Sung teaches a class for interns at National Taiwan University Hospital in Taipei City in 2002. (Photo courtesy Liver Disease Prevention and Treatment Research Foundation)

Veteran medical professionals work to research, treat and prevent liver disease.

Every year, the Taipei City-based Health, Welfare and Environment Foundation holds the Medical Dedication Awards to recognize those who have made significant contributions to enhancing Taiwan’s health care environment. Among the recipients of the awards this year were members of the Liver Disease Prevention and Treatment Research Foundation (LDRF), which has been touring local communities around Taiwan to conduct liver disease screenings for more than two decades.

Great progress has been made toward the eradication of liver diseases in Taiwan over the past 20 years, according to LDRF Executive Officer Yang Pei-ming (楊培銘). Statistics from the Ministry of Health and Welfare (MOHW) show that during the 1980s and most of the 1990s, chronic liver disease, including cirrhosis, was consistently ranked the sixth most common cause of death in the country. The number of cases began to decrease significantly around the turn of the century, with the illness falling to 10th place in 2016. There has also been a substantial decline in diagnoses of liver cancer, once the most common form of cancer in Taiwan.

According to Yang, a physician and professor emeritus at National Taiwan University’s College of Medicine (NTUCM), in the early 1980s, one out of every five or six people in the country were carriers of hepatitis B, a major cause of cirrhosis and liver cancer. This meant that Taiwan had one of the highest infection rates in the world. “We had little choice but to make progress toward controlling the disease,” he said. “Now the rate has dropped to below 1 percent among people under the age of 33.”

Liver Disease Prevention and Treatment Research Foundation President Sheu Jin-chuan poses in front of an image of organization co-founder Sung Juei-low. (Photo by Huang Chung-hsin)

Turning the Tide

 

A major turning point in the fight against hepatitis B came 33 years ago, when the government launched a nationwide vaccination program targeting infants born to mothers known to be carrying the virus. Because of the milestone measure, those born in and after 1984 are dubbed “New Taiwanese” by many medical professionals like Yang and LDRF President Sheu Jin-chuan (許金川). Within two years of its introduction, the plan was expanded to cover all newborns, making Taiwan the first country in the world to conduct universal vaccination efforts against the disease. Many nations followed suit with similar initiatives soon afterward. “Those who contract viral hepatitis are all potential cirrhosis and liver cancer patients,” said Sheu, also a professor emeritus at NTUCM and former head of the Division of Gastroenterology at NTU Hospital’s Department of Internal Medicine. “Reducing the number of virus carriers through the vaccination program was really a breakthrough in effectively controlling liver disease.”

Sheu helped found LDRF together with his teacher Sung Juei-low (宋瑞樓), one of the first Taiwan physicians to specialize in hepatology. Sung was a graduate of Taihoku Imperial University’s Medical School, the forerunner of NTUCM founded during Japanese colonial rule (1895-1945). In the 1970s, he led an NTU Hospital research team that determined maternal transmission of hepatitis B was especially common via the birth canal. “Cesarean section was found to cause less infection than natural delivery,” Yang said. When hepatitis B vaccines became available in the early 1980s, Sung’s team began promoting the idea of universal inoculation. In 1981, he was put in charge of a committee under the Department of Health, reorganized as the MOHW in 2013, to oversee efforts to control viral hepatitis. Sung later became a major force behind the landmark 1984 vaccination program.

The cover of a Taiwan health magazine from August 1984 shows an infant being vaccinated for hepatitis B at the start of a nationwide campaign to combat the disease. (Photo courtesy LDRF)

National Effort

 

In the mid-2000s, after significant lobbying and other efforts by LDRF and similar organizations, the government began covering certain treatment expenses for hepatitis B and C under the National Health Insurance (NHI) program, marking another major step in the nation’s fight against liver disease. The NHI, launched in 1995 to provide universal health coverage, is widely regarded as one of Taiwan’s most notable achievements as it provides affordable and easily accessible medical services ranging from Western and traditional Chinese medicine to dental care.

 

At the beginning of 2017, NHI coverage was extended to oral forms of antiviral medications for those suffering from advanced cases of hepatitis C. LDRF does not consider these efforts sufficient, and is calling for an expansion that would cover the medicine regardless of the variety or severity of the disease. In Taiwan, Yang noted, hepatitis B and C lead to more than 85 percent of all cirrhosis and liver cancer cases, while non-viral factors such as alcohol consumption, medication and metabolism problems are also major contributors.

The Silent Organ

Despite measures put in place to reduce the frequency of hepatitis, Yang said he is sometimes frustrated by the reluctance of virus carriers to seek medical treatment. “Only around a third of them do so and another third go to clinics or hospitals just once or twice. The rest of them don’t seem to care about it at all,” he said. “The liver is a silent organ, meaning symptoms of a disease usually don’t develop until it has reached very advanced stages.” As a result, there has not been a significant decline in the death toll caused by chronic liver disease in “Old Taiwanese”—nationals over the age of 33—who did not receive hepatitis B vaccinations when they were young.

Since its establishment in 1994, LDRF has toured communities around Taiwan to conduct liver disease screenings. (Photo courtesy LDRF)

Consequently, LDRF will continue its efforts to promote hepatitis screenings through blood tests and abdominal ultrasound scans. Yang said a major mission for his group is to continue educating people about the development pattern of liver disease by organizing events for local community residents and releasing relevant articles in print and internet media. The organization also cooperates with local government medical departments and community health stations, particularly in such places as Miaoli County in northern Taiwan and the southern counties of Yunlin and Chiayi where there are higher concentrations of hepatitis C. Yang said he believes cases of the disease are more prevalent in these areas because local health workers failed to adequately disinfect needles in the past.

Yang and Sheu are also respectively CEO and president of the Taipei-based Good Liver Foundation, established in 2012 as an extension of LDRF. The organization operates the Good Liver Clinic in the capital’s downtown area. Sheu pointed out that the facility, which is part of the NHI system, was set up with the goal of helping form a hospital system specializing in the treatment and research of liver diseases.

Sheu insists that in the field of hepatology, there are still many issues and questions to be addressed to further bring down the number of hepatitis cases. “That’s why research and other efforts in fighting liver disease will not stop in the foreseeable future,” he said.