Asia Pacific Viral Hepatitis Policy Survey and Assessment: Taiwan J Wallace, M Pitts and S Locarnini

Transcription

1 Australian Research Centre in Sex, Health & Society Asia Pacific Viral Hepatitis Policy Survey and Assessment: Taiwan J Wallace, M Pitts and S Locarnini

2 AustralianResearchCentreinSex,Health&Society(ARCSHS) FacultyofHealthSciences LaTrobeUniversity Abodypoliticandcorporate ABN ARCSHSoperatesfromwithintheacademicenvironmentofLaTrobeUniversity. LaTrobeUniversityisaStatutoryBodybyActofParliament. Level2 215FranklinStreet Melbourne3000 FranklinStCampus Telephone (+613) Facsimile (+613) Online Monographseriesno.91 ISBN: Suggestedcitation:Wallace,J.,Pitts,M.andLocarnini,S.(2013).AsiaPacificViralHepatitisPolicySurveyand Assessment:Taiwan.ARCSHSMonographSeriesNo.91,Melbourne:AustralianResearchCentreinSex,Healthand Society,LaTrobeUniversity. TheSummaryReportandFullReportareavailableathttp:// Disclaimer Theinformationcontainedinthispublicationisindicativeonly.Whileeveryeffortismadetoprovidefullandaccurateinformationatthetimeofpublication,theUniversity doesnotgiveanywarrantiesinrelationtotheaccuracyandcompletenessofthecontents.theuniversityreservestherighttomakechangeswithoutnoticeatanytimein itsabsolutediscretion,includingbutnotlimitedtovaryingadmissionandassessmentrequirements,anddiscontinuingorvaryingcourses.totheextentpermittedbylaw, the University does not accept responsibility of liability for any injury, loss, claim or damage arising out of or in any way connected with the use of the information containedinthispublicationoranyerror,omissionordefectintheinformationcontainedinthispublication. LaTrobeUniversityisaregisteredproviderundertheCommonwealthRegisterofInstitutionsandCoursesforOverseasStudents(CRICOS).CRICOSProvider00115M

3 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan Tableofcontents 1. EXECUTIVESUMMARY 3 2. INTRODUCTION 5 3. RATIONALE 7 4. METHODOLOGY 9 5. CHRONICVIRALHEPATITISANDLIVERCANCER THETAIWANCONTEXT HEALTHDELIVERYCONTEXT 13 Figure1aHepatitisPolicyandServiceStructure VIRALHEPATITISCONTEXT HepatitisB HepatitisC POLICYCONTEXT 23 Table1aTimelineofviralhepatitisresponsesinTaiwan PARTICIPANTINTERVIEWS Historyandpoliticalcontext Healthservicestructure Viralhepatitis preventionoftransmission Viralhepatitis screening Viralhepatitis clinicalmanagement Clinicalmanagementaresourcing Knowledge,InformationandEducation Humanrights,stigmaanddiscrimination DISCUSSION 49 Table2aSummaryofachievementsandchallengesintheresponsetoviralhepatitisinTaiwan55 11.REFERENCES 57 APPENDIXA:OTTAWACHARTERFORHEALTHPROMOTION 63 A.1 Healthpromotion 63 A.2 Threebasicstrategiesforhealthpromotion 64 A.3 Localneedsandpossibilities 64 A.4 Areasforpriorityaction 64 A.5 Commitmenttohealthpromotion 65 LaTrobeUniversity1

4 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan Acknowledgement TheauthorswouldliketothankMsVickiAngforherorganisationalandadministrativeskills, andofhercoordinationoftheprojectintaiwan. ThisprojectwasfundedbytheCoalitiontoEradicateViralHepatitisinAsiaPacific(CEVHAP). CEVHAPisanonaprofitorganisationdedicatedtopublicpolicyreformtoreducethesignificant health,socialandeconomicburdenofviralhepatitisintheasiapacificregion. Thisprojectwouldnothavebeenpossiblewithoutthegenerosityandsupportofthekey stakeholdersandprojectparticipantsinterviewedintaiwan. 2AustralianResearchCentreinSex,HealthandSociety

5 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan 1. ExecutiveSummary Overfivehundredmillionpeoplegloballyareestimatedtobeinfectedwithchronicviral hepatitiswithmost(75%)livingintheasiapacificregion.hepatitisbandhepatitisccause significantglobalmortalityandmorbiditywith1,285,000deathseachyearattributabletothem andtheirsequelaeofcirrhosis,liverfailureandhepatocellularcancer. TheburdenofviralhepatitisandlivercancerissignificantforTaiwan.ResearchfromTaiwan haschangedhowtheworldrespondstotheinfectionincludingidentifyingthelinkbetween hepatitisbandcancer,thetransmissionofhepatitisbfrommothertochild,howthis transmissioncanbereduced,thedevelopmentofavaccinetohaltthistransmission,andthe implementationandsuccessofapopulationlevelvaccinationprogram. Inareflectionofthecomplexandmultifacetedresponsesneededtoreducetheburdenofviral hepatitis,significantchallengesinthetaiwanresponsetoviralhepatitisremain.these challengesarereflectedinthepoorunderstandingandresponsestotheinfectionbypeople withviralhepatitis,barriersinthetimelyclinicalmanagementfortheinfectionandthelate clinicalpresentationofpeoplewithchronicviralhepatitis,oftenwithhepatocellularcancer. Thisreportdescribes,assessesandanalysesthepublicpolicyresponsestochronicviral hepatitisb,hepatitiscandlivercancerintaiwanwithanaimofidentifyingthesuccessful componentsofthetaiwaneseapproachincludingexistingbestpracticeandpublicpolicy strengthsandchallenges.dataforthereportwasobtainedthroughsemiastructuredinterviews withcliniciansandotherprofessionalsworkinginpublichealth,communicablediseasesor publicpolicyadvocacyintaiwanandareviewofpubliclyavailablepolicydocuments. TheTaiwanresponsetoviralhepatitisisframedwithinahealthsystemarchitectureestablished duringthejapanesecolonisationbetween1895and1945.withinthissystemtheimpactof infectiousdiseaseswasrecognised,anddiseasepreventionformedanessentialpartofthe overallhealthapproach.specificculturalinfluencesexistsupportingtheresponsetoviral hepatitisintaiwanwiththeprivilegingoftheliverwithinchinesecultureandoftheprivileged statusofmedicalprofessionals.morerecentlytheintroductionofapopulationwidehealth insuranceschemelargelyaddresseseconomicbarrierstoaccessinghealthservices. ViralhepatitispublicpolicyadvocacyanddevelopmentinTaiwanhasbeenlargelyledby specialistcliniciansandresearchers.publicpolicyforviralhepatitiswasestablishedin1982by framingthethensometimescontentiousimplementationofthehepatitisbvaccination program.withsuccessfuladvocacy,successivefiveyearplansincorporatingtreatmentand careinterventionsweredevelopedandimplemented. LaTrobeUniversity3

