbols, including license plates, that identify the companies or individuals who own the vehicles. This avoids any negative repercussions for the vehicles’ owners when the public sees them being used in this way. When finished using any vehicles to transport bodies, thoroughly clean them. Any commercial vehicles should then be inspected and approved by government officials as being safe to transport their normal cargo.⁹

Never use ambulances to transport the dead; they are valuable resources designed to help the living. While this practice is common (and inappropriate) during minor incidents, using ambulances in this way when there are mass fatalities is dangerous and potentially harms survivors. Even in mass casualty situations with few survivors (e.g., airplane crash), use alternative vehicles such as trucks, pickups, hearses, and vans to transport the remains of the dead.

Short-Term Holding Areas

Initially, take bodies to a short-term holding area (temporary morgue). Ideally, this site will have controlled access, sufficient space, good ventilation, and be air-conditioned—or at least be out of the sun—to avoid rapid decomposition. It should also have facilities for the staff and areas in which to counsel relatives and, if necessary, to do limited autopsies and embalming. Planning the site layout as soon as the site is chosen is a key element in organizing body identification.

Good on-site organization is essential. Sorting bodies by category helps workers easily locate specific bodies when the family arrives or identifying information becomes available. Place the remains in groups by gender and age (e.g., elderly men) and then further divide them into subgroups, such as by skin color, and then by hair color. For example, there may be six initial parts of the holding area for groups of men and women, each divided into elderly, adult, and child/teenager. With a sizable number of casualties, subdivide each of these areas for bodies of a different skin color (e.g., black, white, other) and hair color (e.g., black, brown, blond, other). If the number of bodies is substantial, further subcategorize these groups by height and hair length. Then, even with hundreds or thousands of bodies, the small subset with the six characteristics can be easily located. Computer programs may be useful to help sort and identify remains.

Storage

Several methods may be available to store bodies. Use any or all of these as the situation requires. Before storing bodies, put each body or body part in a body bag or wrap it in a sheet. Because these will often be unidentified bodies, give each a unique identification number matched to a master list of bodies. Put any identifying information with the body or part, and put their identification number on waterproof labels (e.g., paper in sealed plastic). Do not write the identification numbers directly on the body, body bag, or covering sheet, because the numbers can rub off during storage.

Refrigeration

Cold storage is optimal, especially in hot climates where decomposition advances so rapidly that facial recognition is not possible after 12 to 24 hours. The optimal temperature for storage is between 2°C and 4°C (35.6°F and 39°F). If available, the refrigerated transport containers used by commercial shipping companies can each store up to 50 bodies. Because sufficient refrigeration is rarely available immediately at a disaster site, try to obtain commercial refrigerator trucks. Move them close to the site for use as temporary storage and, later, to transport remaining corpses.

Burial

Use burial either as temporary storage or as a permanent disposition.

Temporary burial provides a good option for immediate storage, sometimes at the disaster site itself, when no other method is available or when longer-term temporary storage is needed. Use this method for individual deaths in remote areas when the body cannot safely be removed at that time. One benefit is that temperatures are lower underground than at the surface; this helps to preserve the body. Design temporary burials so that it is possible later to locate and recover the bodies. To ensure retrieval, use individual burials for a smaller number of bodies and trench burial for a larger number. All bodies should have waterproof identification tags on them and in the body bags or sheets.

However, do not use common mass graves. Rushing to dispose of bodies without proper identification traumatizes families and communities, cannot be justified as a public health measure, and violates important social norms. It also wastes scarce resources and may make it difficult or impossible to recover and identify remains later.^4,10 Likewise, mass cremations are not only technically and logistically difficult, but also waste tremendous amounts of scarce resources (mainly fuel and usually wood). They also destroy evidence for any future identification. Complete incineration is difficult, usually resulting in partially incinerated remains that must be buried.¹¹

Grave Construction

If possible, bury human remains in clearly marked, individual graves, although after very large disasters, communal graves may be unavoidable. When digging the graves, consider what the prevailing religious practices say about the bodies’ orientation, such as that the head must face east or toward Mecca. Bury each body with its unique reference number on a waterproof label. This number must be clearly marked at ground level and mapped for future reference.

The following are the general guidelines for constructing graves, although the distances may have to be increased depending on soil conditions. Graves should be ≥1.5 meters (5 feet) deep. Communal trench graves should consist of a single row of bodies placed parallel, ≥0.4 meters (1.5 feet) apart. Bury them in one layer—never stack the bodies on top of each other. Graves with fewer than five bodies should allow for ≥1.2 meters (4 feet) between the bottom of the grave and the water table or any level to which groundwater rises; allow ≥1.5 meters (4.5 feet) if the burials are in sand. Communal graves should have ≥2 meters (6 feet) between the bottom of the grave and the water table or any level to which groundwater rises.¹²

Grave Location

When choosing any burial site, consider (a) the number of bodies needing burial—allow some leeway, (b) soil conditions, (c) the highest water-table level, (d) the location’s acceptability to nearby communities, and (e) the distance from nearby water sources. Clearly mark burial sites and surround them with a buffer zone ≥10 meters (30 feet) wide to allow the community to plant deep-rooted vegetation and to separate it from inhabited areas.

For public health reasons, place burial sites at least 200 meters (600 feet) from any water source, such as wells, streams, lakes, springs, waterfalls, beaches, and the shoreline. The distance, in part, will vary with the number of bodies being buried, soil porosity, and the water-table level. The more porous the soil and the higher the water table, the farther the grave should be from the water source.¹² The suggested distances between burial sites and drinking-water sources are:

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  200 meters (600 feet) if there are 4 or fewer bodies per 100 m².

  
  
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  250 meters (750 feet) if there are 5 to 60 bodies per 100 m².

  
  
• 
  

  350 meters (383 yards) if there are more than 60 bodies per 100 m².¹³

Ice and Dry Ice