In May 2005, the Pan American Health Organization (PAHO), the World Health Organization (WHO) and the International Committee of the Red Cross (ICRC) organized an expert meeting on lessons learned from the management of the deadFootnote 1 in the aftermath of the 2004 Indian Ocean tsunami. Held in Lima, Peru, the meeting identified the need for practical, easy-to-follow guidelines on the management of the dead for non-expert first responders, who are almost always at the forefront of disaster response in large emergencies. The result was the first edition of Management of Dead Bodies after Disasters: A Field Manual for First Responders Footnote 2 (2006 Manual), developed in close collaboration with the ICRC's Forensic Advisory Board, which is comprised of internationally leading experts in the in the field of forensic science. This document offered practical guidelines for non-specialists on how to handle human remains in the aftermath of mass fatalities. It was translated into multiple languages and has since become the most consulted and downloaded document on the PAHO website.
The humanitarian community recognizes the proper and dignified management of the dead as one of the three pillars of disaster response, along with the recovery and care of survivors and the supply of basic services. Neglect of this core principle has the potential to cause trauma and emotional suffering to bereaved families, long outliving the physical effects of the disaster in question.Footnote 3 Unfortunately, in mass disasters, it is not unusual for only a few of the deceased to be identified.
The first response, often carried out by members of the affected communities in the initial hours and days, lays the crucial foundation for the dignified handling of those who have died. This early response will condition the later identification of the dead, and as such, should be properly handled. In simple steps, the Manual sets out the elements of this proper procedure for non-experts acting as first responders. By filling this gap in the emergency response, the Manual complements other guidance aimed at forensic specialists, such as the Interpol disaster victim identification (DVI) guide.Footnote 4 The DVI guide, launched in 1984 and updated several times since, is aimed at a different audience: police and forensic specialists. It has systematized the technical aspects of human identification, making an important contribution to the response to small and medium-sized disasters. However, in large disasters where the authorities simply cannot respond, or when experts are not available at the scene, guidance for those providing the first response is needed. It is this gap that the Manual was designed to fill.
In the ten years since the 2006 Manual was released, its usefulness and importance have become apparent. It has found frequent application in disaster response planning and preparedness, including in countries with highly developed forensic services and disaster response agencies. Over the past decade, there have been important scientific and technical developments in mass fatality management. In addition, lessons have been learned in the aftermath of the 2013 Typhoon HaiyanFootnote 5 in the Philippines, during the 2014/15 Ebola epidemic in West AfricaFootnote 6 and following the 2015 earthquake in Nepal.Footnote 7 Together, these have generated improvements to the recommendations that underpin the Manual's continued usefulness and led to its revision.
The 2016 revised ManualFootnote 8 (2016 Manual or, hereafter, the Manual) is divided into twelve short chapters covering the essential aspects of managing the dead following a mass fatality. In the immediate aftermath of a disaster, these chapters can be photocopied and distributed to first responders tasked with various responsibilities. The Manual furthermore contains eleven annexes which include data collection forms, checklists, practical recommendations, useful additional information and links for anyone involved with the management of the dead in emergency responses.
The Manual continues to serve its original purpose: providing guidance on the appropriate and dignified management of the dead, and on carrying out the early, crucial steps which will assist the later identification of the deceased, as well as promoting respect for the bereaved. The 2016 Manual is not a comprehensive framework for forensic investigations, nor does it replace the need for later specialist forensic identification of victims. Implementation of the Manual's recommendations is required to enable later effective investigations by specialist forensic teams using the Interpol DVI guidelines,Footnote 9 if and when such teams arrive in the field.
To make the information more easily accessible, the aims of each chapter are listed at its beginning, and the material is summarized in a “Do's and Don'ts” section concluding each chapter.
The following sections will outline the content of the 2016 Manual, highlighting its updates and additions.
