January 17, 2005 Page 1 of 14 

Disposing of Liquid Waste from Autopsies in TsunamiAffected Areas: Interim Guidance from the Centers for 

Disease Control and Prevention 

Requested by: CDC, Director’s Emergency Operations Center, Occupational and Environmental Health 

Team 

Requested from: National Center for Environmental Health, Environmental Health Services Branch 

Collaborators from other Agencies and Centers: 

Jim Smith, U.S. Environmental Protection Agency 

Nancy Burton, National Institute for Occupational Safety and Health 

Richard Nickle, Agency for Toxic Substances and Disease Registry 

Larry Cseh, Agency for Toxic Substances and Disease Registry 

Matthew Arduino, National Center for Infectious Diseases 

Background 

In tsunami-affected areas, liquid waste from human autopsies is being generated, collected, and stored. 

Each autopsy generates between 1 and 10 liters of liquid waste consisting of body fluids and rinse water 

used to clean and disinfect work surfaces. Current reports indicate that liquid waste is collected and stored 

in underground storage tanks, but other containers and methods of storage are likely being used. Because 

of the lack of storage facilities and onsite wastewater treatment operations, the CDC Field Team was 

asked to provide guidance on the final disposal of this waste. 

Characterization of Waste Stream 

Blood and body fluids generated during autopsy are collected and placed in storage tanks along with 

solutions used to clean and disinfect autopsy work surfaces. Common mortuary chemicals such as 

formaldehyde, formalin, or phenol are not being used during these autopsy procedures. The liquid waste 

mixture collected during autopsy is not disinfected or treated before being transferred to a stainless steel 

holding tank. 

Potential Risks 

Liquid waste generated during autopsy procedures may present environmental and public health hazards 

similar to those associated with medical waste and wastes generated at mortuaries and funeral homes. 

Although pathogens may be present in cadavers and in discharged blood and body fluids, little evidence 

exists that disease agents are transmitted to the public from these sources (U.S. Army 2001a; Harvey et 

al. 2002; Morgan 2004). Pathogens in the autopsy waste stream would be similar to those found in 

community-generated sewage. As with sewage, if properly managed, this autopsy waste presents minimal 

health and environmental risks. 

Agents of endemic disease may be present in both autopsy waste streams and community-generated 

sewage. Diseases prevalent in Indonesia include cholera, dengue fever, hepatitis A, hepatitis B, Japanese 

encephalitis, leptospirosis, malaria, plague, schistosomiasis, typhoid, and yellow fever (U.S. Department 

of State 2005). Autopsy liquids may also contain hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis 
Disposing of Liquid Waste from Autopsies in Tsunami-Affected Areas: Guidance from the 

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D virus (HDV), hepatitis E virus (HEV), human immunodeficiency virus (HIV), tuberculosis bacillus, group 

A streptococcal bacteria, and organisms that cause gastrointestinal illness. 

The development of disease from exposure to pathogens is dependent on pathogen virulence, dose size, 

route of exposure, and individual susceptibility. In bloodborne infections, transmission requires a 

percutaneous exposure (needle stick or sharp penetrating object); direct contact with mucous membranes 

such as eyes, nose, or mouth; or direct contact with skin that is abraded, chapped, or afflicted with 

dermatitis (WHO 1983; CDC 1983; Reinhardt and Gordon 1991). Such direct contact or percutaneous 

exposure places pathologists and waste handlers at risk. Disease risk from any particular pathogen for 

persons working at autopsy facilities varies by the type of activity each person performs. A critical need 

exists to apply universal precautions and implement a postexposure plan of action to follow in the event of 

exposure. Persons who may come in contact with blood or body fluids should follow universal precautions, 

including the use of protective gloves, eyewear, mask, gown/apron, and shoe covers while working (CDC 

1988; U.S. Army 2001b). 

If autopsy waste is properly managed, the public will not come in contact with untreated or treated 

autopsy waste and is therefore not at risk for exposure to pathogens. The likelihood that pathogens will be 

present in this waste stream is reduced, because infectious disease agents survive for only a short time 

outside the human host. The World Health Organization (WHO) reports that most disease-causing agents 

do not survive long in the human body after death. HIV survives in dead people for up to 6 days (WHO 

2004). HBV can survive outside the body for at least 7 days and still be infectious (CDC 2004). Organisms 

that may present an environmental exposure risk include HAV, HEV, Vibrio cholerae, Leptospira 

interrogans, and Salmonella species. 

