International Journal of Nasopharyngeal Carcinoma (IJNPC) Vol. 02, No.

03, September 2020 | 64-66

International Journal of
NASOPHARYNGEAL CARCINOMA
Journal homepage: https://talenta.usu.ac.id/IJNP

Association between Mosquito Coils Use with Nasopharyngeal Carcinoma

Witri Septiani1*, Yussy Afriani Dewi1, Irvan Afriandi2
1
Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine Padjadjaran University, Hasan Sadikin General Hospital, Bandung, Indonesia
2
Department of Public Health, Faculty of Medicine Padjadjaran University, Hasan Sadikin General Hospital, Bandung, Indonesia

Abstract Article Info

Introduction: Nasopharyngeal carcinoma (NPC) is a malignancy of squamous cells on the nasopharyngeal Article history:
epithelial layer and is the most common otorhinolaryngology malignancy found in Indonesia. The etiology of Received: 6th August 2020
NPC is multifactorial, including food, environment, genetics, and Epstein-Barr virus infection. Mosquito coils
Received in revised form: 3rd September 2020
contain volatile carcinogens, such as formaldehyde and acetaldehyde, which may cause malignancy on upper
respiratory tract epithelial cells. Accepted: 4th September 2020
Objectives: The study aimed to understand the association between mosquito coils use with the incidence of
nasopharyngeal carcinoma. Keywords:
Methods: This was a hospital-based unmatched case-control study design involving 80 patients on the Oncology Mosquito coil, nasopharyngeal carcinoma, risk
Clinic of Department of Otorhinolaryngology-Head and Neck Surgery at Dr. Hasan Sadikin General Hospital factor
from September to October 2015. The questionnaire about NPC risk factor exposure, including the history of
mosquito coil use, was applied as a study instrument. Statistical analysis used the chi-square test to acquire the *Corresponding author:
association between two categorical variables and was considered significant if P-value is <0.05. Address: Jl. Pasteur No. 38, Bandung, 40161,
Results: The percentage of mosquito coil users in the case group (52.7%) was higher than in the control group Jawa Barat, Indonesia
(30%). Statistical analysis using the chi-square test revealed P = 0.041 with OR (CI 95%) equals 2.58 (1.03-
6.45). This result showed that mosquito coil use might increase the risk of nasopharyngeal carcinoma incidence
e-mail: septianiwitri@gmail.com
by 2.58-fold.
Conclusion: There is an association between mosquito coils use with nasopharyngeal carcinoma.