Planning and coordination
In the event of a disaster, time is of the essence. Planning and effective coordination are the backbone to any successful disaster response operation. Command structures, logistics and the necessary resources to successfully implement a plan of action for the management of the dead need to be developed in advance. At the local, regional and national levels, it is paramount to quickly appoint the agencies and individuals in charge of overseeing operations, as well as coordination groups. Responsibilities must also be allocated promptly. At a local level, this includes:
• health and safety;
• search and recovery;
• allocating unique codes to the bodies;
• taking photographs and recording data;
• the temporary storage of bodies;
• the traceable long-term storage of bodies;
• providing support to the bereaved;
• the collection and management of information on the missing;
• communications with next of kin and the media;
• logistics; and
• liaison with operational partners and authorities.
On a regional and national level, coordination groups to advise on liaison with local agencies, logistical support of police or military, technical support for data collection, information management, and legal issues related to identification need to be established. Liaison with the public and the media, as well as with diplomatic missions and external organizations, should also be addressed.
The Manual includes a helpful and comprehensive checklist of items needed for the recovery of the dead, including personal protective equipment (PPE), recovery, transportation and storage equipment, and recording equipment.Footnote 10
Health and safety, including infectious disease risk of dead bodies
In all disaster response scenarios, the health and safety of the first responder are of the utmost importance. Contrary to circulating misconceptions, human remains do not generally pose a risk of causing epidemics. However, as with the deceased in any circumstances, there is always a chance that an individual who died in a mass fatality was already infected with a blood-borne disease such as hepatitis or HIV.Footnote 11 In such cases, the risk of transmission to body handlers can be kept in check by ordinary precautions such as adequate PPE (gloves, boots and apron), while the risk to the public not in direct contact with such remains is negligible.Footnote 12 The exceptions to usual disasters are situations where the deaths occurred as a result of a highly infectious disease (i.e., an epidemic) or the disaster occurred in an area where such disease is endemic. For example, in the Ebola crisis, handling the dead was one of the main modes of transmission of the disease. In such circumstances special precautions are required, and these are explained in the Manual.Footnote 13 Importantly, the Manual stresses that untrained first responders are not to be involved in responses to chemical, biological (epidemic) or radiation disasters.
Other hazards are much more common, and it is these issues that the Manual focuses on: the risk of injury from collapsing buildings and falling debris, heatstroke, hypothermia, tetanus from simple cuts, and the psychosocial effects of dead body management. Psychological support, including debriefing and the option of counselling for body handlers, is an important component of risk management.Footnote 14
Allocating a unique code to dead bodies
Allocating a unique code to each recovered body or body part at the earliest possible time is crucial. Although the need for this procedure was included in the 2006 Manual, the concept is so important that it has been clarified and given a separate chapter of its own in the revised edition.Footnote 15 It ensures that the body or the body part can be traced and that related information can be associated with it. This helps to prevent bodies from getting “lost”, remaining unidentified or being misidentified. The code, which is a sequential number, is unique and must be included in all photographs and records related to the remains, in addition to the place where the body was found and the name of the person or team that dealt with the body. The unique code should be allocated, the body labeled and photographs taken as soon as possible, preferably all at the time when the body is first located.
Taking photographs and recording data from dead bodies
The 2016 Manual has also dedicated a separate chapter to the taking of photographs and recording of data from human remains.Footnote 16 Good photographic documentation of the remains, taken as early as possible, together with the recording of any associated details and artefacts, is indispensable. Decomposition begins and progresses rapidly, particularly in warmer climates, rendering visual recognition impossible after a few days or sometimes even hours. As it may take days for forensic specialists to be dispatched and arrive at the scene, prompt photographic documentation by first responders is invaluable.
Prior to photographing, bodies should be cleaned as much as possible to show facial features, and the unique body code must be included in each picture. If possible, a standard photographic scale or an object of known size – a dollar bill, for example – should appear in the picture. At a minimum, the following photographs should be taken: a full-length front-view picture of the body, a front view of the entire face, any obvious distinguishing features (such as tattoos or jewellery) and all clothing.