Environmental Surface Disinfection Procedure To Be Used 

When handling liquid waste and the chemicals used for disinfection, personnel should follow universal 

precautions as described in this section. Disinfecting agents should be applied with care to minimize 

overuse and unnecessary exposure to chemicals. Surfaces that have come in contact with blood or body 

fluids should be cleaned with detergent and clean water. After surfaces have been cleaned, personnel 

should then disinfect the surfaces by wetting them with a solution of chlorine bleach (sodium hypochlorite) 

mixed with clean water to reach a concentration of 525 to 600 mg/L of available chlorine (CDC 2003). 

Other disinfectants labeled for use on environmental surfaces in hospital or health care settings can be 

used in place of chlorine. 

To form the solution to be used to disinfect contaminated environmental surfaces, add common household 

or laundry bleach (unscented) containing 5.25 to 6% available chlorine (52,500 to 60,000 mg/L) to clean 

water to develop a 1 to 100 dilution (1% solution = 525 to 600 mg/L). This solution will be effective on 

most pathogens but may not eliminate bacterial spores and parasites. 

A 1% chlorine solution for routine disinfection of surfaces can be prepared by adding 

• 10 milliliters of 5.25 to 6% bleach to 1 liter of clean water, 

• 50 milliliters of 5.25 to 6% bleach to 5 liters of clean water, 

• 100 milliliters of 5.25 to 6% bleach to 10 liters of clean water, 

• 200 milliliters of 5.25 to 6% bleach to 20 liters of clean water, or 

• 1 liter of 5.25 to 6% bleach to 100 liters of clean water. 

The effectiveness of the disinfection processes is influenced by the following: 

• type of chemical used 
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• amount of chemical used 

• contact time between disinfectant and liquid waste 

• organic load of the waste 

• temperature, humidity, and pH 

Additional guidance on the use of disinfectants can be found in Attachment 1 of this document. 

Worker Safety and Health Issues 

The risk for developing disease from infectious agents in autopsy fluids is low. Proper handling and 

disposal of these wastes is needed to control exposure and to ensure an aesthetically and culturally 

acceptable method of waste management. Autopsy waste handlers have potential exposures to blood and 

body fluids; human waste pathogens; and environmental microbial contaminants from the decaying 

process (which have been associated with opportunistic infections) during generation, cleanup, 

transportation, storage, treatment, and disposal processes. Critical guidance is outlined in subsequent 

sections of this document. Additional guidance may be found in the documents referenced at the end of 

this document and at the Web sites listed under “Additional References” at the end of this section. 

Recommendations for Personal Protective Equipment, Including Universal Precautions 

and Personal Hygiene 

• Handwashing with soap or alcohol-based hand sanitizer is probably the most important step, 

because several of the microbial agents can be transmitted by a fecal-oral route. 

• No one should eat, drink, or smoke in work areas where autopsy waste is handled. 

• Universal precautions should be used to protect against bloodborne diseases. These precautions 

include the use of latex or nitrile gloves, safety goggles or face shields, impervious clothing or 

aprons, and masks. 

• Aerosolization of pathogens while handling this waste is possible. The generation of aerosols (for 

example, by the use of high-pressure hoses for cleaning) in these work areas should be minimized. 

Avoiding procedures that create aerosols and using the appropriate work practices described 

previously should make respiratory protection unnecessary. In situations where workers may be 

exposed to aerosolized microorganisms, disposable NIOSH-approved N-95 respirators can be used 

for respiratory protection. Note: A respirator will work only if it is used correctly. Key elements for 

respiratory protection are fit-testing and training of each worker in the use, maintenance, and care 

of the respirator. Disposable facemasks and N-95 cartridges become ineffective when exposed to 

liquid splash directly on the filter materials. They should be replaced when splashed and when 

obviously soiled or contaminated with water or other potentially pathogenic material. 

• Vaccinations for all employees handling human autopsy waste should include tetanus and 

diphtheria (Td), hepatitis A, typhoid, hepatitis B, and polio. 

