Remoteness, race and social disadvantage: disparities in hepatocellular carcinoma incidence and survival in Queensland, Australia

Chronic hepatitis B care in regional Australia: implications for clinical practice and public health policy

BACKGROUND

Australia is struggling to meet its National Hepatitis B Strategy care targets, particularly in nonmetropolitan settings. It is vital to engage priority populations and improve their access to recommended care to reach these targets.

AIMS

This retrospective study examined people living with chronic hepatitis B (CHB) in regional North Queensland, Australia, and determined whether their care adhered to current national CHB management guidelines. The analysis aimed to identify gaps in care that might be addressed to improve future outcomes.

METHODS

All individuals referred to the gastroenterology clinic at the Townsville University Hospital in regional North Queensland, Australia, for CHB care between January 2015 and December 2020 were identified. Their linkage to care, engagement in care and receipt of guideline-recommended CHB care were determined.

RESULTS

Of 255 individuals, 245 (96%) were linked to care; 108 (42%) remained engaged in care and 86 (38%) were receiving guideline-recommended care in 2021. There were 91/255 (36%) who identified as Indigenous Australians. Indigenous status was the only independent predictor of not being linked to care (odds ratio (OR): 0.13 (95% confidence interval (CI): 0.03-0.60), P = 0.01), not being engaged in care (OR: 0.19 (95% CI: 0.10-0.36), P < 0.0001), not receiving guideline-recommended CHB care (OR: 0.16 (95% CI: 0.08-0.31), P < 0.0001) or not being engaged in a hepatocellular carcinoma surveillance programme (OR: 0.08 (95% CI: 0.02-0.27), P < 0.0001).

CONCLUSION

Current approaches are failing to deliver optimal CHB care to Indigenous Australians in regional North Queensland. Targeted strategies to ensure that Indigenous Australians in the region receive equitable care are urgently needed.

Spatial statistical machine learning models to assess the relationship between development vulnerabilities and educational factors in children in Queensland, Australia

BACKGROUND

The health and development of children during their first year of full time school is known to impact their social, emotional, and academic capabilities throughout and beyond early education. Physical health, motor development, social and emotional well-being, learning styles, language and communication, cognitive skills, and general knowledge are all considered to be important aspects of a child's health and development. It is important for many organisations and governmental agencies to continually improve their understanding of the factors which determine or influence development vulnerabilities among children. This article studies the relationships between development vulnerabilities and educational factors among children in Queensland, Australia.

METHODS

Spatial statistical machine learning models are reviewed and compared in the context of a study of geographic variation in the association between development vulnerabilities and attendance at preschool among children in Queensland, Australia. A new spatial random forest (SRF) model is suggested that can explain more of the spatial variation in data than other approaches.

RESULTS

In the case study, spatial models were shown to provide a better fit compared to models that ignored the spatial variation in the data. The SRF model was shown to be the only model which can explain all of the spatial variation in each of the development vulnerabilities considered in the case study. The spatial analysis revealed that the attendance at preschool factor has a strong influence on the physical health domain vulnerability and emotional maturity vulnerability among children in their first year of school.

CONCLUSION

This study confirmed that it is important to take into account the spatial nature of data when fitting statistical machine learning models. A new spatial random forest model was introduced and was shown to explain more of the spatial variation and provide a better model fit in the case study of development vulnerabilities among children in Queensland. At small-area population level, increased attendance at preschool was strongly associated with reduced physical and emotional development vulnerabilities among children in their first year of school.

Current status of disparity in liver disease

Disparities have emerged as an important issue in many aspects of healthcare in developed countries and may be based on race, ethnicity, sex, geographical location, and socioeconomic status. For liver disease specifically, these potential disparities can affect access to care and outcome in viral hepatitis, chronic liver disease, and hepatocellular carcinoma. Shortages in hepatologists and medical providers versed in liver disease may amplify these disparities by compromising early detection of liver disease, surveillance for hepatocellular carcinoma, and prompt referral to subspecialists and transplant centers. In the United States, continued efforts have been made to address some of these disparities with better education of healthcare providers, use of telehealth to enhance access to specialists, reminders in electronic medical records, and modifying organ allocation systems for liver transplantation. This review will detail the current status of disparities in liver disease and describe current efforts to minimize these disparities.