1. INTRODUCTION
Nasopharyngeal carcinoma (NPC) is a malignancy of squamous cells
on the nasopharyngeal epithelial layer [1]. The prevalence of NPC in
Indonesia is 6.2 per 100,000 residents per year or around 12,000 cases per
year, and is the most commonly found otolaryngology malignancy in
Indonesia [2]. There are 692 (43,7%) NPC patients in Hasan Sadikin
General Hospital, Bandung within 2010-2014 with more male patients
(65.7%), and occur mostly in the 46-55 age group (29.6%) [3]. The etiology
of NPC is multifactorial; food (salt-preserved fish consumption),
environmental (mosquito coil, sawdust, and insecticide exposure), genetic,
and Epstein-Barr infection have been proven as risk factors for NPC -[5].
Some research has found that the gas phase of mosquito coils contains
some carbonyl compounds, such as formaldehyde and acetaldehyde, which
may irritate the upper respiratory tract [6]. Formaldehyde is proven to have
a carcinogenic effect on humans and the nasal part of mice. International
Agency for Research on Cancer (IARC) has proven that formaldehyde and
acetaldehyde are significantly associated with the occurrence of NPC.
Acetaldehyde-bound cells will undergo replication problems and oncogenic
mutation [7]-[8]. Aldehyde synthesis is found can induce NPC through
binding to the DNA, and cellular protein can stir the cellular protein into a
cascade of immunological reactions [9]. The toxicity of acetaldehyde is
related to its activity by being an electrophilic molecule that related to
nucleophilic components including DNA, RNA, and protein that can lead a
formation of crotonaldehyde-deprived propano-dGs, which can promote
DNA miscoding in a human cell by G into T transversion mutation and
inhibit DNA synthesis later [10]. Formaldehyde in moderate concentration
can induce DNA damage that can trigger cell death and induce oxidative
stress, which leads apoptosis, and in high concentration, formaldehyde can
induce necrosis, especially neuronal cell, it was found that it is highly
sensitive towards the toxicity of formaldehyde [11]. Not only carcinogenic,
but formaldehyde also genotoxic, mutagenic, embryogenic and also had an
adverse effect on reproductive organs that can lead a infertility by damaging
the germinal cell, intrude the morphological structure of the testicle, reduce
the quantity of sperm, and also serum testosterone level [12]. In a cohort
study, a significant correlation between long exposure and high dose
formaldehyde that lead an NPC had been found with the highest odds ratio
of 4.0 [13]. The risk of NPC has also been found increased significantly
by increasing the cumulative, duration, and probability of exposure of
formaldehyde [14]. Basic Health Research in 2013 shows Indonesia
mosquito coil use is 48.4%, followed by mosquito net bed canopy
(25.9%), mosquito repellent (16.9%), insecticide (12.2%), and window
mosquito mesh (8.0%) [15]. Based on these regards, a study is conducted
to understand the association between mosquito coils use with the
incidence of NPC.
2. MATERIALS AND METHODS
The hospital-based unmatched case-control study design was used in
this research. Data collection was started from obtaining the outcome or
dependent variable, the case group, which was NPC patients presented to
the Oncology Clinic of Otorhinolaryngology-Head and Neck Surgery
Department of Hasan Sadikin General Hospital, Bandung diagnosed based
on histopathology result; and control group, which were patients with other
malignancies other than NPC presented to the clinic of Department of
Otorhinolaryngology-Head and Neck Surgery Hasan Sadikin General
Hospital, Bandung. Anamnesis was done on both groups using
questionnaire adapted from Head and Neck Surgery Oncology Study Group,
Indonesian Otorhinolaryngology-Head & Neck Surgery Society to
recognize sample behavior in using mosquito coil and assess risk factors of
NPC, which include alcohol consumption, sawdust exposure, routine
insecticide exposure, family history, smoking history and consuming salt-
preserved fish since childhood. This study has been approved by the Hasan
Sadikin General Hospital ethical committee, and informed consent has been
done to all respondents.
Unpaired comparative analysis formula was used to calculate sample
size with alpha standard deviation Zα=1.96 and beta standard deviation
Zβ=0.84; a value of P1 = 0.79 and P2=0.49; thus, the sample size was

Copyright © International Journal of Nasopharyngeal Carcinoma, Published by TalentaPublisher, ISSN: 2656-9027 e-ISSN: 2656-9035, DOI: 10.32734/ijnpc.v2i03.4381 64
International Journal of Nasopharyngeal Carcinoma (IJNPC) Vol. 02, No. 03, September 2020 | 64-66

calculated as 40 for each case and control group, or 80 people in total. mosquito coils use and NPC incidence resulted in a P-value <0.05 with OR
Nonprobability consecutive sampling was done to select samples; patients 2.58. This showed a significant test result between two variables; mosquito
presented to the Oncology Clinic of Otorhinolaryngology-Head and Neck coil use might increase the risk of nasopharyngeal carcinoma incidence by
Surgery Department of Hasan Sadikin General Hospital, Bandung within 2.58-fold.
September to October 2015 were appointed as samples on this study. After mosquito coil user data were obtained, a sub analysis was done to
Collected data were selected based on the inclusion criteria, which was NPC identify the association between amounts of mosquito coils used with the
patients diagnosed based on histopathology result; and the exclusion incidence of nasopharyngeal carcinoma (Table 3) and the association
criteria, which was patients with multiple malignancies. between duration of mosquito coils use with incidence of nasopharyngeal
A Chi-square test was used to test the association between two carcinoma (Table 4).
categorical variables. The significance of the test result was determined by
P-value, should P<0.05, the result was considered significant or that there Table 3. Association between amounts of mosquito coils used with NPC
Case Control
was a relation between the two variables. The excess risk was measured by Characteristic
Group Group
P-value OR (CI 95%) *

