Open Access Open Badges Research article

Geographic patterns of hepatocellular carcinoma mortality with exposure to iron in groundwater in Taiwanese population: An ecological study

Horng-Jeng Shyu12, Chia-Chi Lung34, Chien-Chang Ho5, Yi-Hua Iris Sun6, Pei-Chieh Ko3, Jing-Yang Huang3, Chia-Chen Pan3, Yi-Chen Chiang34, Shih-Chang Chen7 and Yung-Po Liaw348*

Author Affiliations

1 Jen-Ai Hospital, Taichung City 41265, Taiwan

2 Department of Healthcare Administration, Asia University, Taichung City 41354, Taiwan

3 Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City 40201, Taiwan

4 Department of Family and Community Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan

5 Department of Health and Leisure Management, Yuanpei University, Hsinchu City 30015, Taiwan

6 School of Dentistry, Chung Shan Medical University, Taichung City 40201, Taiwan

7 Department of Leisure Industry and Health Promotion, National Ilan University, Yilan County 26047, Taiwan

8 Department of Public Health and Institute of Public Health, Chung Shan Medical University, No. 110, Sec. 1, Chien-Kuo N. Road, Taichung City 40201, Taiwan

For all author emails, please log on.

BMC Public Health 2013, 13:352  doi:10.1186/1471-2458-13-352

Published: 16 April 2013



Many studies have examined the risk factors for HCC (including hepatitis B virus, hepatitis C virus, aflatoxin, retinol, cigarette smoking, and alcohol consumption). However, data from previous studies on the association between iron exposure, land subsidence, and HCC mortality/incidence were limited, especially in Taiwanese population. We aimed to explore the geographical distribution of HCC mortality rates by township-specific data and to evaluate the association between HCC mortality, land subsidence, and iron levels in groundwater in Taiwan.


We conducted an ecological study and calculated the HCC age-standardized mortality/incidence rates according to death certificates issued in Taiwan from 1992 to 2001 and incidence data from 1995–1998. The land subsidence dataset before 2005 and iron concentrations in groundwater in 1989 are also involved in this study. Both geographical information systems and Pearson correlation coefficients were used to analyze the relationship between HCC mortality rates, land subsidence, and iron concentrations in groundwater.


Township-specific HCC mortality rates are higher in southwestern coastal townships where serious land subsidence and higher township-specific concentrations of iron in groundwater are present. The Pearson correlation coefficients of iron concentrations in groundwater and ASRs of HCC were 0.286 (P = 0.004) in males and 0.192 (P = 0.058) in females for mortality data; the coefficients were 0.375 (P < 0.001) in males and 0.210 (P = 0.038) in females for incidence data.


This study showed that HCC mortality is clustered in southwestern Taiwan and the association with the iron levels in groundwater in Taiwanese population warrant further investigation.

Hepatocellular carcinoma; Age-standardized mortality; Land subsidence; Iron; Groundwater; Geographical information systems