At the time of taking photos, information about the remains should be recorded in the Dead Body Information Form (Annex 1 of the Manual) as soon as possible. The form has room for basic information on physical appearance and the recovery location. Mandatory data include the person's sex (if recognizable), the approximate age range, personal effects, obvious identifying features, height, colour and length of hair, and visible dental features. Any personal effects need to stay with the body, in order to facilitate their return to the families or next of kin.
Each separate body part should be managed like a whole body would, as it may not belong to the nearest incomplete body. This means allocating and labelling it with a unique code, taking photographs and filling out the Dead Body Information Form. Following the above procedure will help to ensure that all human remains, associated items and information remain traceable throughout the process, and will provide strong support to later attempts at identification.
Recovery of dead bodies
Throughout the recovery operations, the health and safety of recovery personnel are crucial. In terms of management of the dead, body recovery is the first step and needs to take place as early as possible.Footnote 17 Recovery goes hand in hand with the allocation of a unique code, labelling and documentation. Ideally the body should be placed into a body bag at the location of recovery. The Manual includes a series of photographs illustrating how to respectfully and efficiently roll a body into a body bag.Footnote 18 After the recovery, human remains need to be kept in a cool place, secure from scavengers, public viewing and direct sunlight.
Temporary storage of dead bodies
There are two separate chapters dedicated, respectively, to the temporary storage of dead bodies (Chapter 7)Footnote 19 and the traceable long-term storage and disposal of dead bodies (Chapter 8).Footnote 20 In mass fatality events that overextend local capacities, the authorities might not be able to quickly process remains in terms of data collection. In these cases, organized and respectful short-term storage to protect the remains as efficiently as possible needs to be established. For this, a centralized collection centre where all data recording can take place needs to be determined.
Each dead body (or individual body part) needs to be bagged separately and have its own unique code on waterproof labels attached to the body (or body part) as well as attached to the bag. Ideally the remains should be kept refrigerated between 2 °C and 4 °C. When this is not possible, storage should be in a protected, cool location. Alternatively, temporary burials can be considered. In such cases, if there are small numbers of bodies, they should be placed in individual graves. Larger numbers can be placed in trench graves, side by side, with at least 0.4 metres between bodies. Each body, and each bag, needs to be individually labeled. The location of the body, with its unique code, must be recorded at the surface of the grave site, and on a plan of the whole burial site.
Traceable long-term storage and disposal of dead bodies
The identification of the dead is the responsibility of the authorities. However, once identified, the remains need to be released to the next of kin as soon as possible. Unidentified remains and unclaimed bodies need to be placed in properly documented long-term storage. In these situations, the preferred option is burial, as it is dignified and preserves the body for potential future identification and return to the family. Each body should be traceable after storage and burial to enable easy future location and recovery when necessary.
Selection of the burial site needs to be carefully considered, taking into account local customs, proximity to the local community, soil conditions and distance from drinking water sources. All human remains should be buried in clearly marked individual graves, which need to be carefully documented and mapped to ensure continuity and traceability. Unidentified bodies should not be cremated.
Support for families and relatives
Proper consideration of the next of kin is of the utmost importance. For this, a family liaison focal point – in the case of a large mass fatality, a Family Assistance Centre – should be established wherever possible. All next of kin need to be given realistic expectations of the recovery and identification process and should be informed about the findings prior to the media or anyone else. Children should not be expected to aid in the visual identification of remains. However, if the family wish to view the body as part of their grieving process, this should be respected and facilitated. Psychological support to families should be provided, taking into account the families’ needs, cultures and context. In some instances, material support to help with funerary rites may need to be provided, and special legal provisions put in place to expedite the issuing of death certificates and other urgent documents.