6 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan Newmodelsofpublicpolicyhavebeenintroducedoverthepast20yearsthatcouldbeusedto furtherinformthisresponse.theseincludetheworldhealthorganizationpreventionand ControlofViralHepatitisInfection:FrameworkforGlobalActionandtheOttawaCharterfor HealthPromotion,bothofwhichcouldbeusedtoevaluateandreframecurrentresponsesto viralhepatitis. Thesignificantprevalenceofviralhepatitiswithinthecommunity,thesilenceoftheinfectionat anindividuallevel,andthelevelofactivitythathasbeenharnessedintaiwanovermanyyears providesauniquesetofproblems.whilethereareonlyfewbarrierstothephysicalaccessto treatmentandcareservicesforpeoplewithviralhepatitis,theyaresignificant. Peoplewithviralhepatitisareoftennotengagedfullyinrespondingtotheirinfection.Thismay resultfromapassiveprocesswherepeoplearescreenedbutnotcomprehensivelyinformedin waysthatareaccessibletoamemberofthepublicoftheimpactoftheinfection,includingits naturalhistory,andhowpeoplewiththeviruscanbestrespondtotheinfection.whilemost peoplewithviralhepatitisrequireclinicalmonitoring,onlyaminorityrequirepharmaceutical treatment.framinggovernmentpolicyandhealthpromotionresourcesfromtheperspective ofapersonlivingwithviralhepatitiswillbemoreaccessible,accurateandmeaningful. Understandinganddescribingviralhepatitisasachronicillnessrequiringregularmonitoring,as opposedtoaninfectionoftheliverorasacommunicablediseaserequiringpharmaceutical treatmentcouldprovideinsightsintoimprovingcomplianceandstrengthenrelationships betweenpeoplewithviralhepatitisandtheirclinicians.theprovisionofclinicalmanagement includingpharmaceuticaltreatmentoccursthroughpublichospitalsandessentiallylimits accesstothisclinicalmanagement.thedevelopmentofnewmodelsofcareinvolving communitybasedphysicians,andparticularlywiththeuseofspecialisthepatologynurses wouldincreasethenumberandreachofservicesinwhichpeoplewithviralhepatitiscould accessservices. AsizeableproportionoftheTaiwanpopulationhasviralhepatitisandtheyareanimportant resourcewhichisnotsystematicallyusedinthetaiwaneseresponsetotheinfection.many peoplewithviralhepatitiscomefromfamiliesinwhichtheinfectionhasbeenanissuefor generations.therewillbeavastreservoirofknowledgeinhowtheseindividualsandfamilies respondtoviralhepatitis,whichifsystematicallyinvestigatedcouldbeofuseforpolicy developersandimplementersintaiwan. Viralhepatitisisalargelysilentinfectionatanindividuallevel,andparticipantswereconcerned ofcomplacencywithingovernmentgivenitslongtermcommitmenttoreducingtheburdenof infection.thiscommitmenthasbeengeneratedbythededicationofresearchersandclinical specialistsovermanyyears.thisreporthighlightsthatthelongjourneyisstillrequired. 4AustralianResearchCentreinSex,HealthandSociety

7 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan 2. Introduction Itisestimatedthat,globally,overfivehundredmillionpeopleareinfectedwithchronicviral hepatitiswithmost(75%)livingintheasiapacificregion.hepatitisbandhepatitisccause significantglobalmortalityandmorbiditywith1,285,000deathseachyearattributabletothem andtheirsequelaeofcirrhosis,liverfailureandhepatocellularcancer.(1)despiteeffective preventioninterventionsparticularlywithvaccinationforhepatitisb,andanincreasingrangeof effectivetreatmentoptionsforbothhepatitisbandhepatitisc,theburdenofchronicviral hepatitisonhealthsystemswithintheregionwillcontinuetoincreaseunlessstrategic, coordinatedandintegratedpublichealthresponsesareimplementedwithinandacrossthe region. Thisreportdescribes,assessesandanalysesthepublicpolicyresponsestochronicviral hepatitisb,hepatitiscandlivercancerintaiwanwithanaimofidentifyingtheindividual componentsofthetaiwaneseapproachincludingexistingbestpracticeandpublicpolicy strengthsandchallenges. TheCoalitiontoEradicateViralHepatitisinAsiaPacific(CEVHAP)isanonaprofitorganisation dedicatedtopublicpolicyreformtoreducethesignificanthealth,socialandeconomicburden ofviralhepatitisintheasiapacificregion.thisprojectisamonganumberofprojectsbeing conductedthroughcevhaptodetermineandassesstheconstituentelementsofa comprehensiveandeffectivepublichealthresponsetoviralhepatitisthroughouttheasiaand Pacificregion. Taiwanwasselectedgiventhenumbersofpeoplewithchronicviralhepatitiswithinits jurisdiction,theexistenceofacivilsocietyandaclinicalinfrastructurerelatedtobloodborne virusesincludinghiv/aidsandhepatitis.identifyinggapswithin,orbarriersto,thesestructures canthenbeusedtoidentifypolicyissuesinwhichadvocacyinterventionswithinspecific countriesandacrosstheregioncanbedeveloped.themethodologyusedinthispilotproject willbeevaluatedtoidentifyhowitcanbestbeadaptedandreplicatedforadditionalpolicy assessmentsinothercountriesintheregion. Taiwanisrecognisedinternationallyforitspioneeringroleinpreventingthetransmissionof hepatitisb.thisroleisrecognisedthroughinnovativeresearchidentifyingthelinkbetween hepatitisbandcancer,(2)thetransmissionofhepatitisbfrommothertochild,(3)howthis transmissioncanbereduced,(4)thedevelopmentofavaccinetohaltthistransmission,andthe implementationandsuccessofapopulationlevelvaccinationprogram.(5,6)thisleadership wasreinforcedwithclinicalresearchoverthepastthreedecadeswhichhastransformedhow hepatitisbandhepatitisctreatmentsaredelivered.inspiteofthis,significantgapsinthe LaTrobeUniversity5

8 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan Taiwanresponsetoviralhepatitisremain.Thesegapsareessentiallyreflectedbythepoor understandingandresponsestotheinfectionbypeoplewithviralhepatitis,withonlya minorityaccessingtimelyclinicalmanagementfortheirinfection,andthelateclinical presentationofpeoplewithchronicviralhepatitisoftenwithhepatocellularcancer(7). HepatitisDisnotspecificallyaddressedinthisreport,giventheprimacyandfocusof governmentresponsestohepatitisbandhepatitiscandtherelationshipoftheseviruseswith livercancer. Thispolicyassessmentreviewedliteratureandconductedaseriesofinterviewswithkey participantsand/orpartnersinthenationalresponsetochronicviralhepatitisintaiwan.they includeclinicians,governmentofficials,advocates,representativesfromnonagovernment organisations,andpharmaceuticalcompanies.theinterviewswereconductedintaiwan duringjune/july AustralianResearchCentreinSex,HealthandSociety

