Health Concerns Associated with Disaster Victim Identification After a Tsunami --- Thailand, December 26, 2004--March 31, 2005

The number of persons confirmed dead from the Indian Ocean tsunami that struck on December 26, 2004, had exceeded 174,000 as of March 31, 2005; the majority of decedents were buried or cremated without being identified. In contrast, in Thailand, disaster victim identification (DVI) continues, with approximately 1,800 persons identified among the 5,395 persons confirmed dead; of the dead, approximately 50% were not citizens of Thailand (1). This large-scale, multinational effort faced immediate challenges, including establishment of four temporary morgues, implementation of safeguards against environmental and occupational health hazards, and coordination of forensic procedures and safety protocols among Thai and international forensic teams. Public health and other agencies performing large-scale DVI in temporary morgues might consider implementing the recommendations and procedures described in this report.

Temporary Morgue Operations

After the tsunami struck, DVI teams totaling at least 600 persons, from Thailand and approximately 30 other countries, converted temples and other buildings in the provinces of Phangna, Phuket, and Krabi into four temporary morgues by modifying buildings and procuring DVI equipment and supplemental electricity. To store and preserve bodies, which were initially cooled with dry ice, refrigerated containers were procured. Bodies were stored in these containers until identified and released.

Approximately 30 DVI teams at the four morgue sites initially used different forensic protocols, including various numbering systems and methods for obtaining DNA specimens. These factors and the long travel times between the morgue sites (i.e., up to 6 hours by road) delayed data sharing between morgues and, consequently, victim identification. As a result, the multinational Thailand Tsunami Victim Identification committee (TTVI) was formed on January 12, 2005, to create specific, standardized protocols and procedures for DVI, based on the Interpol Disaster Victim Identification Guide (2) and subsidiary procedures for pathology, odontology, photography, fingerprinting, reexamination, moving of bodies, chain of custody, and DNA testing of antemortem and postmortem samples (targeting 16 genetic loci). TTVI also recommended appointment of an infection-control officer. Postmortem data were recorded on Interpol forms and matched with antemortem data (e.g., primary data such as dental, fingerprint, or DNA data and secondary data such as age, race, sex, hair color, and jewelry) compiled regarding missing persons at an information center (IMC) in Phuket. Antemortem data often were provided by relatives or friends directly to IMC or through the Royal Thai Police, embassies, or consulates. The Plass System (Plass Data Software, Holbaek, Denmark) and DNA-matching software were used to generate preliminary matches. If these matches were confirmed by a review board of Thai medical and police authorities, identification was confirmed, a death certificate issued, and the body released.

An estimated 700 bodies were identified and released by using varying protocols in place at the temporary morgues before establishment of the TTVI process. Since January 12, a total of 4,082 postmortem, and 2,164 antemortem data files had been created for matching as of March 31, 2005. From these data files, 1,112 bodies were identified, including 1,046 on the basis of one type of data (962 dental, 71 fingerprint, 10 physical, and three DNA); 66 others were identified by combinations of data types. Approximately 95% of identifications were of persons aged >18 years. Because little antemortem dental or fingerprint data are available for children, their identification will rely more heavily on DNA matching.

Site Safety and Health Assessment

Until TTVI decided in late March to centralize DVI operations at a newly built morgue, Wat Yan Yao in northern Phang Na Province was the largest temporary morgue, handling approximately 3,000 bodies during the first 3 months after the tsunami. To ensure optimal worker safety, health, and environmental protections, on January 8, the Thai Ministry of Public Health (MOPH) requested an assessment of this morgue by occupational and environmental health teams from MOPH and CDC. They were joined by staff from the Armed Forces Research Institute for Medical Science, Bangkok.

At Wat Yan Yao, the temple grounds were separated into a front semipublic area and a rear area restricted to DVI procedures. By mid-January, an estimated 300 persons per day were working at the temple. Interviews were conducted with a convenience sample of 20 DVI workers and four administrators. Tasks included lifting bodies out of trucks or refrigerated containers, performing autopsies, collecting other victim information and property, entering data regarding the deceased, disposing of waste, communicating with the public and media, and issuing death certificates. DVI procedures were conducted in the open, in converted open enclosures, or in air-conditioned closed enclosures; these procedures included general observation of the body, photography, fingerprinting, dental examination and radiographs, and extraction of teeth and sampling of bone (e.g., clavicle, rib, or femur) for DNA testing. Equipment for DVI procedures included scalpels, knives, scissors, probes, hand and oscillating saws, dental pliers, and dental radiograph equipment.

Investigators learned that no overall site safety and health plan was in effect and that certain site staff members and nearby residents had expressed concerns regarding the risk for infection from bodies and proper disposal of liquid autopsy waste. Investigators observed that multiple procedures to ensure occupational and site safety were already in place, including restricted access to DVI processing areas and refrigerated containers, collection of solid and sharps waste in labeled biohazard bags or containers, and transportation of solid waste to a local hospital for incineration. Liquid waste was stored in large holding tanks and then transported by truck to a local hospital sanitary drain for municipal wastewater treatment. Personal protective equipment (PPE) was available, including disposable gowns, aprons and coveralls, nitrile and latex gloves, rubber boots, various types of respirators, and surgical masks. However, use of PPE was left to the personal preference of workers, often resulting in overuse and increased risk for heat stress and dehydration. Moreover, many workers did not remove PPE when exiting DVI areas and returning to public areas. Eye protection was available but infrequently used, except by dentists. Hand-washing facilities were insufficient; rest, food, and refreshment areas were inappropriately located within DVI work areas adjacent to forensic procedure areas, generating risk for contamination of food and refreshments; and limited worker training on bio- or physical safety was provided. Multiple trip hazards were noted, including electrical wires and open drains.