Collection and management of information on the missing, including those presumed dead
It is vital that information on missing persons is effectively collected, recorded and made accessible in a manner allowing for the recovered human remains to be identified. By definition, human identification is the attribution of the correct name to human remains. Only the bodies of those known to be missing (i.e., whose names have been collected onto a list) will have the possibility of being identified. Personnel in charge of data management need to be appointed. The recording of as much information as possible about the missing, as well as its consolidation and centralization, ideally in an electronic database, is particularly important. It is not uncommon for individuals to be reported missing multiple times to different agencies and by different individuals, and to be listed under different names and aliases. There is a potential for duplication and confusion if the data are not managed appropriately.
The process of obtaining ante mortem information of missing persons from relatives requires trained personnel who will treat next of kin with sensitivity, sympathy and respect. Annex 2 of the Manual provides a convenient template for this.
Communications with families and the media
Good communication is a key factor in effective disaster management, because it helps maintain the victim's dignity, minimizes additional grief to the next of kin and also contributes to successful victim recovery and identification.
A Family Assistance Centre should be established as soon as possible so that the next of kin can be briefed regularly, swiftly and collectively. The briefings should include information about the recovery and identification process, the storage and disposal of remains, and anything else of relevance. The families of identified individuals should be briefed privately before information is released to the media. The privacy of victims and families is a high priority. In large-scale disasters, the Internet, noticeboards or other media outlets such as newspapers, TV and radio will need to be used to communicate with the next of kin. Having a media liaison officer to regularly hold briefings with the press minimizes the risk of inaccurate or premature reporting. Close working relationships with operating relief agencies are crucial, as these agencies frequently work in close direct contact with the affected communities and are a valuable conduit for information. Good communications with external agencies are also important, as these agencies are not always well informed and may provide mistaken information to the community and the media – as is often the case, for example, with regard to the infectious disease risk of dead bodies.
Frequently asked questions
The “Frequently Asked Questions” section of the Manual addresses the myths of health risks to the public from the dead, the recovery and disposal of human remains, and existing opportunities for assisting in the response efforts. Because of the experience with the Ebola epidemic, the 2016 edition emphasizes that in such circumstances (and epidemics of, for example, Lassa fever or cholera), untrained first responders should not be involved in handling the dead. An additional question has been included: what are the minimum steps needed to identify as many bodies as possible? Sometimes, even the authorities do not know the answer to this question. In order to reach an identification, information gathered about a missing person is compared and matched to information collected from the recovered body. In relation to the former, a list of the missing, as well as specific information about each missing person, is required. This is then compared with information about the dead bodies: for example, photographs preferably taken prior to the onset of decomposition, identifying features, clothing and personal effects. When a comparison is positive, or further examination of the body is required, the body can be tracked and retrieved because its location is recorded and the body itself is labeled with the same unique code that is on the information recorded.Footnote 21
Conclusion
The dignified management of the dead after a mass fatality, including their identification, is a fundamental component of disaster response. When the local emergency response capacity collapses as a result of a disaster, the management of the dead frequently falls to first responders from the affected community until the arrival of outside agencies, including forensic services. The popularity of the 2006 Manual demonstrates the demand for practical and easy-to-follow guidelines, a gap which the Manual filled. The revised 2016 Manual takes into consideration experiences and lessons learned from ten years of application in the field, namely from the management of the 2014 Ebola epidemic, as well as technical and scientific developments of the past decade. With increasing globalization, the majority of mass fatalities nowadays incorporate an international dimension, making a standardized approach in the crucial first hours and days after the event indispensable. For the success of subsequent identification efforts, the revised Manual is a timely and important resource.
Annex 1: Dead Body Information Form
Annex 1, previously called the “Dead Bodies Identification Form”, is now called the “Dead Body Information Form”. It can be printed online or photocopied from the Manual and handed out to first responders to help them in the crucial task of recording information about human remains as accurately and as early as possible in the response phase, which might aid in future identifications. The form includes the unique body code and prompts the recording of data under sections titled “Physical Description” and “Associated Evidence”.
