Effects of Annual Haze Exposure on

Morbidity and Mortality of Children

for Respiratory Infection in
Pekanbaru, Riau Province, Indonesia

Research Project Proposal

Submitted By
dr Suyanto, MPH
Public Health Lecture,
Medical Faculty, Riau University, Indonesia
Email:
suyantounri@gmail.com

Table of Contents
Effects of Annual Haze Exposure on Morbidity and Mortality of Children for Respiratory
Infection in Pekanbaru, Riau Province, Indonesia......................................................................1
Abstract.......................................................................................................................................3
Introduction.................................................................................................................................4
Justification of study...................................................................................................................5
Purpose of the study....................................................................................................................5
Spesifically, there are three spesific objective to be achieve of this study:................................5
Research Question......................................................................................................................5
Research Design, Methods and Procedures................................................................................6
Significance of the study.............................................................................................................7
References...................................................................................................................................7
ANNEX 1....................................................................................................................................9
Time Table of the PhD-Project...............................................................................................9

Abstract
Background
Every year, Indonesia experiences severe smoke haze pollution from uncontrolled forest fires.
Although the relation between outdoor air pollution and respiratory infection occurance has
been examined in several publication, there is limited research concerning the health effects of
haze in Indonesia. This study was undertaken in Pekanbaru, Indonesia to investigate the
effects of annualy haze period on mortality and mortality specially on children age group
with an emphasis on particulate matter (PM*).
Objective:
There were three primary aims: (1) To estimate the effect of exposure to daily
mean concentrations (microg/m3) of PM10, on hospital admissions of
children for acute lower respiratory infection.
(2) To examine the
associations of daily mortality due to all natural causes and daily causespecific mortality
respiratory infection causes with daily mean
concentrations (microg/m3) of PM10; (3) To determine the characteristics
contributing to increased susceptibility, e.g. differences in underlying
health status, access to medical care, and exposure to indoor triggers
Method:
The retrospective observational design will be taken in documenting data
about mortality and morbidity on respiratory infection and air pollutant
exposure . Regression analyses were conducted using time-series
approaches,

Introduction
The haze crisis is an annual event in Indonesia 1234, but it is especially
intense with El Nino phenomenon on 2015 5. Smoke haze from forest fires
in Indonesia periodically causes very high pollution readings particularly in
the Sumatra and Kalimantan1. The level of PM 10 (one of particulate air
pollution indicators) has reached very hazardous levels as record high of
3000 on 2015, 24 October6.
The health impact of exposure to particulate matter in the air depends on
the concentration and duration of the exposure, as well as the health
status and level of activity of the individual 789.

Children10, pregnant

women, elderly11, and people with chronic lung disease9, heart diseases
patients1213 in the haze crisis are the vulnerable group which have severely
threatened their health .
According statement from Natural Disaster Mitigation Agency Head, more
than 500,000 Indonesians are suffering from acute respiratory infection
after having been exposed to fire-induced haze for months14. Particularly in
Pekanbaru, Riau, one of the worst-affected by the haze where I live, the
number of people with respiratory problems due to haze problem has risen
to 54135 people on 3 October15, most of them are children and some have
died from a respiratory infection during the haze crisis16.
Air pollution has adversely affected the health of Pekanbaru residents.
Pekanbaru as like typical urban environment, actually the population is
also experiencing prolonged air pollution exposure vary on dry and rainy
season. The routine respiratory infection registry at Public Health Centre
also indicate as the first rank of children morbidity cause.

Justification of study
Evidence showed air pollution exposure linked to adverse respiratory
outcomes. Fewer studies have been published in spesifically Indonesia haze
setting. This study will focus on the association between respiratory
infection morbidity and mortality with continuous exposure over several
years to high ambient pollution from haze particles on children age group.

Purpose of the study

The overall objective of this study is to provide a number of key scientific issues to be
addressed concerning the children health due to effects of haze in Indonesia.
Spesifically, there are three spesific objective to be achieve of this study:
(1)To estimate the effect of exposure to daily mean concentrations
(microg/m3) of PM10, on hospital admissions of children for acute
lower respiratory infection (ALRI)
(2)To examine the associations of daily mortality due to all natural
causes and daily cause-specific mortality

respiratory infection

causes with daily mean concentrations (microg/m3) of PM10;

(3)To

determine

the

characteristics

contributing

to

increased

susceptibility, e.g. differences in underlying health status, access to

medical care, and exposure to indoor triggers.

Research Question
Questions remain whether the health burden such as morbidity, hospital
admission and mortality on children during haze period is related to higher
air pollution exposures, or greater susceptibility due to other risk factors,
such as severe existing respiratory condition, poor access to care and
exposure to indoor triggers, or both.
5

Research Design, Methods and Procedures

The retrospective observational design will be taken in documenting data
about health burden and air pollutant exposure. A multi-method approach
will include the use of secondary data observation; collection of visual data
via digital images; and the ongoing completion of a learning journal. In
addition to an analysis of the entire study period, the effects of air
pollution in just the dry season which tends as haze period (from April to
September) and rainy season which tend as regular period (from October
to March) were separated.
Admissions health data were obtained from records of Children's clinic on
public and private hospital in Pekanbaru at least from 10 years ago.
Mortality data were retrieved from routine databases with underlying
causes of death coded using the World Health Organization (WHO)
International Classification of Diseases, 9th revision or 10th revision (ICD9, ICD-10). Some patient characteristics available will explored to gather
information

on

sosio

economic

residential

history,

disease

result

examination, and exposure to indoor air pollution sources based on

anamneses record.
Daily citywide 24-hour average concentrations of particulate matter (PM)
< or =10 microm in aerodynamic diameter (PM10), nitrogen dioxide (NO2),
and sulfur dioxide (SO2) and 8-hour maximum average concentrations of
ozone (O3) were estimated from the Pekanbaru Environmental Protection
Agency. Another data set such as daily meteorologic information including
temperature and relative humidity were collected from Pekanbaru
Meteorological Center.
Analyses were conducted using time-series approaches. The unit of
observation was daily counts of hospital admissions for respiratory
6

infection. Poisson regression with smoothing functions for meteorologic

variables and variables for seasonal and long-term trends was used.
Secondly, a regression of the logarithm of daily counts of mortality due to
all natural causes and cause-specific mortality on the daily mean
concentrations of the four pollutants while controlling for weather factors,
and other important covariates.