• HIV prophylaxis should be available in case a person’s mucous membranes are accidentally 

exposed to autopsy waste. Administration of HIV prophylaxis in case of accidental exposure should 

be based on the type of exposure. Exposed workers should immediately report any blood or body 

fluid exposure to a qualified medical authority for appropriate assessment and treatment. 

• Chemicals used to treat the autopsy waste stream may include chlorine (sodium hypochlorite), lime 

(calcium oxide), and soda ash (sodium carbonate). The occupational hazards associated with these 

three chemicals indicate that safe handling practices should be used for these chemicals. Chemicalresistant protective gloves and safety goggles would protect workers from accidental splashes 

during the treatment or disposal process. 

Additional References 

www.who.int/mediacentre/factsheets/fs253/en/
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www.who.int/water_sanitation_health/medicalwaste/en/microbhazards.pdf

www.bt.cdc.gov/disasters/tsunamis/handleremains.asp

www.who.int/hac/techguidance/pht/en/11818.pdf

www.paho.org/English/DD/PIN/pr040923.htm

www.who.int/hac/techguidance/ems/flood_cds/en/

www.cdc.gov/niosh/npg/npg.html

Liquid Waste Management and Disposal Options 

Seven options are proposed for consideration in disposal of wastes generated during the autopsy process. 

Authorities with an understanding of local conditions will need to assess the suitability of the options 

presented here and select the best practice for each waste-generation location. 

1. Waste Reduction 

If practical, blood and body fluids generated during autopsy should be absorbed on suitable material and 

placed in the body cavity. The body can than be moved to the location of final disposition (Dunsmore 

1986). 

2. Public Wastewater Treatment and Disposal System 

A properly designed and functioning public wastewater disposal system has the capacity to adequately 

treat liquid wastes from many sources and dispose of these wastes in a manner that will not create an 

environmental or public health hazard. Disposal of wastes from the processing of corpses creates a waste 

stream that should be easily treatable by properly functioning public wastewater treatment and disposal 

systems. Communities where such wastewater disposal systems are available and properly operating 

should consider using this method of disposal for wastes generated from the autopsy processes. If this 

disposal option is selected, it is of critical importance that blood and body fluid waste be added slowly to 

the treatment system. This slow addition of liquid waste over a period of time will prevent overloading of 

the wastewater treatment system. 

3. Septic Tank and Drain Field 

On-site disposal of liquid wastes through the use of a septic tank and soil-absorption drain-field system 

has been an accepted method of human waste disposal for most of the past century, as long as the septic 

tank and drain field are properly designed, functioning, and maintained. However, many variables must be 

considered before using a septic tank system to dispose of autopsy waste. Assessing the system’s 

performance history would be necessary. Adequate separation should exist between the bottom of the 

absorption field trench and the seasonally high water table or any impervious horizon such as bedrock or 

restrictive clays. The septic tank should be inspected to ensure water tightness. (Water tightness is 

ensured by removing the manhole cover and determining the depth of the liquid. If the tank is not filled to 

a level just below the inlet, tank leakage is likely occurring.) The system should also be of adequate size 

to accommodate the increase in the waste load. Shock loading of the septic tank system with an additional 

flow of wastewater could cause surface failure, such as the seeping of liquid waste to the ground surface. 

Any discharge of these wastes to a septic tank system should be done over a period of time without 

exceeding the design capacity of the system (NFDA 2004). 

Preservative chemicals such as formaldehyde, formalin, and methanol present in the waste may impair 

the operation of subsurface disposal systems. Alternative disposal methods should be considered if 

chemicals are present in the waste stream. 
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4. Hospital/Commercial Incineration 

Disposal by incineration using a hospital incinerator designed to destroy infectious waste or a using a 

commercial incinerator such as a rotary kiln or a fluidized bed are very effective methods of disposal for 

these types of wastes. However, such disposal may be costly, and care would need to be taken to ensure 

the proper injection rate of the material into the incineration unit. Transporting the liquid waste to an 

incineration site may also be an issue. 