calculating the odds ratio (OR) and confidence interval (CI) 95%. (n=21) (n=12)
Amount of mosquito
0.523**
coils used
3. RESULTS Less (≤1 piece) 19 (90.5)* 12 (100) 0.312 (0.01-7.57)
Medium (2-4 pieces) 2 (9.5) 0 (0)
There were 83 data obtained using the nonprobability consecutive *) OR (CI 95%): Odds Ratio (Confidence Interval 95%)
**) Fisher’s Exact Test: used on variables which have cells with the expected value (E) less than 5
sampling technique. Among the 83 data, 3 were excluded due to incomplete
data. From the remaining data, there were 40 data for each case and control Most respondents (90.5% of the case group and 100% of the control
group, thus made a total of 80 data. group) used less amount of mosquito coils. Statistical analysis using the chi-
square test revealed P-value >0.05 with OR 0.312, which was achieved by
Table 1. Characteristics of Research Subjects
Case Control
adding 0.5 in every cell. This showed an insignificant test result between
Characteristic
Group Group
P-value OR (CI 95%) * both variables, and that there was no association between the amounts of
n=40 (%) n=40 (%) mosquito coils used with the incidence of NPC.
Sex 0.044
Male 26 (65) 17 (42.5) 2.51 (1.02-6.19) Table 4. Association between duration of mosquito coil use with NPC
Female 14 (35) 23 (57.5)
Age (Years) 0.478 Case Control
<20 1(2.5) 5(12.5) Reference Characteristic P-value OR (CI 95%)*
Group Group
20-29 6(15) 5(12.5) 0.67 (0.14-1.93) (n=21) (n=12)
30-39 5(12.5) 8(20) 0.32 (0.03-3.60) Duration of mosquito
40-49 9(22.5) 7(17.5) 0.16 (0.02-1.65) 0.010*
coil use (hour)
50-59 12(30) 7(17.5) 0.12 (0.01-1.21) 1-4 hours 6 (28.6) 9 (75.0) 7.50 (1.49-37.66)
≥60 7(17.5) 8(20) 0.23 (0.02-2.46) ≥5 hours 15 (71.4) 3 (25.0)
Alcohol Consumption 0.432** *) OR (CI 95%): Odds Ratio (Confidence Interval 95%)
Yes 5 (12.5) 2 (5) 2.71 (0.49-14.90) **) Chi-square test
No 35 (87.5) 38 (95)
Sawdust Exposure 0.723
Yes 4 (10) 5 (12.5) 0.78 (0.19-3.14) Most respondents of the case group use mosquito coil for ≥ 5 hours
No 36 (90) 35 (87.5) every night (71.4%), while in the control group, the users of mosquito coil
Routine Insecticide Exposure 1.000
Yes 6 (15) 6 (15) 1.00 (0.29-3.41) for 1-4 hours every night was higher (75.0%). Statistical analysis using the
No 34 (85) 34 (85) chi-square test revealed P-value <0.05 with OR 7.50. This showed a
Family History of Cancer 1.000**
Yes 4(10) 5(12.5) 0.778 (0.19-3.14) significant test result between both variables, and that there was an
No 36(90) 35(87.5) association between the duration of mosquito coils use with the incidence
Smoking History 0.730
Non-smoker 10 (25) 12 (30) Reference
of NPC.
Passive 10 (25) 13 (32.5) 1.08 (0.33-3.51)
<10 years 3 (7.5) 1 (2.5) 0.27 (0.02-3.10) 4. DISCUSSION
>10 years 17 (42.5) 14 (35) 0.68 (0.22-2.05)
Salt-Preserved Fish 0.013
Consumption This study showed that there was an association between gender and
Yes 28 (70) 17 (42.5) 3.15 (1.26-7.94) nasopharyngeal carcinoma. Table 1 showed P-value <0.05 for sex variable
No 12 (30) 23 (57.5)
and OR 2.51, which meant males had a 2.51-fold higher risk of having
*) OR (CI 95%): Odds Ratio (Confidence Interval 95%)
**) Fisher’s Exact Test: used on variables which have cells with the expected value (E) less than 5 nasopharyngeal carcinoma compared to females. This result was parallel to
previous research conducted by Adham et al. [2] in Indonesia that showed
In this research, most case group respondents were male (65%), while NPC patients male to female ratio was 2.4:1. The ratio differences might
in the control group were female (57.5%). In terms of age, most case group occur because of the protective role of estrogen in women [16].
respondents were aged 50-59 years (30%), while in the control group, most Study results about the association between age and nasopharyngeal
were aged 30-39 years and ≥60 years, which is 20% for each age group. carcinoma did not reveal significant results. NPC group was dominated with
Most respondents, 85.5% on the case group and 95% on the control group people from 50-59 age group; this corresponded with previous hospital-
were not consuming alcohol. There were more respondents (85% of each based research held by Chang et al. in the United States that showed the
case and control group) not exposed to sawdust than the exposed ones. peak age of NPC patients was from the 50-59 age group, and the prevalence
In terms of family history, most respondents (90% of the case group and was declining on older age, this occurred due to higher carcinogen
87.5% of the control group) did not have a family history of cancer. Most exposures on younger age [17].
respondents had more than 10 years of smoking history, 42.5% of the case group There was no correlation between alcohol consumption, sawdust
and 35% of the control group. More respondents (70%) of the case group exposure, routine insecticide exposure, family history of cancer, and
routinely consumed salt-preserved fish. Meanwhile, more respondents (57.5%) smoking history with the incidence of NPC. This result was suited with
of the control group did not routinely consume salt-preserved fish. previously held hospital-based research by Polesel J et al. [18] in Italy that
Table 2. Association between mosquito coils use with NPC each alcohol consumption and smoking history was not associated with the
Case Control incidence of NPC. However, this result did not correspond with a case-
Characteristic P-value OR (CI 95%)*
Group Group control study conducted by Ji Xuemei et al. [19] in China that showed that
n=40 (%) n=40 (%)
Mosquito coil use 0.041** smoking history and family history had a significant association with the
Yes 21 (52,5) 12 (30) 2.58 (1.03-6.45) incidence of NPC. Uncertain association between those risk factors with the
No 19 (47,5) 28 (70)
*) OR (CI 95%): Odds Ratio (Confidence Interval 95%)
incidence of NPC was probably due to multifactorial NPC etiology. Thus,
**) Chi-square test the effects of those factors might be overwhelmed by other risk factors such
as salt-preserved fish consumption and mosquito coil use.
The percentage of mosquito coil use was higher in the case group (52%) This research showed that routine salt-preserved fish consumption and
compared to the control group (30%) with 5 years of minimal period incidence of nasopharyngeal carcinoma were associated; that routinely
exposure. Statistical analysis using the chi-square test between the variables

