RISK FACTORS FOR RESPIRATORY DEATH AMONG INDONESIAN PILGRIMS IN 2018

1 Department of Epidemiology, Faculty of Public Health, University of Indonesia, prilliasyafiraliani@gmail.com 2 Department of Epidemiology, Faculty of Public Health, University of Indonesia, putri.bungsu10@ui.ac.id Corresponding Author: Putri Bungsu Machmud, putri.bungsu10@ui.ac.id, Department of Epidemiology, Faculty of Public Health, University of Indonesia, Pondok Cina, Beji, Depok, Indonesia, Postal Code 16424


INTRODUCTION
The Hajj pilgrimage in Saudi Arabia is a once-in-a-lifetime obligation for all Muslims (Pane et al., 2019). In 2018 or 1439 H, the number of pilgrims from all over the world reached 2,371,675, with 203,351 of these pilgrims traveling from Indonesia (Kemenkes RI, 2018). Risk factors that exist in Saudi Arabia and within the pilgrims themselves can increase the likelihood of several diseases that have the potential to cause death. Deaths among pilgrims are proven by the existence of a Certificate of Death (CoD), which is the main source of death or mortality data. The writing of the cause of death follows the rules set by the WHO in ICD-10 (Pane et al., 2019).
Data from the Indonesian Ministry of Health Hajj Health Center indicates that the number of pilgrims who died during the Hajj pilgrimage in Saudi Arabia has fluctuated over the past three years (2016)(2017)(2018). In 2016, 341 pilgrims died, which increased to 658 in 2017, then decreased to 386 pilgrims in 2018. The leading cause of death for the last three years has been cardiovascular and respiratory disease (Kemenkes RI, 2018). In 2016 and 2017, cardiovascular disease was the cause of death for 165 (48.39%) and 176 (26.74%) pilgrims, respectively, while respiratory disease was the cause of death for 88 (25.80%) and 114 (17.33%) pilgrims, respectively. This changed in 2018, with respiratory disease becoming the leading cause of death (142 pilgrims; 36.79%) (Alfridaningrum, 2018).
Several risk factors contribute to the number of deaths due to respiratory disease during the Hajj pilgrimage, such as having a pre-existing respiratory disease and old age (Rudiyanto, 2013). For example, pilgrims aged ≥60 years with or without disease and pilgrims aged <60 years with disease are included in the high-risk group according to the Indonesian Ministry of Health, and this is marked on their Pilgrim Health Card in orange (Kemenkes RI, 2018). Another risk factors that also contribute to the health condition of pilgrims are behavioral risk factors, such as smoking, not having an influenza vaccination, high or low body mass index (BMI), low physical activity, and high stress, socioeconomic risk factors, such as low levels of education and certain types of work and environmental risk factors specific to Saudi Arabia, such as the mass gathering of pilgrims causing the transmission of respiratory disease, temperatures reaching highs of 45˚C and lows of 19˚C with low humidity, and reduced access to health facilities and services (Rudiyanto, 2013). Previous studies have shown that age, education, and pre-existing respiratory disease are the factors most associated with the death of pilgrims (Rudini, 2016;Rudiyanto, 2013). This study analyzes the risk factors associated with death caused by respiratory disease in Indonesian pilgrims in 2018.

METHODS
This study used an analytic observational and cross-sectional study design. Secondary data was obtained from the Integrated Computerized Hajj System for Health (Siskohatkes or Sistem Komputerisasi Haji Terpadu Bidang Kesehatan) and included the medical records of the pilgrims' first, second, and third health examinations before they left for the Hajj pilgrimage. The data was sourced from the Hajj Health Center, Ministry of Health of the Republic of Indonesia in 2018.
Indonesian Hajj pilgrims who died during the pilgrimage in Saudi Arabia in 2018 were included in the study if their complete risk factor data was recorded in the Integrated Computerized Hajj System for Health. After 27 pilgrims with extreme data values had been excluded as outliers, the data of 361 remaining pilgrims was entered into the study.
The dependent variable in this study was the death of the Hajj pilgrims due to respiratory disease as stated in the CoD contained in the Siskohatkes data. The independent variables included the age of the pilgrims when they died according to their passports (categorized as <60 years and ≥60 years) and whether or not they had a pre-existing respiratory disease, which was determined by the ICD-10 (J00-J99).
Risk factors related to the socioeconomic environment included level of education, which was categorized into higher education (diploma/Bachelor or higher degree), secondary education (high school/SMA), and primary education (junior high school/SMP, elementary school/SD, and no school); and type of employment, which was categorized as outdoor (e.g. farmer or military/police) or indoor (e.g. government civil servants/PNS, private sector, BUMN/BUMD employee, traders, housewives, and retirees).
Other risk factors analyzed in this study included smoking status and influenza vaccination status, which were based on the information in the pilgrims' first Hajj health examinations and were categorized as smoking/not smoking and vaccinated/not vaccinated, respectively. The pilgrims' BMI was also included in the analysis as this is a simple index used to determine if someone is under or overweight. A person's BMI is obtained by dividing their body weight in kilograms by the square of their height in meters (kg/m2). That person can then be categorized as being of normal weight (BMI 18.50-24.99), underweight (BMI <18.50), or overweight (BMI ≥25.00).