Significance of the study

This is the first study of the health effects of air pollution in Pekanbaru, Indonesia. For these
reasons, the outcomes of this study may have national and international implications. It verify
important health effects of air pollution in local regions in South East Asia, and determine the
relevance of existing air pollution studies to mortality and morbidity for policymaking and
environmental controls. At the national level, the results of this study will be presented to the
Indonesia government for developing health management in order to prevent air pollution due
to forest burn haze in the future.

References
1.

World Health Organization. Sumatera and Kalimantan Fires and Haze.; 2006.

2.

Heil A, Goldammer JG. Smoke-haze pollution: a review of the 1997 episode in

Southeast Asia. Reg Environ Chang. 2001;2:24-37.

3.

Heil A. Air Pollution Caused by Large Scale Forest Fires in Indonesia 1997.; 1998.
http://www.fire.uni-freiburg.de/se_asia/projects/airpoll.html.

4.

Kunii O, Kanagawa S, Yajima I, et al. The 1997 Haze Disaster in Indonesia: Its Air
Quality and Health Effects. Arch Environ Heal An Int J. 2002;57(1):16-22.
doi:10.1080/00039890209602912.

5.

How Indonesias fires became one of the world's biggest climate disasters - Vox.
http://www.vox.com/2015/10/30/9645448/indonesia-fires-peat-palm-oil. Published
7

2015. Accessed November 1, 2015.

6.

Marufish World of Disaster Prevention. Sorry, the PM10 concentration at Borneo is out
of the range! _. http://marufish.com/2015/10/24/sorry-the-pm10-at-borneo-is-out-ofthe-range/. Accessed November 1, 2015.

7.

Maghami M, Hizam H, Gomes C. Evaluation of the 2013 Southeast Asian Haze on

Solar Generation Performance. PLoS One. 2015:1-19.
doi:10.1371/journal.pone.0135118.

8.

Public Health and Air Pollution in Asia (PAPA. Coordinated Studies of Short-Term
Exposure to Air Pollution and Daily Mortality in Two Indian Cities. Research Report.;
2011. http://pubs.healtheffects.org/getfile.php?u=623.

9.

Public Health and Air Pollution in Asia (PAPA). Public Health and Air Pollution in
Asia (PAPA) Coordinated Studies of Short-Term Exposure to Air Pollution and Daily
Mortality in Four Cities. Boston, Mass., U.S.A; 2010.

10.

Mehta S, Ngo LH, Van Dzung D, et al. Air pollution and admissions for acute lower
respiratory infections in young children of Ho Chi Minh City. Air Qual Atmos Heal.
2013;6(1):167-179. doi:10.1007/s11869-011-0158-z.

11.

Simoni M, Baldacci S, Maio S, Cerrai S, Sarno G, Viegi G. Adverse effects of outdoor

pollution in the elderly. J Thorac Dis. 2015;7(1):34-45. doi:10.3978/j.issn.20721439.2014.12.10.

12.

Tsai SS, Goggins WB, Chiu HF, Yang CY. Evidence for an Association Between Air
Pollution and Daily Stroke Admissions in Kaohsiung, Taiwan. Stroke.
2003;34(11):2612-2616. doi:10.1161/01.STR.0000095564.33543.64.

13.

Shah AS, Langrish JP, Nair H, et al. Global association of air pollution and heart
failure: a systematic review and meta-analysis. Lancet. 2013;382(9897):1039-1048.
doi:10.1016/S0140-6736(13)60898-3.

14.

Globe J. Haze Over 500,000 Indonesians Suffer Acute Respiratory Infection

_.http://countmein.thejakartaglobe.com/news/haze-500000-indonesians-suffer-acuterespiratory-infection/.

15.

The Jakarta Post. 54,135 people in Riau suffer from haze-related illnesses _.
http://www.thejakartapost.com/news/2015/10/03/54135-people-riau-suffer-hazerelated-illnesses.html.

16.

The Jakarta Post. Prolonged haze kills baby

8

_.http://www.thejakartapost.com/news/2015/11/05/prolonged-haze-kills-baby.html.

ANNEX 1.
Time Table of the PhD-Project

Time Period

Activities/ Procedures

1st year

Initial Literature Review

Preparation of Initial Research Proposal
Initial visit to Reseach Target Stakeholders
Finalising of Research Proposal
Ongoing literature Review
Approving Proposal by Supervisor
Finalising the design and development of research protocol
Finalising the data collection instruments
Final visit to Reseach Target Stakeholders
Submitting Ethical Approval
Piloting of instruments for validity and reliability
Training of assistance in the conduct of data collection
Fully data collection process
Analysis of data
Preparation of initial draft of thesis

2nd

year

3st year

Writing final draft of thesis

4st year

Submission of final thesis

10