Annex 2: Missing Persons Information Form
Annex 2, the Missing Persons Information Form, is to be filled out by those with requisite training in interviewing the next of kin of missing individuals. It includes the categories “Physical Description” and “Personal Effects”.
Annex 3: Label for the dead body with unique body code and chain of custody record
Annex 3 comprises a photocopiable template for the dead body label, which is to be filled out by the first responders. It has room for the unique body code as previously described. In addition, the label allows for the chain of custody of the body to be recorded. This label should be either waterproof or paper sealed in plastic, and duplicated. One copy should be securely attached to the body or a body part inside the body bag, while the other should be attached to the outside of the bag, allowing for the chain of custody form to be easily accessed so it can be updated at each handover of the body.
Annex 4: Mass Fatality Plan Checklist
The Mass Fatality Plan Checklist in Annex 4 outlines the key elements of an effective mass fatality plan. The Checklist is split into categories: Purpose; Activation; Command and Control; Logistics; Welfare; Identification and Notification; International Dimensions; Site Clearance and Recovery of Deceased; Mortuary; Disposal: Final Arrangement; Chemical Biological, Radiological, Nuclear (CBRN) Disasters; Public Information and Media Policy; Health and Safety; and Disaster Mortuary Plan.
Annex 5: Coordination plan flowchart for management of the dead: An example
Annex 5 is an adaptable example of a coordination plan flowchart, which lists the most fundamental aspects to be considered in a mass fatality response, and which can be adapted to individual scenarios and contexts.
Annex 6: Dealing with the bodies of persons who died from an epidemic of infectious disease
Another new feature of the Manual is Annex 6, which is dedicated to the management of the dead from an epidemic of infectious disease. As previously stated, it is important to stress that untrained first responders should not handle the dead in these circumstances. When infected with Ebola virus disease (EVD), the bodies remain very infectious for some time after death. If first responders and non-experts are to be trained to handle human remains in these circumstances, this training should be provided by individuals who are experienced in handling the disease. Those providing training should also understand the mode of transmission, be experienced in handling the bodies and know the correct and crucial procedures for donning and doffing PPE. The annex includes a summary of the WHO guidelines on safe handling and burial of deceased victims of EVD, while emphasizing that this is not a replacement for proper training.
The following is an excerpt from Annex 6.
Annex 7: Cemeteries
Annex 7 addresses concerns and considerations for choosing a burial ground for temporary or long-term storage of bodies in the aftermath of disasters. Points covered include the potential for the contamination of drinking water from decaying human remains, preventing predator access and topographical considerations, as well as cultural, religious and legal aspects of burial.
Annex 8: Processes enabling the use of forensic DNA analysis in a large mass fatality disaster
It is a mistake to think that the use of DNA simplifies the management of the dead in a mass disaster. When the correct procedures are being adhered to, DNA analysis is an extremely powerful tool which helps increase the number of victims identified following a mass fatality disaster. DNA sampling takes place subsequent to the assigning of a unique body code and the examination of the remains according to the procedures outlined in the Manual. The extracted samples (which could be muscle, bone or perhaps fingernails or toenails – this needs to be agreed in advance with the laboratories involved) need to be secured, labelled and properly stored to decelerate DNA degradation. A comprehensive list of missing individuals and their ante mortem information are still required, as well as biological reference samples from surviving family members, for identifications based on DNA profiling to be successful. Other considerations include the identification of laboratories for the analyses; samples taken from human remains and biological reference samples should normally be processed in separate laboratories, each with the capacity and technical standards to deal with the large number of samples and to analyze and interpret the results, including the statistics required for ascertaining the identity of human remains. Financing for these analyses needs to be sourced.