Distribution of Cause of Death and Risk Factors of Death in Indonesian Hajj Pilgrims
There were 361 pilgrims who died during the implementation of the pilgrimage and respiratory diseases were the highest causes of death for pilgrims, amounting to 135 (37.40%) ( Table 1).

Relationship between Risk Factors and Death Caused by Respiratory Disease
Bivariate test results showed that age, sex, education level, type of work, BMI, influenza vaccination status, and smoking status did not have a significant relationship with death caused by respiratory disease (ps > 0.05) ( Table 3). In contrast, having a pre-existing respiratory disease was significantly associated with death due to respiratory disease (p = 0.02), with pilgrims who had a pre-existing respiratory disease 1.49 times more likely to have died from respiratory disease compared to pilgrims who did not have a preexisting respiratory disease. The results also found that being underweight according to the BMI was significantly associated with death due to respiratory disease (p = 0.03), with underweight pilgrims 1.44 times more likely to have died from respiratory disease compared to pilgrims with a normal BMI. Similarly, influenza vaccination status was also significantly related to death due to respiratory disease (p = 0.03), with pilgrims who had not had the influenza vaccination more likely to have died due to respiratory disease (PR = 1.34) compared to pilgrims who had had the influenza vaccination (Table 3).

Most Influential Risk Factors
The PR-adjusted model showed that the most influential risk factor was pre-existing respiratory disease (PR = 1.55; 95% CI: 1.16-2.90), with pilgrims who had a pre-existing respiratory disease 1.55 times more likely to have died from respiratory disease compared to pilgrims who did not have a pre-existing respiratory disease. Influenza vaccination status was the second most influential risk factor (PR = 1.39; 95% CI: 1.07-1.81), with pilgrims who had not had the influenza vaccination 1.39 times more likely to have died from respiratory disease compared to pilgrims who had had the influenza vaccination (Table 4).

Distribution of Diseases That Cause Death in Indonesian Hajj Pilgrims
The results found that the highest cause of death during Hajj pilgrimage in 2018 were due to respiratory diseases amounted 135 (37.40%) pilgrims died and the rest were other diseases amounted 226 (62.60%). In the last three years, respiratory disease is the third largest cause of death in Indonesian pilgrims, in 2016 = 88 (25.80%) and in 2017 = 114 (17.33%) of the total pilgrims who died in that year (Alfridaningrum, 2018).

Relationship between Genetic Risk Factors and Death Caused by Respiratory Disease
The results of this study stated that there is no correlation between age and death in Indonesian pilgrims. It differ from other studies, there is a relationship between age and death in Indonesian pilgrims (Rudini, 2016;Rudiyanto, 2013). This difference could be due to the different population and analysis techniques. Rudiyanto (2013) found that the higher the age of the pilgrims, the higher their risk of death. That study also found that pilgrims aged over 60 years were more at risk of death caused by respiratory disease compared to those aged under 60 years. As we get older, the respiratory system undergoes various anatomic, physiological, and immunological changes. Other factors such as new environmental conditions and new activities can make it difficult for elderly pilgrims to adapt, and mass gatherings of pilgrims from all over the world can potentially lead to the The results indicated that sex is not a risk factor for death in Indonesian pilgrims, which is in line with Rudini (2016) findings. In contrast, a study conducted in Russia looking at death caused by respiratory disease found that men were twice as likely to die from respiratory disease compared to women (Manakov, Kolosov, Polyanskaya, & Naryshkina, 2017). This difference could be due to the due to differences in activities in Saudi Arabia, differences in unhealthy living habits before leaving for Hajj (such as smoking), and the different levels of awareness of treatment between male and female (Rudiyanto, 2013).
The results showing a relationship between having a pre-existing respiratory disease and death in Indonesian pilgrims are in line with other studies (Pane et al., 2019;Rudini, 2016). The available data also indicated that the most common respiratory diseases found in pilgrims were COPD (chronic obstructive pulmonary disease), asthma, and pneumonia. Hajj requires a large amount of physical activity, and someone who has a respiratory disease or other illness will already be in poor health. There are also several risk factors associated with Hajj in Saudi Arabia that can contribute to the severity of respiratory disease, such as a lack of rest and dehydration. Pilgrims with pre-existing respiratory diseases like asthma or COPD may experience asthma attacks or difficulty breathing, which if not dealt with immediately can cause respiratory failure and death (Ihaji, Gerald, Helen, & Ogwuche, 2014;Pane et al., 2019;Rahman, Thu, Arshad, & Van der Putten, 2017;Rudini, 2016).