9 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan 3. Rationale Thispolicyassessmentwasconductedgiventheinternationalfocusonthedevelopmentof publicpolicyresponsestoreducetheburdenofchronicviralhepatitissince2009.thisactivity hasincluded: ViralHepatitis:GlobalPolicy,bytheWorldHepatitisAlliance(2010) SixtyathirdWorldHealthAssemblyresolutionWHA63.18onViralHepatitis(2010) WorldHealthOrganization,PreventionandControlofViralHepatitisInfection:Frameworkfor GlobalAction(2012). Thefirstdocument,fromtheWorldHepatitisAlliance,Viral&Hepatitis:&Global&Policy&(8)mapped nationalgovernmentpoliciesandprogramstargetingviralhepatitiswithdatacollectedthrough selfareportedsurveysofhealthministries/departmentsacrossallworldhealthorganization memberstates.thereportsummarisedviralhepatitispreventionandcontrolprogramsand policiesatglobal,regionalandcountrylevelaccordingtosixkeythemes:policy;awarenessand education;surveillance;testing;treatment,andcare;andcivilsocietyengagement.dataforthe documentwereobtainedthroughselfareportfromrespectivegovernmentsourcesandthe reportnotesthat theexistenceofapolicyorprogrammecannotbetakenastestamenttoits implementation,effectivenessorcomprehensiveness. ThediplomaticstatusofTaiwanis contentious.taiwanisnotamemberoftheworldhealthorganization,andwhileattending andpresentingattheworldhealthassemblysince2009aschinesetaipei,(9)themappingof policyconductedbytheworldhepatitisalliancedidnotoccurwithintaiwan. In2010,theSixtyathirdWorldHealthAssemblyadoptedresolutionWHA63.18which acknowledgetheimpactofchronicviralhepatitisandprovidestherationaleanddesignatesthe 28JulyofeachyearasWorldHepatitisDay.(8)Theresolutionurgedmemberstatesto undertakearangeofactivitiesandrequestedthedirectorgeneraltoestablishthe developmentof guidelines,timeboundgoals,strategiesandtoolsforthepreventionand controlofviralhepatitis. ThethirdglobalresponseistheWorldHealthOrganization,PreventionandControlofViral HepatitisInfection:FrameworkforGlobalAction.(10)Thisframework,releasedin2012, declarestheworldhealthorganizationvisionofaworldwhereviralhepatitistransmissionis stoppedandwhereeveryonehasaccesstosafeandeffectivecareandtreatmentthroughthe developmentofapublichealthapproachtoreducingtheburdenofinfection.theframework identifiesfouraxesinwhichactivityisrequired: LaTrobeUniversity7

10 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan 1. Raisingawareness,promotingpartnerships,andmobilisingresources 2. Evidenceabasedpolicyanddataforaction 3. Preventionoftransmission 4. Screening,careandtreatment. Policyinterventionsspecificallyaddressingchronicviralhepatitisshouldseektoreducethe burdenofinfectionanditssequelaeatanindividualandhealthsystemslevelbyassessingthe scopeoftheproblem,identifyingstrategiesandprioritisingactivitiesthataimtoreducethe currentandfutureburdenofinfection,andbyidentifyingthekeypartnersandother stakeholdersrequiredtoimplementtheinterventions.thiscouldincludepoliciesspecifically addressingprevention;accesstoscreening,testingandclinicalmanagementincluding treatment;andidentificationofbarriersforpeoplewithchronicviralhepatitistoparticipatein theseinterventions.unlikeresponsestootherbloodbornevirusessuchashiv/aids,where countriesintheregionhavedevelopedintegratedandspecificpolicyandregulatory infrastructuretocoordinateresponsestoreducetheburdenofhivinfection,thereislittle evidenceofpolicycoordinationimplementedinresponsetochronicviralhepatitis. Whilemanychallengesarecountryspecific,thereareanumberofissuesthatarecommon acrosstheasiapacificthatwereidentifiedatthehepatitisbpolicyworkshopheldalongside the20 th ConferenceoftheAsiaPacificAssociationfortheStudyoftheLiver(APASL)inBeijingin March2010.(11)Theseissuesincluded: Lowpatientandpublicunderstandingofthediseaseanditsimplications Differingopinionsamongmedicalexpertsonbestclinicalmanagementregime Lackofeffectiveprevalenceand/orsurveillancedatainmanycountries Lackofpolicycoordinationacrossdifferentareasofgovernment Noidentificationofcommonadvocacymessagesorcoordinationofadvocacyactivity amongststakeholderswithinspecificcountriesoracrosstheregion Competingprioritiesforpolicymakers/shorttermfocusofgovernments. Thispolicyassessmentisinnovativeinitsapproachbyinterviewingkeyparticipantsusinga qualitativemethodologytoidentifyandinterrogatepolicyidentifiedbykeyparticipants.the useofthismethodologyprovidestheopportunitytoexploreandcapturethecomplexityof experiencesdescribedbyparticipantsinrelationtotheresponsetoviralhepatitisintaiwan, particularlyintheconnectionbetweenthedevelopmentofpolicy,andofthepractical implicationsofitsimplementation.therearelimitstothisqualitativeapproachandtheanalysis doesnotclaimtoberepresentativebutseekstoprovideusefulinsightstoinformthedirection anddevelopmentofstrategicandprogrammaticinterventions. 8AustralianResearchCentreinSex,HealthandSociety

11 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan 4. Methodology TheprojectwasconductedintwostageswithapprovalfromtheLaTrobeUniversityFacultyof HealthSciences,HumanEthicsCommittee(approvalFHEC12/6). Stageoneconsistedofsemiastructuredinterviewswith26keyTaiwanbasedparticipants identifiedthroughtheirparticipationincevhaporthetaiwanassociationforthestudyofthe Liver.Semiastructuredinterviewsprovidedtheflexibilitytoinvestigateunexploredtopicswith theschedulerevisedasinterviewsprogressedtoinvestigateemergingthemes.(12)thesemi structuredinterviewsconsistedofthefollowingquestions: WhathealthorsocialissuesaffectpeoplewithchronicviralhepatitisinTaiwan? Whatorganisationsareinvolvedinrespondingtochronicviralhepatitis? (Clinical/Specialist/Generalpractitioner/Community/Patientsupport/Prevention) Howdopeoplewithchronicviralhepatitisfindoutthattheyareinfected? Howarepeoplewithchronicviralhepatitisclinicallymanaged? Towhathealthservicesaretheyreferred? Whatpublicpoliciesaffecttheseprocesses? Whodevelopshealthpolicy?Howisthisdone? Whoimplementshealthpolicy? Whatarethestructuresofhealthpolicydevelopmentandimplementation? Aretherebarrierstotheseprocesses?Whatarethesebarriers? WouldaneffectivepublicpolicyresponsetochronicviralhepatitisinTaiwanlooklike? Whatarethebarrierstoachievingthis? Additionalparticipantswereidentifiedafteraninternetwebsearchofprofessionalsworkingin publichealth,communicablediseasesorpublicpolicyadvocacyintaiwanorasaresultof referralfromanotherparticipant.whilepeoplewithhepatitiswerenotpurposivelyrecruitedto theproject,twoofthesamplevoluntarilydisclosedtheirindividualexperienceoflivingwiththe infections.participantsdocumentedthehealthpolicyinfrastructureoperatingintaiwan includingfundingandpolicyarrangements;clinicalorganisationsandstructures,andformal andinformalparticipantsanddriversofhepatitisarelatedpolicyincludingacademicandnona governmentorganisations.themajorityofinterviewswereheldinenglishwithamandarin speakinginterpreteravailablewhenrequired. Datacollectedfrominterviewsinthisstagewereinaqualitativeformwithinterviews electronicallyrecorded,transcribedandverified.transcriptswereanalysedusingnvivo10(qsr InternationalPtyLtd,VIC,Australia)byorganisingdataintocodesinwhichmainthemeswere LaTrobeUniversity9