65
International Journal of Nasopharyngeal Carcinoma (IJNPC) Vol. 02, No. 03, September 2020 | 64-66
consuming salt-preserved fish might increase the risk of NPC incidence by
3.15-fold. This suited preceding research by Tabuchi et al. [20] in Japan,
which stated that people who routinely consume salt-preserved fish had a
higher risk of having NPC. The reason behind this statement was because
salt-preserved fish contained nitrosamine, which might cause
carcinogenesis on nasopharynx epithelial cells [19].
Analysis test results in Table 2 showed that mosquito coil use and NPC
were associated. This result meant that mosquito coil use might increase the
risk of NPC incidence by 2.58-fold. This result corresponded with earlier
research conducted by Moore MA et al. [21] in Indonesia and Malaysia,
which stated that mosquito coils had been proven to be a risk factor of NPC.
This was possible because of the presence of carcinogenic substances
contained on the mosquito coil smoke, which was proven to be a risk factor
of lung cancer and NPC in some countries, such as Taiwan and the
Philippines [22]. IARC had also proven that formaldehyde, which
composed mosquito coils, had a significant association with the incidence
of nasopharyngeal carcinoma [7]. Formaldehyde and acetaldehyde, which
were constituents of mosquito coil smoke, might bind with intracellular
proteins, thus disturbing the DNA replication process and causing oncogenic
mutation, and eventually caused morphological, cell function and
immunological reaction abnormalities on nasopharynx epithelial cells [8].
In vivo experiment on mammals had been done by Seithz et al. and had
proven that acetaldehyde might cause mutagenic lesions in DNA. IARC
stated that formaldehyde and acetaldehyde were proven to be carcinogenic
based on animal trials [7]-[8].
There was no significant association between the amounts of mosquito
coil used with the incidence of NPC. This did not correspond with prior
research conducted by Salthammer et al. [18], which stated that even a small
concentration of formaldehyde (0.2-0.3 ppm) might cause irritation to the
nasopharynx. This unsuitability might have resulted from the number of
respondents, which is smaller in this research, thus reducing the precision
of the study and did not elaborate well on the condition of the population.
Analysis test results in Table 4 showed that the duration of mosquito
coil use and NPC were associated. There had not been studies conducted to
explain this phenomenon, but it was assumed to happen because prolonged
exposure could cause more severe irritation to the epithelial layer of the
nasopharynx.
Mosquito coil use might increase the incidence of nasopharyngeal
carcinoma. The limitation of this research was that partial restriction in
subject selection which aimed to increase precision and research efficiency
(matching) was not done on case group since this was hospital-based
research. Hence it needed a number of respondents. Besides, the
questionnaire was used on this research, hence recall bias, which was false
information given by the respondents while trying to recall the experienced
risk factor exposures, might occur thus decreased the data accuracy. With
the knowledge of the association between mosquito coil use with incidence
of NPC, this research humbly suggested health care professionals and health
care services should focus on preventing NPC since this disease could be
prevented by avoiding its risk factors.
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