5. Disposal at Sea 

The rapid logarithmic dilution of autopsy liquid waste by deep-sea disposal is an effective alternative 

under the current disaster circumstances. The waste would need to be transported to a boat or ship with 

the capacity to haul the liquid at least 5 miles beyond the shoreline for deep-sea disposal. To ensure 

maximum dilution, the waste needs to be slowly released while the ship is moving parallel to or away from 

the shore. If this option is considered, local authorities would need to determine and ensure compliance 

with national and international laws and regulations governing sea disposal. 

6. Land Application 

Applying liquid wastes to the land surface can be an effective method of waste disposal. However, as with 

septic tank systems, many variables must be considered to protect health and the environment. Siting of 

the disposal area is critical to proper land application of liquid wastes. Factors that must be carefully 

considered are location (including minimum distances from wells, surface waters, and residences), 

topography, drainage, soil depth, groundwater depth, security and access, and properly designed loading 

and application rates (U.S. EPA 1995a). 

Because land application has the greatest exposure potential for human contact, it is very important to 

include a chemical stabilizer such as slaked lime [Ca(OH)2] or quicklime (CaO) to the waste before 

applying it to the land surface. Slaked or hydrated lime is readily available in most parts of the world and 

is easy to handle and safe to work with. Lime added to the liquid waste in sufficient quantities to raise the 

pH above 12 for 2 hours or more after contact can reduce bacterial and viral pathogens by 99% or more. 

Lime stabilization reduces parasites including helminthic parasites by one or more logs (U.S. EPA 1995b). 

Lime can be mixed with liquid waste in a mixing tank. Mixing must be sufficient to ensure that the entire 

content comes into contact with the lime and undergoes the increase in pH. The pH of the liquid lime 

mixture should be measured at several locations to ensure that the pH is raised throughout the material 

(Spinosa and Vesilind 2001). 

After uniform distribution over the land surface by use of a mechanical spreader or similar device, the 

waste should be mixed thoroughly in the upper soil horizons by using a tractor-pulled plow or farming 

disk. Lime stabilization effectively reduces potential exposures and minimizes health risks associated with 

land application of liquid waste (Spinosa and Vesilind 2001). 

Land Application—Vector Attraction Reduction and Odor Control: Adult filth flies may be attracted 

to and feed on land-applied blood or body fluids. Mechanical transfer of pathogens by flies to humans and 

food is possible. Proper lime stabilization will reduce the attraction of vectors to the site and greatly 

decrease the risk for pathogen transfer by vectors. 

Vector attraction reduction is best accomplished by holding the waste at a pH of 12 or higher for at least 2 

hours, and then at a pH of 11.5 or more for an additional 22 hours. 

Lime stabilization does not reduce volatile solids. Field experience has shown that the application of limestabilized material after the pH has dropped below 10.5 may create odor problems. Therefore, it is 
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recommended that land application of biosolids take place as soon as possible after vector attraction 

reduction is completed and while pH remains elevated (U.S. EPA 1995c). 

7. Trenching 

Disposing of waste by pouring it into trenches is an appealing option because of the low-cost limited work 

required. However, trenching may present the greatest threat to groundwater contamination, because no 

mechanism exists for primary treatment (such as a septic tank), and uniform distribution of the waste 

could be difficult. Methods for trenching should follow the same guidance as those for installation of the 

drain-field portion of a conventional septic tank system. This guidance includes installing level trenches at 

depths that ensure a minimum of 1.5 meters of separation between the bottom of the trench and 

groundwater, bedrock, or any other restrictive horizon, and a minimum amount of soil cover to ensure 

that contact with humans is not possible. Other factors that must be carefully considered in addition to soil 

depth are location (including minimum distances from wells, surface waters, and residences), topography, 

soil permeability, and properly designed loading and application rates. 

If chemicals such as formaldehyde or formalin are present in the waste stream in more than trace 

quantities, subsurface disposal by the trench disposal method should not be considered. 

Environmental Considerations for the Selection of Land Disposal Sites: Assessment of 

Potential Sites for Land Application or Trench Burial of Liquid Waste from Cadaver 

Processing 

This section and the following survey instrument describe considerations for assessing the suitability of a 

site for land application or trench burial of liquid waste from cadaver processing during the emergency 

situation following the tsunamis in Southeast Asia. This section describes general assessment 

considerations. Attachment 2 of this document provides a checklist for environmental health professionals 

to use in rapidly assessing a proposed liquid waste disposal site. 