12 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan identified.thedatawasindexedwithaninterpretationdevelopedthroughthecreationof typologiesandassociationsbetweenthemes. Datagatheredduringstagetwooftheresearchwasdeskabasedandfocusedonpublicly availablepolicyresponses,withthetranslationofdocumentsarrangedifnecessary.mostpolicy fell,althoughnotexclusively,withinthescopeandresponsibilityofrespectivehealth authoritiesandincluded: Primarypreventionprogramsincludingpubliceducationcampaigns,vaccination,blood supplysafetyandantenatalcare Secondarypreventionincludingtesting,screening,diagnosis,notificationandreportingof hepatitisbandhepatitisc Accesstotreatment,andcoordinatedandstrategicactivitiesseekingtoimproveaccessto treatment Linkstootherhealth,socialandeconomicpolicyareasincludingmaternalhealth,human rightsandcancerprevention. 10AustralianResearchCentreinSex,HealthandSociety

13 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan 5. ChronicViralHepatitisandLiverCancer thetaiwancontext TaiwanisaPacificOceanislandphysicallyseparatedfrommainlandChinabytheTaiwanStrait. Theislandwashistoricallyknownas'Formosa',fromthePortuguese,Ilha&Formosameaning beautifulisland.whilethepoliticalcontextoftaiwanhasbeenparticularlycomplexsince1944, theaustraliangovernmentdescribestaiwanascurrentlyhavinga vibrantdemocracy since theendofaneraofmartiallawin1987. Taiwanhadapopulationof23,224,912in2011.TheTaiwanCentersforDiseaseControlreport approximately2.5millionpeoplelivingwithchronichepatitisb(surfaceantigenpositive)and 700,000peoplewithhepatitisC(RNApositive),(13)apopulationprevalenceof10a15%for hepatitisband2a5%forhepatitisc.significantvariationsinthehepatitiscpopulation prevalenceexistwith2.1%ofthepopulationintaipeiinfected,risingto26.5%ofthe populationintaitungcountywithanincreasingprevalencerateassociatedwithage. HepatitisBandhepatitisCvirusinfectionsarethemajorcausesofcirrhosis,hepatomaand otherliverdiseasewhichtogetherconstitutedtheeighthleadingcauseofdeathintaiwanin 2011.HepatitisBaccountsfor1%ofthetotalinpatientexpenditure(14)withsignificantsocioa economicsavingsexpectedtoresultfromitssuccessfulcontrol.(15) Ofthe152,030peoplewhodiedinTaiwanin2011,42,559peoplediedofcancer,whichhas beentheleadingcauseofdeathinthecountrysince1962.thetopthreecancersarecancersof thelung,liverandcolorectalsystem,withcancersoftheliverandbileductsaccountingfor almost19%ofallcancerrelateddeaths,or11,077peopleintaiwan(16)withanadditional 5,153peopledyingasaresultofchronicliverdiseaseandcirrhosisin2011.TheDepartmentof Health,intheirreportofdeathsinTaiwanin2011a2012,notesthemedianageofdeathhas increased,withtheexceptionofchronicliverdiseaseandcirrhosisandthattherankingof deathsfromcirrhosisandliverdiseasehasdroppedfromthe6 th highestcauseofdeathtothe 8 th leadingcauseofdeath.otherpublichealthissuesaffectingtaiwanidentifiedbythetaiwan governmentinclude: Anageingpopulationwithalowbirthratewithestimatesof20%ofpeopleinTaiwanbeing overtheageof65yearsby2025andwiththecountrybeingdefinedasa superaaged societybytheunitednations. Tobacco Obesity LaTrobeUniversity11

14 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan Tuberculosis,describedbytheDepartmentofHealthasTaiwan s mostdangerous communicabledisease with638peopledyingasaresultoftheinfectionin2011 HIV,with22,822peopleinfectedwiththevirusincluding2,028newinfectionsin2011.The proportionofnewhivinfectionsfromunsafeinjectingdroppedfromahighof72%in2005 to5%in2011.thegovernmentidentifiesthisreductionoccurringasaresultofthe implementationofaharmreductionplanin2008,whichincludedthedistributionofsterile injectingequipment,drugsubstitutionprograms,andinformation,educationand communicationstrategies InfluenzaA(H1N1) DengueFeverwith1702casesandfivedeathsreportedin2011concentratedmainlyin southerntaiwanandpenghucounty Outbreaksofenterovirus,whichresultedin177deathsofyoungchildrenbetween1998 and AustralianResearchCentreinSex,HealthandSociety

15 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan 6. Healthdeliverycontext Figure1aHepatitisPolicyandServiceStructure TheTaiwannationalgovernmentconsistsoftheOfficeofthePresidentandfivebranches,the ExecutiveYuan,LegislativeYuan,JudicialYuan,ExaminationYuanandControlYuan.The ExecutiveYuanhasacouncil(orCabinet)comprisedofthepremier,whochairsitsmeetings, thevicepremier,theheadsofministriesandcommissions,andministerswithoutportfolio. Thereareeightministriesand29otherCabinetalevelorganizationsundertheExecutiveYuan includingtheministryofhealthandwelfare(alsoknownasthedepartmentofhealth). Healthservicedeliveryoperatesattwolevels:atthenationallevelthroughtheDepartmentof Health,andthroughmunicipal,countyorcityhealthauthorities.TheDepartmentofHealth providestechnicalassistance,supervisionandcoordinationoflocalhealthagencies.the LaTrobeUniversity13

16 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan CentersforDiseaseControl,BureauofHealthPromotionandBureauofNationalHealth Insurancearedescribedas affiliatedorganisations withinthedepartmentofhealth. RegulatoryauthorityforcommunicablediseasepreventionoccursthroughtheCommunicable DiseaseControlAct,andtheHIVInfectionControlandPatientRightsProtectionAct.(17) TheCentersforDiseaseControl(CDC)aredescribedbytheDepartmentofHealthasbeing responsiblefordevelopingcommunicablediseasecontrolstrategiesandforthesupervision, directionandevaluationofcommunicablediseaseprogramsconductedbylocalhealth authorities.viralhepatitisrelatedactivity,includingpreventionandclinicalmanagementfalls undertheresponsibilityofthedivisionofacuteinfectiousdiseasesandimmunizationwithin thecentersfordiseasecontrol. ExamplesofcityormunicipallevelhealthactivityincludetheTaipeiCityHealthDepartment, whichcontainsadivisionfordiseasecontrolandpreventionresponsibleforimplementing immunisationprogramsandahealthpromotiondivision.inaddition,thecityhealth departmentisresponsiblefortheoperationofhospitalsandotherclinicalsettingsincluding communitybasedhealthcentresandtheprovisionoflivercancerscreeningthroughtheir cancercontrolprogram.thekinmungbranchofthetaipeicityhealthcenterincludesharm reductionprogramsincludingneedleandsyringeprograms,theprovisionandoperationof methadoneprogramsandtheresearchanddevelopmentcenterforsexuallytransmitted DiseasesandAIDS. Atthecity/countylevel,eachlocalgovernmenthasaBureauofHealththathandleshealtha relatedissuesandsuperviseshealthstationswithinitsadministrativeregion.thesehealth stationsareadistinctivefeatureoftaiwan spublichealthnetworkandtheirhistoryhasbeen tracedtothemedicalpolicesystemofthejapanesecolonialperiod.ahealthstationhasa medicalaadministrativedirectorandseveralpublichealthnurses,thenumberofwhichdepends ontheassignedworkloadandareaofconcern.healthstationsprovidephysicalcheckups, routinevaccinationsincludinghepatitisb,(17)followinguppeoplewithmajorillnesses, reportinglocalhealthissues,promotinghealtheducationand,inmanyruralareas,providing basicmedicaloutpatientcare. Taiwanhasanationalpremiumafinancedhealthinsurancesystem,theNationalHealth Insurance.(18)Thisschemecommencedin1995andisamandatorymedicalinsurancescheme providingabroadrangeofmedicalcoverageincludingtraditionalchinesemedicineanddental services.thebureauofnationalhealthinsurancestatesthat99%oftheentirepopulationare coveredbythisinsurance,withtheremainderconsistingofforeignnationalswithintheirfirst sixmonthsofresidenceorwhoarenotemployed,ortaiwaneselivingoutsideoftaiwan. Prisonershaverecentlybeenincludedintothescheme(2012). 14AustralianResearchCentreinSex,HealthandSociety