Annex 9: The management of dead foreign nationals following a large mass fatality disaster
As mass fatality events frequently include individuals of foreign nationality, arrangements applying to overseas nationals following their identification need to be made. These procedures should be established in advance and may need to include Interpol and foreign embassies. It is crucial that a systematic approach to management of all the dead and their identification is taken, and that this process is not distorted by pressure to prioritize the identification of foreign nationals.
Annex 10: Supporting publications
Annex 10 is a list of supporting publications which the reader of the Manual may wish to consult to gain more in-depth knowledge on the individual topics discussed. The list includes the following references:Footnote 22
Claude de Ville de Goyet, “Epidemics Caused by Dead Bodies: A Disaster Myth that Does Not Want to Die”, Pan American Journal of Public Health, Vol. 15, No. 5, 2004, pp. 297–299, available at: http://publications.paho.org/english/editorial_dead_bodies.pdf.
H. Douceron, L. Deforges, R. Gherardi, A. Sobel and P. Chariot, “Long-lasting Postmortem Viability of Human Immunodeficiency Virus: A Potential Risk in Forensic Medicine Practice”, Forensic Science International, Vol. 60, No. 1–2, 1993, pp. 61–66.
William D. Haglund, Melissa Connor and Douglas D. Scott, “The Archaeology of Contemporary Mass Graves”, Historical Archaeology, Vol. 35, No. 1, 2001, pp. 57–69.
ICRC, Forensic Human Identification, Geneva, 2013, available at: www.icrc.org/en/publication/4154-forensic-identification-human-remains.
ICRC, Missing People, DNA Analysis and Identification of Human Remains: A Guide to Best Practice in Armed Conflicts and Other Situations of Armed Violence, 2nd ed., Geneva, 2009, available at: www.icrc.org/en/publication/4010-missing-people-dna-analysis-and-identification-humanremains-guide-best-practice.
Interpol, “Disaster Victim Identification”, Interpol Resolution No. AGN/65/RES/13 of the 65th Interpol General Assembly, Antalya, 23–29 October 1996, available at: www.interpol.int/content/download/22405/210383/version/4/file/65-RES-13-Ang.pdf.
Interpol, Principles of Good DVI Governance, Lyon, available at: www.interpol.int/INTERPOL-expertise/Forensics/DVI.
PAHO/WHO, Resolution on the International Transportation of Human Remains, 1966, available at: http://iris.paho.org/xmlui/bitstream/handle/123456789/2177/CD16.R36en.pdf?sequence=1.
United Nations Office for the Coordination of Humanitarian Affairs, “The Cluster Approach”, Humanitarian Response, available at: www.humanitarianresponse.info/en/coordination/clusters.
WHO, “Ebola Virus Disease”, Fact Sheet No. 103, Geneva, August 2015, available at: www.who.int/mediacentre/factsheets/fs103/en/.
WHO, Field Situation: How to Conduct Safe and Dignified Burial of a Patient Who Has Died from Suspected or Confirmed Ebola Virus Disease, Geneva, October 2014, available at: http://who.int/csr/resources/publications/ebola/safe-burial-protocol/en/.
WHO, Laboratory Biosafety Manual, 3rd ed., Geneva, 2004, available at: www.who.int/csr/resources/publications/biosafety/Biosafety7.pdf?ua=1.
WHO, Personal Protective Equipment in the Context of Filovirus Disease Outbreak Response: Rapid Advice Guideline, Geneva, October 2014, available at: http://who.int/csr/resources/publications/ebola/ppe-guideline/en/.
C. P. Young, K. M. Blackmore, A. Leavens and P. J. Reynolds, Pollution Potential of Cemeteries, Environment Agency, Bristol, 2002.
Annex 11: International organizations
Annex 11 is a list of international organizations, namely WHO, the PAHO, the ICRC, the International Federation of the Red Cross and Red Crescent Societies, and Interpol, all of which may be involved with the response to a mass fatality incident and could be consulted for support and research.
