Causes of Mortality for Indonesian Hajj Pilgrims: Comparison between Routine Death Certificate and Verbal Autopsy Findings

Masdalina Pane,Sholah Imari,Alex R Cook,Gina Samaan,Qomariah Alwi,I Nyoman Kandun,Julian W Tang

doi:10.1371/journal.pone.0073243

Abstract

BackgroundIndonesia provides the largest single source of pilgrims for the Hajj (10%). In the last two decades, mortality rates for Indonesian pilgrims ranged between 200–380 deaths per 100,000 pilgrims over the 10-week Hajj period. Reasons for high mortality are not well understood. In 2008, verbal autopsy was introduced to complement routine death certificates to explore cause of death diagnoses. This study presents the patterns and causes of death for Indonesian pilgrims, and compares routine death certificates to verbal autopsy findings.MethodsPublic health surveillance was conducted by Indonesian public health authorities accompanying pilgrims to Saudi Arabia, with daily reporting of hospitalizations and deaths. Surveillance data from 2008 were analyzed for timing, geographic location and site of death. Percentages for each cause of death category from death certificates were compared to that from verbal autopsy.ResultsIn 2008, 206,831 Indonesian undertook the Hajj. There were 446 deaths, equivalent to 1,968 deaths per 100,000 pilgrim years. Most pilgrims died in Mecca (68%) and Medinah (24%). There was no statistically discernible difference in the total mortality risk for the two pilgrimage routes (Mecca or Medinah first), but the number of deaths peaked earlier for those traveling to Mecca first (p=0.002). Most deaths were due to cardiovascular (66%) and respiratory (28%) diseases. A greater proportion of deaths were attributed to cardiovascular disease by death certificate compared to the verbal autopsy method (p<0.001). Significantly more deaths had ill-defined cause based on verbal autopsy method (p<0.001).ConclusionsDespite pre-departure health screening and other medical services, Indonesian pilgrim mortality rates were very high. Correct classification of cause of death is critical for the development of risk mitigation strategies. Since verbal autopsy classified causes of death differently to death certificates, further studies are needed to assess the method’s utility in this setting.

Highlights

Each year, Muslims from all over the world undertake the Hajj pilgrimage to and in Saudi Arabia [1]
We explore both personspecific and site-specific factors associated with mortality, and compare the cause of death from the routine death certificate to the newly introduced verbal autopsy method
Indonesian pilgrims for the Hajj in 2008

Summary

Introduction

Muslims from all over the world undertake the Hajj pilgrimage to and in Saudi Arabia [1]. In the last two decades, the mortality rate of Indonesian pilgrims, excluding years in which disasters such as stampedes occurred, fluctuated between 200–380 deaths per 100,000 persons during the ten-week Hajj period [5]. Even compared to the yearly mortality rate in Indonesia, the mortality rate for Hajj pilgrims ranged between 1,765 and 3,353 per 100,000 per year; by comparison, the Indonesian estimated national crude death rate was 700 per 100,000 in 2003 [8]. In the last two decades, mortality rates for Indonesian pilgrims ranged between 200–380 deaths per 100,000 pilgrims over the 10-week Hajj period. This study presents the patterns and causes of death for Indonesian pilgrims, and compares routine death certificates to verbal autopsy findings. A greater proportion of deaths were attributed to cardiovascular disease by death certificate compared to the verbal autopsy method (p

Methods

Results

Discussion

Conclusion