17 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan Peoplewithinsurancehaveaccesstomorethan19,000healthcarefacilitiesthathave contractswiththebureauofnationalhealthinsurance.thesefacilitiesincludeinpatientand ambulatorycare,dentalservices,traditionalchinesemedicinetherapies,obstetricservices, physicalrehabilitationandchronicmentalillnesscare,amongotherservices.mostformsof clinicalmanagementsuchastreatmentaccessandsurgeryarecoveredbythesystemincluding examinations,laboratorytests,prescriptionmedication,medicalmaterialsandparaphernalia, limitedhomenursingcareandcertainoveratheacounterdrugs. Fundingoftheinsuranceschemeissplitbetweenemployees(paying30%ofthepremium), employer(60%)andthecentralgovernment(10%).premiumsforpeopleonlowaincomesare coveredbythecentralgovernmentwithsubsidiesorinterestafreeloanstocoverpremiums providedtootherdisadvantagedgroups,includingcertainruralresidents,indigenouspeople andlowaincomegroups. Coapaymentsexistforpeopleaccessinghospitalservicesandfordrugprescriptionswiththiscoa paymentbeing toremindtheinsuredthatmedicalresourcesareusedtohelppeoplewhoare illorinjuredandshouldnotbewastedunderanycircumstances. (19)Thispaymentranges from$ntd50/us$1.67fordentalcareandtraditionalchinesemedicineto$ntd450/us$15for emergencycareandpeopleaccessingoutpatientcareatahospitalwithoutareferralpayan additional$ntd150/us$5.00(2011).exemptionsforpeopleorpopulationsexperiencing barrierstohealthservices(20)withcoapaymentscappedatnt$52,000/us$1,750perhealth conditionpercalendaryear.(21)arecentamendmenttothenationalhealthinsurancesystem (2012)includesa2%supplementarypremiumchargeonpartatimeincome,stockdividends, interestearnings,rentalincome,professionalpracticeincomeandbonusesexceedingfour months salary.thebureauofnationalhealthinsurancecurrentlyreimbursescontracted healthcareservicesonacostforfeebasisandfrom2013ismovingtoadiagnosisrelated paymentsystem,whichincludeshepatitisbandhepatitisc,withanaimoflimitingtheoveruse ofclinicalresources. Thedevelopmentandimplementationofthenationalinsuranceschemehasoccurredwithin thecontextofmuchdebate.someofthekeyissuesandresearchfindingssurroundingthe implementationofnationalhealthinsuranceincludeanincreaseinaccessibility(22,23)and demandforhealthservices(24)withoutanincreaseinwaitingtimes.(23)anarrowinginhealth disparitiesacrossthecountryhasbeenfound,(23)withtheavailabilityofaccesstohealth servicesaccordingtoneed,(25)andanoticeableimprovementinthegeographicaldistribution ofwesternandchinesemedicinehealthcareprofessionalsanddentists.(26) IntermsoftheimpactofNationalHealthInsuranceonphysicians,thelackofa gateakeeper or referralprotocolshasbeenreportedtoincreaseaccesstospecialistserviceswithinacontextof anincreasinglackofphysicians(22,27)withphysiciansseeingmorepatientsperhour LaTrobeUniversity15

18 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan comparedtothosein Westerncountries. (24)Thereisareportedvariablequalityofcare(22, 28)andtheschemeasawholefacesincreasingfinancialpressures,whilehavinglow administrativeoverheads.(22,24,28)thepharmaceuticalindustryarereportedtobe concernedthatdrugpricesintaiwanare unsustainablylow withdelaysinnewdrug approvalsaffectingthewillingnessofdrugcompaniestolaunchdrugsinthecountry.(24,29) Intermsofthephysicalinfrastructureofthehealthcaresystem,theDepartmentofHealth reportsjustover69hospitalbedsper10,000population,inatotalof507hospitals.whilethis numberofhospitalsisdecreasingovertime,thereisagradualincreaseinthenumberof medicalclinics. Thecontextinwhichactivitytoreducetheindividualandsocialimpactofviralhepatitisis framedbyawellaestablishedandrelativelystablegovernment,withclearanddefined structuresinwhichgovernmentsupportedpolicyandactivityisundertaken.theintroduction ofthebureauofnationalhealthinsurancesuccessfullyprovidesaccesstohealthcareservices forthevastmajorityofthepopulationwithaneffectiveandresourcedphysicalinfrastructure inwhichhealthservicesareprovided. 16AustralianResearchCentreinSex,HealthandSociety

19 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan 7. ViralHepatitisContext HepatitisB 2,400,000(975,000women,1,446,000men)areinfectedwithchronichepatitisBinTaiwan Between10a15%oftheTaiwanpopulationhavechronichepatitisB 417acutecasesoccurperyear 67,411peoplewithhepatitisBreceivedtreatmentbetweenOct03toDec10 HepatitisBispreventedbyvaccination 96.59%ofbabiesreceivedtheir3 rd hepatitisbvaccinationdosein %ofelementaryschoolstudentsreceivedtheir3 rd vaccinationdosein2009. HepatitisC 700,000peopleinTaiwanarechronicallyinfectedwithhepatitisC Between2 5%oftheTaiwanpopulationhavehepatitisC 36,641peoplewithhepatitisCweretreatedbetweenOct03andDec10 Over4,000,000needlesandsyringesdistributedin2009. Livercancer 42,559peoplediedofcancerin2011,11,077ofthemasaresultofcancersoftheliverandbile ducts HepatitisBcauses70%oflivercancer,whilehepatitisCcauses20%oflivercancer Anadditional5153peoplediedin2011asaresultofchronicliverdiseaseandcirrhosis Treatmentforhepatitisreduceslivercancer.Of1068peoplesurveyed:82%hadbeentested forviralhepatitisand70%didnotknowtherelationshipbetweenhepatitisandlivercancer HEPATITISB Taiwanhasoftenledtheworldinunderstandingandrespondingtoviralhepatitisandits impact.pioneeringresearchfromtaiwanidentifiedprocessesfordetectingliverdisease,the useofliverbiopsy,thelinkbetweenhepatitisbandcancer,(2)thetransmissionofhepatitisb frommothertochild,(3)howthistransmissioncanbereduced,(4)thedevelopmentofa vaccinetohaltthistransmission,andtheimplementationandsuccessoftheimplementationof apopulationlevelvaccinationprogram.(5,6) LaTrobeUniversity17