The Impact of Socioeconomic Status on Mortality in Patients with Hepatocellular Carcinoma: A Korean National Cohort Study

Background/Aims

We studied the impact of socioeconomic status (SES) on mortality in hepatocellular carcinoma patients and analyzed the effect of SES on initial treatment allocation.

Methods

A cohort study was conducted using data from the National Health Insurance Service- National Sample Cohort of Korea. A total of 3,032 hepatocellular carcinoma patients who were newly diagnosed between January 2003 and December 2013 were included. Income level was categorized as Medical Aid and ≤30th, 31st-70th, or >70th percentile as an SES indicator.

Results

The proportion of Medical Aid was 4.3%. The highest risks of all-cause mortality associated with Medical Aid were evident in the transcatheter arterial chemoembolization group (fully adjusted hazard ratio [HR], 2.40; 95% confidence interval [CI], 1.25 to 4.58), the other treatments group (fully adjusted HR, 2.86; 95% CI, 1.85 to 4.41), and the no treatment group (fully adjusted HR, 2.69; 95% CI, 1.79 to 4.04) but not in the curative treatment group. An association between the lower-income percentile and higher liver cancer-specific mortality was also observed, except in the curative treatment group. The association between income percentile and all-cause mortality was nonlinear, with a stronger association in the lower-income percentiles than in the higher income percentiles (p-value for nonlinear spline terms <0.05).

Conclusions

Patients in the lower SES group, especially patients not eligible for curative treatment, had an increased risk of mortality. In addition, the association between SES and the risk for mortality was stronger in the lower-income percentile than in the moderate to higher income percentiles.

Immunotherapy and Transarterial therapy of HCC: What the interventional radiologist needs to know about the changing landscape of HCC treatment?

Hepatocellular carcinoma (HCC) is the fourth most common cancer worldwide and its incidence is increasing in Australia. Transarterial therapy, predominantly transarterial chemoembolization (TACE) but increasingly transarterial radioembolization (TARE), plays an important role in patients with intermediate‐stage disease and preserved liver function. However, despite advances in TACE, TARE and adjunctive procedures, overall survival has only modestly increased over the last 20 years. Immunotherapy has emerged as a newer cancer treatment and uses antibodies directed at checkpoint inhibitors to upregulate T‐cell mediated tumour‐specific death. These drugs have been shown to increase survival in patients with HCC and have changed the landscape for advanced disease. Trials are now ongoing combining transarterial therapy and immunotherapy. This manuscript introduces these trials and interventional radiologists should be aware of the changing landscape so that they can partner with immunotherapy and remain relevant in the HCC multidisciplinary group as immunotherapy use increases.

Remoteness of residence predicts tumor stage, receipt of treatment, and mortality in patients with hepatocellular carcinoma

Background and Aim

Surveillance and early detection and curative treatment of hepatocellular carcinoma (HCC) are the mainstay of improving survival for patients, but there are several barriers to achieving this goal. We reported the impact of remoteness of residence on receipt of treatment, tumor stage, and survival in patients with HCC in Queensland.

Methods

We conducted a retrospective cohort study of 1651 HCC patients (147 migrants) from 1 January 2007 to 31 December 2016. We used Wilcoxon rank‐sum test to compare the median age at the time of diagnosis and Bayesian Weibull accelerated failure time regression to identify independent predictors of time to death.

