Despite Taiwan’s success in treating hepatitis, the prevalence of liver illnesses continues to rise.

Taiwan has made great strides treating liver disease, especially the inflammatory condition hepatitis, which is usually caused by viral infections but may also result from alcohol or drug abuse or autoimmune diseases. If left untreated, hepatitis may permanently damage the liver, resulting in cirrhosis (scarring). People with liver cirrhosis have a heightened risk of developing liver cancer.

More than 10% of Taiwanese children under six once carried the hepatitis B infection, a chronic condition. In 1986, the government implemented a hepatitis B vaccination program for infants – the world’s first – and it has succeeded in reducing the carrier rate from over 10% to 0.8%, within the guidelines of below 1% set by the World Health Organization (WHO).

“Taiwan has been incredibly effective in reducing the incidence of hepatitis B,” says Claudio Avila, senior director of medical affairs for Asia-Japan at Gilead Sciences. “There is now hope that younger generations [of Taiwanese] will be free of this disease.”

In 2013, the European Association for the Study of the Liver gave an award to Liaw Yun-fan, director of the Liver Research Unit at Chang Gung Memorial Hospital, for his extensive contributions to viral hepatitis clinical research and treatment strategies. International medical professionals have adopted Liaw’s groundbreaking treatment recommendations.

From this year, the government will provide free hepatitis A (acute hepatitis) vaccinations to about 200,000 infants. People usually contract the virus from direct exposure to others who are infected or from contaminated food or water.

Despite Taiwan’s achievements in the fight against hepatitis, liver disease remains common here. Doctors say that liver ailments caused by alcohol, drugs, and metabolic disorders are increasingly prevalent. Some 13,000 people die of liver disease in Taiwan every year, according to government data. Of those deaths 5,000 are from cirrhosis or hepatitis, while 8,000 are from liver carcinoma.

Indeed, the greatest danger for people with liver disease is that destruction of the liver cells’ DNA eventually leads to cancer, and liver cancer is hard to cure because it often occurs in people with damaged livers, limiting treatment options. The liver’s intricate network of blood vessels and bile ducts makes surgery difficult. And in cases when localized tumors are resectable, no symptoms of the disease may be evident. By the time a person is aware of the cancer, it has often spread to regional blood vessels, lymph nodes, or even nearby organs, making curative treatment nearly impossible.

Liver carcinoma is hard to detect at an early stage in part because of the organ’s size, says Kao Jia-Horng, director of the National Taiwan University Hospital (NTUH) College of Medicine and a physician in the Department of Internal Medicine and Division of Gastroenterology. Weighing about 1.5 kilograms, “the liver is the largest internal organ, so a person isn’t necessarily going to be aware there’s a 1 centimeter tumor growing inside it,” he says.

In a physical exam, a small liver tumor cannot be easily felt because the right rib cage covers most of the organ.

In the United States, where liver cancer awareness is not high, the five-year survival rate is just 18%. In contrast, Taiwan’s liver cancer five-year survival rate – at 27.9% – is the highest in the world, according to a study of 37.5 million cancer patients conducted by the CONCORD-3 program between 2000 and 2014.

“Long-term survival of liver cancer can be achieved, but it’s necessary to resect a tumor when it is still localized [3 centimeters or less in size],” Kao says. Unfortunately, the disease has a high recurrence rate of 70%, he notes.

Maintaining a healthy liver

Meanwhile, hepatitis C remains a major health issue in Taiwan. About 400,000 Taiwanese are afflicted with the virus, according to the Association for the Study of the Liver.

Kevin Chueh, MSD’s regional director of medical affairs for Asia-Pacific and China, points out that most Taiwanese with the disease go untreated. “Because traditional drugs used to treat hepatitis C cause significant discomfort [nausea, weakness, coldness] people are hesitant to get treated now – even though the new drugs cause far fewer side effects,” he says.

For instance, MSD and several other big pharma firms developed the drug Zepatier, which blocks different steps of the hepatitis C virus lifecycle.  Serious side effects from Zepatier use are rare. Taken orally as a pill once a day, the drug can cure hepatitis C in three months, Chueh says.

Hepatitis C, which is spread by infected blood, is particularly problematic because often becomes a chronic infection. According to the U.S.’s Centers for Disease Control, 75-85% of people infected with the virus end up with a chronic infection. Most people contract hepatitis C from a contaminated blood transfusion, unsafe healthcare equipment, intravenous drug use, or sexual intercourse.

Worryingly, hepatitis C can increase the risk of other ailments outside of the liver, notes Gilead’s Avila. A long-term study of Taiwanese infected with chronic hepatitis C found that they have an elevated risk of type-2 diabetes and late-stage kidney disease, according to an August report in the English-language Taipei Times.

Hepatitis C may also put people at higher risk of developing lymphoma (cancer of the lymph nodes), depression, and decreased cognitive functions, says NTUH’s Kao.

Ultimately, Taiwan needs to raise awareness of the health risks posed by hepatitis C so that those infected receive proper curative treatment, says Chueh. Taiwan’s National Health Insurance (NHI) began covering a new oral hepatitis C treatment in January 2017 and expanded coverage in May 2017, he observes.

Lifestyle choices by Taiwanese are also responsible for the nation’s high incidence of liver disease. About 17% of Taiwan’s 23.5 million people smoke. Toxins released by burning tobacco inflame the liver, aggravating the risk of cirrhosis and cancer.

Alcohol abuse is an even bigger problem. A 2017 study by Taiwanese researchers published in an Elsevier journal found that liver disease was among the most common alcohol-attributable ailments in Taiwan.

There are several ways alcohol harms the liver. As the organ breaks alcohol down, if the amount is excessive the ensuing chemical reaction may damage cells. When the liver tries to repair itself, inflammation and scarring occur. Toxins in intestinal bacteria may also find their way to the liver after alcohol has damaged the intestines. Those bacteria, which don’t belong in the liver, can cause inflammation and scarring.

It’s hard to find reliable data on alcohol consumption in Taiwan. Most major global studies of per-liter alcohol consumption don’t include Taiwan. Local efforts to control alcohol consumption target drunk driving but not alcohol use itself.

Reducing binge drinking at banquets would be a good way to tackle Taiwan’s drinking problem head on, observers say, noting that in these settings local businessmen often drink themselves into a stupor in the name of securing a deal or celebrating a holiday. The combination of salty, greasy banquet food with glass after glass of Scotch and sorghum liquor wreaks havoc on the entire gastrointestinal system.

Speaking broadly, NTUH’s Kao offers some advice for maintaining long-term liver health: “Live a pure life,” he says.