Note: This section does not address the availability of suitable equipment for land application (such as 

tractors, disk plows, tank trucks, or trailers with spreading apparatus), or cultural considerations related 

to land application of liquid waste from cadavers. These are inherently local issues that will need to be 

addressed onsite. 

Location and Geography 

The site should be located away from populated areas, surface water (e.g., streams, lakes), and water 

supply sources (including wells) as much as possible. WHO recommends that burials be sited at least 30 

meters from surface water or springs and at least 250 meters from drinking water sources (including 

wells). However, these recommendations apply to bodies and not to liquid waste, and they are not 

universally applicable standards. For land application of biosolids, the interim best management practices 

of the city of Ottawa, Canada, recommend a minimum of 90 meters of separation distance from wells and 

450 meters from residential areas and schools. (However, these practices are stricter than are the Ontario 

provincial guidelines.) Other local factors related to soils, hydrogeology, and cultural considerations may 

require larger separation distances. A technical site evaluation by an environmental health specialist, if 

one is available, would aid in appropriate site selection.

Topography 

The site should not be in an area that experiences flooding or ponding during the rainy season. The site 

should also be as level as possible to minimize storm runoff, especially during the current rainy season. If 

significant runoff from the site is unavoidable, trenches should be dug around the site to collect and store 

runoff onsite. 
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Soils 

Note: To make this document as useful as possible during this emergency situation, the authors have not 

included technical soils descriptions. A site and soils assessment by an environmental health specialist, if 

available, would be very useful. 

The site should be in an area with soils of relatively fine-grained, mixed texture. Sandy soils, which would 

allow very rapid drainage, should be avoided. If the soil is thoroughly wetted and does not remain in a ball 

when squeezed, the soil is probably too sandy. The soil should have a depth of at least 1.5 meters over 

bedrock or any subsurface soil layer that is impermeable. 

Depth to Groundwater 

If waste is applied to the surface, a minimum distance of 1.5 meters should exist between the surface and 

the seasonal high groundwater table. If waste is buried in trenches, the bottom of the trench should be at 

least 1.5 meters above the seasonal high groundwater table. Because the rainy season is currently 

underway in the tsunami-affected areas, the seasonal high water table is likely to be approximately the 

current level of groundwater. 

Access 

Access to the autopsy waste disposal site should be controlled as much as possible, both during and after 

disposal. The site should be fenced and should not be used for agriculture, grazing, housing, or other uses 

during or after waste application. Because this document has been written without the benefit of specific 

information about the waste being disposed of or about the local environment, it is difficult to recommend 

a specific time frame for limiting access after disposal is completed. Guidelines for access to biosolid 

disposal sites vary depending on the content of the material. U.S. EPA biosolids guidance ranges from 

limiting all access for 3 years to allowing activities such as grazing after as little as 30 days. The interim 

best management practices for the city of Ottawa, Canada, state that farmers should wait at least 1 year 

after biosolids application before growing nonroot vegetable crops, 5 years before growing root-vegetable 

crops, and 5 years before using the land as pasture. The Ontario provincial guidelines are weaker, allowing 

for use as pastureland after only 2 to 6 months. All of these guidelines, however, generally require some 

level of monitoring, with modification of time frames if indicated on the basis of that monitoring. Limiting 

access for a minimum of 3 months after the last application of waste should ensure that potential 

pathogens have been attenuated; however, without the authors’ having further information on the 

characteristics of the waste or the environment, this should not be taken as firm guidance. 

Application Rates 

Application rates for biosolids are often determined on the basis of nutrient requirements. This method is 

not applicable here. Also, using this method requires both the soil and the disposed-of material to be 

analyzed, which will likely not be possible. For land application, in the absence of better guidance, the 

liquid waste should be applied at a rate that the soil can readily absorb so that no surface runoff occurs. 

For trench burial, the liquid waste should be applied in narrow trenches so that it covers the bottom of the 

trench uniformly to a shallow depth (e.g., < 10 centimeters), and then covered immediately with soil so 

that no liquid is visible. 