Relationship between Socioeconomic Risk Factors and Death Caused by Respiratory Disease
The results of this study state that there is no correlation between education level and death in Indonesian pilgrims. It contrast with the findings of Rudini (2016) study which showed that there is a significant correlation between education level and death in Indonesia pilgrims. This difference could be caused by different samples or populations and analysis techniques. Level of education can signify knowledge and health seeking behavior. For example, Ihaji, Gerald, Helen, & Ogwuche, 2014) found that someone with a higher level of education had a greater level of awareness when it came to seeking treatment compared to people with a lower level of education.
The results of this study showed that there is no correlation between type of work and death in Indonesian pilgrims. It's in line with other studies. For example, Medistianto (2017) found that type of work was not related because the categorization is less sensitive and the type of pilgrimage work is indeed difficult to say can be directly related to deaths of Indonesian pilgrims that caused by respiratory diseases, even though in that study found the results that the indoor work category is a protective factor. This could be due to the number of pilgrims who were farmers included in the outdoor category as is the largest type of work of Indonesian pilgrims that has died because of respiratory disease, which is 45.70% of each type of work. Farmers also had the highest proportion of pre-existing respiratory disease compared to the other occupations, and it has been found that preexisting respiratory disease is a risk factor for death due to respiratory disease. The farmers who died from respiratory disease also had the highest proportion of smokers compared to the other types of work, and smoking can cause respiratory disease, especially COPD (Riesco et al., 2017)

Relationship between Behavior Risk Factors and Death Caused by Respiratory Disease
The results showed that BMI was not associated with death caused by respiratory disease. Other studies have found that underweight adults have higher rates of respiratory death than adults who are a normal weight, but it is unclear whether this association is causal or reflects illness-induced weight loss (reverse causality) (Kivimäki et al., 2016). The results of other studies have shown that severe COPD is significantly associated with being underweight Eriksson et al (2016), while being overweight or obese is associated with cardiovascular disease or death caused by cardiovascular disease (Gregory et al., 2017;. The results also showed that smoking was not related to death caused by respiratory disease, which is in contrast with another studies. Smoking can make respiratory disease worse rather than directly causing death (West, 2017). It can also negatively affect the immune system and damage lung tissue, causing respiratory disease and increasing the risk of respiratory infections (Zuo et al., 2014). Smoking also increases the risk of pneumonia and chronic bronchitis (Restrepo, Sibila, & Anzueto, 2018). This difference could be due to the the proportion of pilgrims who smoked less (11.40%) than those who did not smoke. This can be caused at the time of the health examination, only smoking behavior was asked, not a history of smoking.
The results showed that influenza vaccination status was associated with death caused by respiratory disease. Respiratory infections are very common and easily transmitted during Hajj, therefore, the influenza vaccination plays an important role in preventing people from catching these infections (Benkouiten, Al-Tawfiq, Memish, Albarrak, & Gautret, 2019; . In a previous study, it was found that pilgrims who had had the influenza vaccination were less likely to have acute respiratory infections, especially influenza-like illnesses (Alfelali et al., 2018). According to other studies, the influenza vaccination is considered effective at reducing respiratory disease infections in pilgrims (Zeitouni et al., 2015). In a systematic review conducted in China, it was found that the influenza vaccination was associated with a significant reduction in mortality due to COPD and pneumonia and that it could also reduce acute exacerbation of COPD (Bekkat-Berkani et al., 2017).
There is a significant relationship between vaccination status and death due to respiratory disease in pilgrims, but this needs to be further understood. The influenza vaccination can directly reduce complications associated with and the exacerbation of COPD, which can help prevent death from respiratory failure, and also directly reduce the transmission of respiratory infections (Alfelali et al., 2018).

Research Limitation
This study used a cross-sectional design, therefore, a causal relationship cannot be identified. Variables such as age, sex, level of education, type of work, BMI, and smoking status are indirect causes of death due to respiratory disease, and the data only included whether the pilgrims smoked at the time of their first health examination rather than providing a smoking history. Not all of the data was used as 27 outliers were excluded.

CONCLUSION
The most influential risk factors for death due to respiratory disease in pilgrims are pre-existing respiratory disease and influenza vaccination. The risk factors of age, sex, level of education, type of work, BMI, and smoking status were found to be unrelated to death caused by respiratory disease in the Indonesian pilgrims in 2018. Pilgrims should make sure they have the influenza vaccination before leaving for Saudi Arabia, especially those with a pre-existing respiratory disease like COPD, asthma, or pneumonia. Although there is a small possibility of respiratory disease transmission after having the vaccination, it still reduces the symptoms of respiratory disease.