20 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan TheCentersforDiseaseControlestimatesthatjustunder1million(975,000)womenand 1,446,000meninTaiwanhavechronichepatitisBwith172a417confirmedacutecases occurringannuallybetween2001and2010(13)andwiththenumberofwomenwithchronic hepatitisbidentifiedthroughprenatalscreeningdecliningfrom17.2%in1998to9.7%in2010. Chenfounda17.3%prevalenceofhepatitisBdecreasingforpeopleovertheageof50,with significantgeographicvariationsandgreaterprevalencebeingfoundinkeelungcityandyilan City.(30) TaiwanwasthefirstcountryintheworldtointroduceanationawidehepatitisBvaccination program.(7,31)fromjuly1984tojune1986,newbornsofhighariskhbsagapositivemothers werevaccinated,(32)withtheprogrammeextendedfromjuly1986toincludeallnewborns, andfurtherextendedtoallpreschoolchildrenfromjuly1987tojune1988whomissedthe scheduledvaccination.healthcarepersonnelwereaddedtothevaccinationprogrammein 1987andin1990,theprogrammecoveredallelementaryschoolchildrenwithvaccinerecords checkedforallschoolentrants.(31)thevaccinationnotonlysignificantlyreducedthe prevalenceofhepatitisbamongyoungpeopleintaiwan,withchronichepatitisbprevalence decliningfrom10.5%priortotheimmunisationprogramto0.8%butalsoproducedasignificant declineinlivercancerincidenceamongchildrenandyoungadults.(6) TheRiskEvaluationofViralLoadElevationandAssociatedLiverDisease/CanceraHepatitisB Virus,morecommonlyknownastheREVEALstudy,wasconductedinTaiwanandinvestigated thenaturalhistoryofchronichepatitisb.thiscommunityabasedprospectivecohortstudy enrolled23,820participantsduring fromseventownshipsinTaiwan.Serum sampleswerecollectedatstudyentryandtestedforhepatitisbsurfaceantigen(hbsag)ande antigen(hbeag),antibodiesagainsthepatitiscvirus,alanineaminotransferase(alt),andaa fetoprotein(afp).incidenceoflivercancer,cirrhosisandliverrelatedmortalitywere significantlyassociatedwithhepatitisbviralload(dna)andgenotype.thestudyalsoshowed thatpeoplewithinactivehepatitisbhadanincreasedriskoflivercancerandliverarelated mortalitycomparedwithpeoplewhowerehbsagaseronegative.(33,34) HepatitisBistheleadingcauseoflivercancer.(35)Theneedtoeffectivelytreatpeoplewith hepatitisbishighlightedbyfwuetal(2010)intheirfindingofexcessriskofdeathduetoboth liveraspecificandnon liverarelatedcausesforwomenwithchronichepatitisbintaiwan.the authorsrecommendeffectivepreventionandtreatmentofhepatitisbvirusinfectionasan importantpublichealthpriority.(36) Whiletherearehighratesofvaccinecoverage,(37)withtheCDCdescribinghepatitisB immunisationcoverageforbabiesbornin2009being97.83%forthefirst,99.8%forthesecond and99.55%forthethirddoseamongelementaryschoolstudentsthereisacontinuedneedfor ensuringtheefficacyofthevaccineovertime.(38)thereareseveralreasonsidentifiedas 18AustralianResearchCentreinSex,HealthandSociety

21 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan supportingthesuccessoftheimplementationofthevaccinationprogramintaiwanincluding thecommitmentanddeterminationofthegovernmenttoreducetheburdenoftheinfection;a rangeofgovernmentandacademicinstitutionsinvolvedintheimplementationoftheprogram; awelladesignedpublichealthinfrastructure;highlytrainednursingstaff;publiceducation takingplaceoverathreeyearperiod,andthecarefuldesignandevaluationoftheprogram.(7, 31,39) ScreeningforviralhepatitisinTaiwancommencedin1984withthescreeningofpregnant women.screeningcurrently(2013)occursthrough: Anteanatalscreening Anationaldiseasescreeningprogramforalladultsovertheageof45years Screeningconductedbynonagovernmentorganisations Entryintouniversityandwithinsomeworkplaces Blooddonation. TheCenterforDiseaseControldescribesactivitiesincludingthescreeningofchildrenbornto motherswhoareeaantigenpositiveevenafterimmunoglobulinandimmunoprophylaxis. Screeningforviralhepatitisoccursinacontextwheresurveysofthegeneralcommunityshow reluctanceofusingscreeningserviceswhentheyhavenosymptoms.anothersurveyof19,000 peopleconductedbythebureauofhealthpromotion,thenationalhealthresearchinstitutes andthebureauofcontrolleddrugsshowedalackofknowledgeaboutscreeningservicesand theireligibilitytoaccesstheseservices.(40) The NationalHealthInsuranceChronicHepatitisBandCTreatmentPlan wasinitiatedin2003 totreatpeoplewithchronicviralhepatitis.the2011cdcannualreportreportsthatthe HepatitisBandCTrialTreatmentProgramtreated67,411patientswithhepatitisBand36,641 patientswithhepatitiscbetweenoctober2003anddecember2010.(60) Treatmentforviralhepatitisisavailablethroughpublichospitalswiththetwomainantiviral treatmentsforhepatitisbbeinginterferonandnucleoside/nucleotideanalogues.linandkao (41)notetherecommendationsoftheAmericanAssociationfortheStudyofLiverDisease (AASLD),theEuropeanAssociationfortheStudyofLiver(EASL),andtheAsianPacific AssociationfortheStudyofLiver(APASL)andthatindicationsforhepatitisBtreatmentshould includequantitativeserumhepatitisbdnalevel,alanineaminotransferase(alt)leveland/or histologicalseverity.governmentreimbursementofhepatitisbtreatmentislimitedtothree yearsindurationwithexemptions. Whiletreatmentisavailable,andofaworldclassstandardinTaiwan,barrierstotreatment includelowawarenessamongstpeoplewithchronichepatitisbparticularlyintheir LaTrobeUniversity19