Basic first-aid was provided at a temporary occupational health clinic in the morgue. Immunization status of workers was not assessed, but the clinic provided tetanus vaccinations. Review of a single day of activity at the clinic in mid-January logged the following: 60 wound dressings, 50 persons with vertigo, 45 persons with headache, 28 persons needing eye washes, 26 persons receiving tetanus vaccination, and one person with a head injury. In addition, interviews with staff members at a nearby hospital determined that workers from the morgue had sought care during the previous 2 weeks for dry-ice burns, abrasions, sharps and construction injuries, and mucosal splashes with body fluids.

Odors and flies at the morgue were controlled by using a commercial bacterial inhibitory solution (EM-1, EMRO, Okinawa, Japan). Several types of disinfectants were available, including chlorine solutions, glutaraldehyde, benzalkonim chloride, isopropyl alcohol, and Virkon^® S (Antec International, Suffolk, United Kingdom). EM-1 and Virkon S are frequently used in animal husbandry and veterinary settings and have not formally been assessed for efficacy against odor and fly control (EM-1) and disinfection (Virkon S) in DVI settings. Formalin solution was used only during the first few days.

Recommendations for Temporary Morgues

To address gaps in worker and environmental safety, the investigative teams provided recommendations to MOPH to improve site and environmental safety at Wat Yan Yao and other temporary morgues (Box). The teams also developed fact sheets in Thai and English regarding 1) the low risk for infection from working with bodies or breathing air in the morgue, 2) what PPE to use when working at the morgue, and 3) what steps to take if splashed with liquid waste from a body or cut with a sharp object. In addition, CDC staff developed guidelines for appropriate disposal of liquid waste from morgue procedures (4). In late January, follow-up interviews with TTVI officials determined that many of the recommendations were implemented at Wat Yan Yao, including distribution of fact sheets to workers, appropriate disposal of liquid waste, movement of food and refreshment areas away from work areas, and installation of hand-washing stations.

Reported by: Thai Ministry of Public Health (MOPH); Armed Forces Research Institute for Medical Science; US Embassy, Bangkok; MOPH-CDC Collaboration, Nonthaburi, Thailand. Joint POW/MIA Accounting Command, Central Identification Laboratory, Hickam Air Force Base, Hawaii. US Dept of State. CDC.

Editorial Note:

The DVI effort in Thailand is likely the largest multinational DVI operation ever conducted. Complex public health and logistical challenges arose related to identifying disaster victims from approximately 30 countries and working in temporary morgues; these challenges resulted in formation of the TTVI committee and institution of standardized protocols among DVI teams.

However, even with standardized protocols, DVI in Thailand and parallel efforts in Sri Lanka and the Maldives are likely to take as long as 1 year. For comparison, after the destruction of the World Trade Center on September 11, 2001 (5), identification of 50%--60% of the 3,025 persons who died took 18 months. Identification of the 202 persons who died from the bombing of a nightclub in Bali, Indonesia, on October 12, 2002 (6), took approximately 6 months. In both events, DVI depended heavily on DNA test results because bodies were so badly damaged. To date, identification of most tsunami victims in Thailand has relied on traditional forensic data (i.e., fingerprints and dental records) rather than DNA results. Centralization of DVI in the new temporary morgue likely will speed the rate of examinations, reduce the number of occupational health and environmental health hazards, and facilitate implementation of site safety recommendations.

The experiences described in this report indicate a need for national and international public health agencies to better prepare for the public, occupational, and environmental health challenges of DVI in multinational situations. Development of an internationally accepted plan for DVI operations might be coordinated through international agencies (e.g., United Nations) and modeled after the international Sphere Project, which provides a humanitarian charter and minimum standards for disaster relief to survivors (7). The protocols and safety and health recommendations developed as part of the Thai tsunami DVI efforts and the existing plans and guidelines of other agencies (e.g., Disaster Mortuary Operational Response Team) (2,8--10) might form the basis for such an international effort.

References

1. CDC. Rapid health response, assessment, and surveillance after a tsunami---Thailand, 2004--2005. MMWR 2005;54:61--4.
2. Interpol. Disaster victim identification guide. Lyon, France: Interpol; 2005. Available at http://www.interpol.com/public/disastervictim/default.asp.
3. CDC. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Control Practices Advisory Committee (HICPAC). MMWR 1997;46(No. RR-18).
4. CDC. Disposing liquid waste from autopsies in tsunami affected areas. Available at
   http://www.bt.cdc.gov/disasters/tsunamis/pdf/tsunami-autopsyliquidwaste.pdf.
5. CDC. Deaths in World Trade Center terrorist attacks---New York City, 2001. MMWR 2002;51(Special Issue):16--18.
6. Lain R, Griffiths C, Hilton JM. Forensic dental and medical response to the Bali bombing: a personal perspective. Med J Aust 2003;179: 362--625.
7. The Sphere Project. Humanitarian charter and minimum standards in disaster response. Revised ed. Geneva, Switzerland: The Sphere Project; 2004. Available at http://www.sphereproject.org.
8. Pan American Health Organization. Management of dead bodies in disaster situations. Washington, DC: Pan American Health Organization; 2004. Available at http://www.paho.org/english/dd/ped/manejocadaveres.htm.
9. CDC. Interim recommendations for workers who handle human remains. Atlanta, GA: US Department of Health and Human Services, CDC; 2005. Available at http://www.bt.cdc.gov/disasters/tsunamis/handleremains.asp.
10. National Medical Disaster System. What is a disaster mortuary operational response team (DMORT)? Washington, DC: US Department of Homeland Security, National Disaster Medical System Section; 2005. Available at http://oep-ndms.dhhs.gov/dmort.html.

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Date last reviewed: 4/14/2005