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Disposing of Liquid Waste from Autopsies in Tsunami-Affected Areas: Guidance from the 

Centers for Disease Control and Prevention 

(continued from previous page) 

 January 17, 2005 Page 12 of 14 

Attachment 1 

Calculation of Concentrations for Surface Decontamination Solutions 

Making liquid solutions from dry materials 

After mixing chlorine powders or high-strength granular products with water, allow the insoluble material 

to settle and pour off the clear liquid. Wear respirator to prevent inhalation of caustic dust. 

General formula: 

Weight of dry material = desired concentration (%) X desired volume X weight conversion

% active disinfectant in dry material 

Weight conversions = 1000 for g and liters 

8.33 for lb and US gal 

10 for lb and UK gal 

Example 1: 1 liter of a 2% chlorine solution is to be prepared for high-strength calcium hypochlorite 

(70% available chlorine): 

 Weight = 2 x 1 x 1000

70 

= 28.6 g 

 Thus, 28.6 g should be mixed in 1 liter of water. 

Example 2: 1 gal (US) of a 2% chlorine solution is to be prepared for high-strength calcium hypochlorite 

(70% available chlorine): 

 Weight = 2 x 1 x 8.33

70 

= 0.24 lb 

 Thus, 0.24 lb should be mixed in 1 gal (US) of water. 

Diluting concentrated solutions of bleach 

To calculate the amount of water per unit volume of disinfectant concentrate: 

General formula: 

Parts of water 

to be added to 

1 part of disinfectant 

= concentration of concentrate (%)

final concentration of solution (%) 

Example: To make a 0.4% chlorin–e solution from household bleach containing a chlorine concentration of 

5.25%: 

 Parts of water = 5.25 

0.4% 

– 1 = 12.1 

 Add 1 part of 5.25% bleach to 12 parts of water 

 (i.e., 1 liter of bleach + 12 liters of water = 13 liters of use solution). 
Disposing of Liquid Waste from Autopsies in Tsunami-Affected Areas: Guidance from the 

Centers for Disease Control and Prevention 

(continued from previous page) 

 January 17, 2005 Page 13 of 14 

Attachment 2 

Rapid Site Assessment Form for Land Application or Trench Burial of Liquid Waste 

from Cadaver Processing 

Location and Geography 

Distance of disposal site from: 

Feature Distance Measured by 

Nearest surface water 

If closer than 30 meters, 

seek another site 

_____ meters Measuring tape 

Survey instrument 

Pacing 

Estimated from map 

Nearest water source 

If closer than 250 meters, 

seek another site 

_____ meters Measuring tape 

Survey instrument 

Pacing 

Estimated from map 

Nearest residential area 

If closer than 450 meters, 

seek another site 

_____ meters Measuring tape 

Survey instrument 

Pacing 

Estimated from map 

Topography 

Is the site relatively flat? 

 Yes 

 No Æ seek another site 

Gradient of site (if possible to measure): _____% slope, as measured by __________ 

Any gradient steeper than a 5% grade should be avoided if possible. 

Soils 

Texture: if soil is thoroughly wetted, does it remain in a ball when squeezed together? 

 Yes 

 No Æ seek another site 

Depth: is the soil at least 1.5 meters deep? 

 Yes 

 No Æ seek another site 

Method of determining soil depth: 

 auger drill dug pit other (specify)_____________ 
Disposing of Liquid Waste from Autopsies in Tsunami-Affected Areas: Guidance from the 

Centers for Disease Control and Prevention 

(continued from previous page) 

 January 17, 2005 Page 14 of 14 

Depth to Groundwater 

Depth: is the depth to groundwater from the ground surface (for land application) or the bottom of the 

trench (for trench burial) at least 1.5 meters? 

 Yes 

 No Æ seek another site 

Method of determining depth to groundwater: 

 auger drill dug pit other (specify)_____________ 

Access 

Can access to the site be controlled both during and after disposal? 

 Yes 

 No Æ seek another site 

Method for controlling access (check all that apply): 

 fence signs guard other (specify)_____________ 

For more information, visit www.bt.cdc.gov/disasters/tsunamis, or call the CDC public response hotline 

at 888-246-2675 (English), 888-246-2857 (español), or 866-874-2646 (TTY).