22 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan understandingoftheneedforregularmonitoringoftheinfection,insufficientknowledgeon thepartofphysiciansoftheimportanceoftimelytreatment,andfinancialbarriers.(7) Stigmaanddiscriminationrelatedtobloodborneinfectionshasbeenreportedasreducing accesstohealthcareservices.(28,42a44)littleresearchhasoccurredintaiwanontheseissues withonestudyoftaiwaneseuniversitystudents(45)comparingknowledge,healthbeliefsand selfaefficacytowardhepatitisbprevention.thisstudyfoundthatmoststudents(regardlessof hepatitisbstatus)reportedtheywouldbeafraidtotellfriendsiftheywereinfectedwith hepatitisb,andwouldbeafraidofbeinginfectediftheirfriendshadhepatitisb,suggesting confusioninrelationtotransmissionandpreventionrelatedissues HEPATITISC TheCentersforDiseaseControlidentifiesapopulationprevalenceofhepatitisCof4.4%in Taiwan.Chen(46)reportedin1990,that0.95%of420volunteerblooddonorswereinfected withhepatitiscwiththeinfectionbeingextremelycommonamongpeoplewithhaemophilia (100%)andpeoplewhoinjectdrugs(81%).Leeetal(47)describedhepatitisCprevalencein Taiwanof0.28%among1,419 healthy peopleand0.8%among500unselectedpaidblood donors(1991).intermsofpeopleathigherriskoftheinfection,bothleeandchenfoundhigh riskgroupsincludedpeoplewithhaemophilia,peoplewithhiv,peoplewhoinjectdrugsand haemodialysispatientswithtransmissionassociatedwithpoorinfectioncontrolandfrequent medicallyabasedinjection. HepatitisCprevalenceishigheramongolderpeople,withspecificgeographicaldifferencesin hepatitiscprevalencerangingto26.5%intaitungcounty.sun(48)foundinacommunity basedsurveyinseventaiwantownshipssignificantgeographicaldifferencesinhepatitisc prevalencerangingbetween1.6%a19.6%witharelationshipbetweenbloodtransfusion, medicalinjections,acupunctureandtattooing. Intermsofprevention,hepatitisCtransmissionoccursprimarilyamongpeoplewhoinject drugsinacontextwherethedepartmentofhealthreportthenumberofcasesofhivamong peoplewhoinjectdrugsincreasingfrom18in2002to624in2003.duringthisperiod,the proportionofhivtransmissionrelatedtounsafeinjectingrosefrom9%ofnewinfectionsin 2003to72%in2005(49)withinacontextofarapidincreaseinoverallHIVdiagnoses.(50)A 2013studyfound90%hepatitisCprevalenceamongheroinusersseekingentryintoadrug substitutionprogram,withonlyoneathirdofthesamplebeingawareoftheirhepatitis infection.(51)this,andotherstudies,havefoundthatthemajorityofpeoplewithhivinfected throughunsafeinjectingarealsoinfectedwithhepatitisc.(50) 20AustralianResearchCentreinSex,HealthandSociety

23 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan TherapidincreaseinHIVinfections,particularlyamongpeoplewhoinjectdrugsledtothe CentersforDiseaseControlintroducingaharmreductionprogram,initiallyinfour administrativeareasandthennationally,withthedistributionofsterileinjectingequipmentin November2005;drugsubstitutionprograminFebruary2006;expansionofaccesstoHIV diagnostictestingandthedevelopmentofhealtheducationandcounsellinginterventionsfor peoplewhoinjectdrugs.thesuccessoftheprogramisdemonstratedbytheareasinwhichthe programwasnotintroducedshowingsignificantincreasesinhivincidence.(52) AnotherformofhepatitisCpreventionoccursthroughreducingthenumberofinjections amongpeoplewhoinjectdrugsbyprescribingdrugsubstitutes,primarilymethadone.this drugsubstitutionprogramcommencedin2005inconsultationwiththedepartmentofjustice anddispensesmethadonethrough60servicestoapproximately15,000people.theprogramis fundeddirectlythroughthetaiwancentersfordiseasecontrolratherthanthebureauofthe NationalHealthInsurancewithmethadonedispensedthroughpublichospitals.Retentionrates ofpeopleonthemethadoneprogramaresimilartootherjurisdictionswith41%oneyearafter commencement,and43%after18months.(53)nofeedbackwasprovidedbypeopleaccessing theprogramandthereforeitisnotpossibletoidentifypeople sreasonsforcontinuingor discontinuingintheprogramme.onestudyreportedaseroprevalenceof18.5%forhepatitisb and89.9%forhepatitiscamongpeopleaccessingthemethadoneprogramthroughtwo hospitals,withonly3.4%ofpeopleusingmethadonewhowereinfectedwithhepatitisc receivingtreatmentfortheinfection.(54) In2009,therewereareported1103needleandsyringeprogramsitesinTaiwandistributing over4,000,000needlesperyearwith9000peoplewhoinjectdrugsaccessingthesesitesovera 12monthperiod.Needlesandsyringescanbepurchasedatover7,000pharmacieswithout prescription.(55) Whilehepatitistreatmentisfreeofchargeandavailable,studiesshowpeoplewhoinjectdrugs experiencebarrierstotreatmentandotherhealthservicesintaiwan.(56,57)linetalfound thatonlyfouroutof15(26.7%)peopleintheirstudywhoinjectdrugsandwhowereinfected withhivwereunderregularclinicaltreatmentfortheirhivinfection,withtheauthorsnoting barrierstotreatmentaccessincludingfearofpoliceinterventionnearhospitals,andthe inabilitytoaffordhospitalcoapayments.(58)peoplewhoinjectwerealsonotedasexperiencing poorlevelsoffamilysupport,withinjectingdruguseresultinginstigmawithinthecommunity andamonghealthserviceproviders.(57) ResearchsuggeststhathepatitisCtreatment,whilehavingpotentiallongtermbenefitsimpacts negativelyonqualityoflifeintheshortterm.taiwaneseresearchshowsthatpeople experiencinghepatitiscinfectionwerenotedashavingimpairedqualityoflifebefore treatment,whichfurtherreducedduringtreatmentandimproved6monthsaftersuccessful LaTrobeUniversity21

24 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan treatment.(59)anotherstudyshowedfinancialstressandlackoffamilysupportaffected qualityoflifeofpeoplewithhepatitiscundergoingtreatment.(60) Leeetalfoundareductioninmortalityoflivercanceramongyoungerpeopleandthatwhile theproportionofhepatitisblivercancerintaiwanprogressivelydecreasedbetween1981and 2001,itwasproposedthattherewasanincreaseinhepatitisCvirusrelatedlivercancer.(61) 22AustralianResearchCentreinSex,HealthandSociety

25 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan 8. PolicyContext Governmentresponsestoreducingtheburdenofviralhepatitisinfectionandlivercancerhave beendetailedthroughregular5ayearlyplanssince1982.theseresponseswereoriginally developedasaresultofhepatitispreventionbeingselectedasoneofeightprioritieswithinthe TaiwanScienceandTechnologyDevelopmentProgram,establishedbytheTaiwangovernment in1978todevelopscientificexpertise.(62)the5ayearlyplansaredevelopedbythecentersfor DiseaseControlonadvicefromaDepartmentofHealthHepatitisPreventionCommittee, originallyestablishedin1981andinitiallychairedbyprofjlsung,(63)whohasbeendescribed asthefather&of&hepatology&and&gastroenterology&in&taiwan.(64) TheplansaimtoreducethemorbidityandmortalityassociatedwithhepatitisB.(64,65)The focusoftheprograminitsinitialdevelopment,whilehavingseveralcomponents,wasto prevent perinataltransmissionthroughimmunisation. (31,66)ProfessorDSChennotesthe changingfocusofthisprogramwiththeinclusionforthetreatmentofviralhepatidesbeing includedintheaimin2002.(64)thetaiwancentersfordiseasecontrol(13)describedthe prioritiesoftheseplansas: Improvingthesurveillancesystemforacutecases SeveringhepatitisAinfectionpaths Enhancinghealtheducationonliverdiseasecontrol Improvingbloodtransfusionmanagement Raisinghepatitisexaminationquality. Intheir2011and2012AnnualReports,theCentersforDiseaseControlstatethatinrelationto viralhepatitis,thedepartmentwill moveinthefollowingdirections:earlydetectionand screeningofhepatocellularcarcinomaandseekingeffectivehepatitistreatment. (13) Currentgovernmentpolicy,includingfunding,isdetailedinthecurrentPreventionand TreatmentplanforChronicViralHepatitis(FirstStagePlan,2012a2016).(67)Thisplan contextualisesactivitytoreducetheburdenofchronicviralhepatitiswiththefollowing information: Morethan3millionadultsareinfectedwitheitherhepatitisBorhepatitisCinTaiwanwith thesevirusesbeingthepredominantreasonfordeathsfromlivercancerwithupto50,000 peoplehavingaccessedfundedtreatmentfortheinfections BasedonprenatalhepatitisBscreening,therateofchronichepatitisBinfectiondropped from17.2%in1989to9.7%in2010 LaTrobeUniversity23

26 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan ThereisahepatitisCprevalenceof4.4%amongadultswithahigherprevalenceamong olderpeople,andwithsignificantgeographicaldifferencesofthelowestprevalence existingintaipeiat2.1%rangingtoaprevalenceintaitungcountyof26.5% ThereareconcernsthatthedurationinwhichthehepatitisBvaccineiseffectivehasnot beenconfirmed Thatchildrenborntomotherswhoareeaantigenpositivehavea10%riskofexperiencinga chronichepatitisbinfection Thegeneralcommunityhaveapoorunderstandingofthelinkbetweenhepatitisandpoor healthoutcomessuchascirrhosisandcancerdespitemostrespondentsintherelevant studybeingtestedforhepatitis AsurveyofpeoplewithhepatitisBshowedthat45%didnotconductregularmonitoring and15%hadnoknowledgeofhepatitisbtreatment ThatregularmonitoringofhepatitisBandhepatitisCreducestheincidenceandmortality oflivercancer Atelephonesurveyfindingthat32outof107peoplewithchronicviralhepatitisfailedto consultdoctorswiththereasonsbeinglackofobvioussymptoms(79.4%),toobusy (17.8%),andnotknowingwheretofindsuitabledoctors(11.1%). ThePreventionandTreatmentplanforChronicViralHepatitis,initsFutureForecastassumes thenumberofpeoplewithchronichepatitisbwillcontinuetodecreaseasaresultof vaccination;thatmigrationfromhighprevalencecountrieswillaffectpreventionandtreatment access,andthatthesharingofinjectionequipmentcontributestothenumbersofpeople infectedwithhepatitisbandhepatitisc. Currentinterventionsdescribedintheplaninclude: HepatitisBvaccinationforallnewaborns OnehepatitisBandonehepatitisCscreeningforeverypersonborninorafter1966 HepatitisBandhepatitisCscreeningavailableforpregnantwomenandpeopleoverthe ageof40yearsaspartofacomprehensivehealthcheckconductedatmunicipalorcity levels AccesstohepatitisBandhepatitisCtreatmentforpeoplemeetingspecificrequirements. ThepreventionofhepatitisCtransmissionthroughtheimplementationofharmreduction initiativessuchasthedistributionofneedlesandsyringesanddrugsubstitutionsprogramsfall undertheresponsibilityofthehiv/tbdivisionofthecentersfordiseasecontrol. Thegoalsoftheplanaretoreducethemortalityfromcirrhosisandchronichepatitisby50% from2008figuresthroughpubliceducation,increasedscreeningofpeoplebetween45and65 yearsandofthenumberofpeopleaccessingtreatment.aseriesofchallengesarenotedasare performanceindicatorsandassessmentcriteria.theplanwillbeimplementedby: 24AustralianResearchCentreinSex,HealthandSociety

27 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan RaisingcommunityawarenessofhepatitisBandhepatitisCpreventioninprimaryschools andaprintandelectronicmediacampaign PromotinghepatitisBvaccination Encouragingthecommunitytohavescreeningtests DevelopingahepatitisBandhepatitisCscreeningdatabase EncouragingpeoplewithhepatitisBandhepatitisCtoaccesstreatmentservicesand reducetheharmassociatedwithchronichepatitisinfection Establishingareferralsystemincludingamedicalrecordforpregnantwomendiagnosed withchronichepatitis Continuouslyrevisingtreatmentguidelines Evaluatingtheimplementationstrategies. Accesstoviralhepatitistreatmentistobebroadenedbyincreasingthenumberandbreadthof medicalservicesabletotreatanda relaxation ofthecriteriaformedicationuseincluding replacingliverbiopsywithdnatesting,extensioninthelengthoftimeavailableforhepatitis treatmentsandtheprovisionoftenofovirasafirststreammedicationforhepatitisb. ThetotalfinancialcommitmentprovidedbytheTaiwangovernmentforimplementingtheplan overthefiveyearsto2016totals$twd20,880,911,000/$us705,676,359withthevastmajority ($TWD20,000,000,000/$US676,064,975)beingfortheprovisionofpharmaceuticaltreatment. ItshouldbenotedthathepatitisBvaccinationcostsarenotincludedinthisdata. Implementationoftheplanandoffundingprovidedin2012inTWD/USDis: 1. PreventionofhepatitisBandhepatitisCviralinfectionthrough($TWD68,000,000/ $US2,289,560): a Raisingpublicawarenessaboutpreventionandvaccination b ProvisionofhepatitisBvaccinationtoinfants; supplementaryvaccinetopreaschoolers andnewenrolledprimarystudents,andtestingandcontinuedscreeningofchildren borntoeaantigenpositivemothers Screening($TWD36,957,000/$US1,2432,527) a Raiseawarenessamongthepublicabouttheirdiseasestatusincludingthroughlocaland communityhealthservices. b PromotehepatitisBandCscreeningamongthegeneralcommunity c Conductscreeningamongpregnantwomen d Discusswiththe CouncilofLabourAffairs theinclusionofviralhepatitisscreeninginto theoverseasworkerhealthcheckaupprogramme. LaTrobeUniversity25

28 AsiaPacificViralHepatitisPolicySurveyandAssessment:Taiwan e DevelopmentofahepatitisBandhepatitisCscreeningdatabaseasan information sharingsystem acrossarangeofservices EnhancingHepatitisBandCTreatmentandfollowaup($TWD4,054,470,000/$US136,118,000 with$twd4,000,000,000/$us134,289,000beingforclinicaltreatments) a Encouragepeoplewithviralhepatitistoaccessclinicalmanagementservices b Developmentofinformationbrochurestargetingpeoplewithviralhepatitis;provide informationthroughwebasites c Ensurethathealthcareworkersareawareoftreatmentaccessandareabletorefer peoplewithviralhepatitis d Establishareferralorcasefollowaupsystemforpeoplewithviralhepatitisincluding i) DoctorsprovidingbrochurestopregnantwomenwithhepatitisBandreferralof peoplediagnosedwithviralhepatitisthroughscreeningprocesses ii) HepatitisBCarriers MedicalRecord addedasanappendixtothepregnancy brochure iii) Localhealthdepartment urged toissuereminderstopregnantwomenwith HBeAg(+)fortreatmentandcheckauphalfyearaftergivingbirth. e Reviewandstandardisethe HealthcarePilotplanforEnhancingChronicHepatitisBand CTreatment. Anadditional$TWD11,000,000/$US369,295areallocatedperyearforevaluatingtheprogram. 26AustralianResearchCentreinSex,HealthandSociety