Results

The median survival time after HCC diagnosis was 9.0 months (interquartile range 2.0–24.0). Metropolitan residence (P = 0.02), non‐English language (P < 0.001), foreign country of origin (P < 0.001), and HBV etiology (P < 0.001) were significantly associated with receiving surgical resection for HCC treatment. The strongest predictors of time to death were undifferentiated tumor at presentation (time ratio [TR] = 0.30, 95% credible interval (CrI) 0.23–0.39), age ≥70 years (TR = 0.42, 95% CrI 0.34–0.53), living in remote areas (TR = 0.67, 95% CrI 0.55–0.80), and presence of ≥1 comorbidity (TR = 0.69 95% CrI 0.54–0.90). All the other covariates adjusted, including country of birth (TR = 0.76, 95% CrI 0.49–1.06), did not predict survival time.

Conclusions

Patients living in rural and remote areas had late stage clinical presentation and poor survival. Remoteness of residence may limit access to HCC surveillance in at‐risk patients such as those with cirrhosis, and timely curative treatment to improve survival in these patients.

Hepatocellular carcinoma amongst Aboriginal and Torres Strait Islander peoples of Australia

BACKGROUND

Liver disease and hepatocellular carcinoma (HCC) are important contributors to the mortality gap between Indigenous and non-Indigenous Australians. However, there is a lack of population based high quality data assessing the differences in HCC epidemiology and outcomes according to Indigenous status. The aim of this study was therefore to perform a large epidemiological study of HCC investigating differences between Indigenous and non-Indigenous Australians with HCC.

METHODS

Study design was a retrospective cohort study. Data linkage methodology was used to link data from cancer registries with hospital separation summaries across three Australian jurisdictions during 2000-2017. Cumulative survival (Kaplan-Meier) and the differences in survival (Multivariable Cox-regression) by Indigenous status were assessed.

FINDINGS

A total of 229 Indigenous and 3587 non-Indigenous HCC cases were included in the analyses. Significant epidemiological differences identified for Indigenous HCC cases included younger age at onset, higher proportion of females, higher rurality, lower socioeconomic status, and higher comorbidity burden (all p < 0.001). The distribution of cofactors was also significantly different for Indigenous Australians including higher prevalence of alcohol misuse, hepatitis B, and diabetes and more frequent presence of multiple HCC cofactors (all p < 0.001). Indigenous Australians received curative HCC therapies less frequently (6.6% vs. 14.5%, p < 0.001) and had poorer 5-year survival (10.0% vs. 17.3%, p < 0.001; unadjusted hazard ratio (HR) =1.42 96%CI 1.21-1.65) compared to non-Indigenous Australians. The strength of the association between indigenous status and survival was weaker and statistically non-significant after adjusting for rurality, comorbidity burden and lack of curative therapy (adjusted-HR=1.20 95%CI 0.97-1.47).

INTERPRETATION

Such data provide a call to action to help design and implement health literacy, liver management and HCC surveillance programs for Indigenous people to help close the liver cancer mortality gap.

Socioeconomic Deprivation Does Not Impact Liver Transplantation Outcome for HCC: A Survival Analysis From a National Database

BACKGROUND

To investigate the value of European deprivation index (EDI) and hepatocellular carcinoma (HCC) characteristics and their relationships with outcome after liver transplantation (LT).

METHODS

Patients undergoing LT for HCC were included from a national database (from "Agence de la Biomédecine" between 2006 and 2016. Characteristics of the patients were blindly extracted from the database. Thus, EDI was calculated in 5 quintiles and prognosis factors of survival were determined according to a Cox model.

RESULTS

Among the 3865 included patients, 33.9% were in the fifth quintile (quintile 1, N = 562 [14.5%]; quintile 2, N = 647 [16.7%]; quintile 3, N = 654 [16.9%]; quintile 4, N = 688 [17.8%]). Patients in each quintile were comparable regarding HCC history, especially median size of HCC, number of nodules of HCC and alpha-fetoprotein score. In the univariate analysis of the crude survival, having >2 nodules of HCC before LT and time on waiting list were associated with a higher risk of death (P < 0.0001 and P = 0.03, respectively). EDI, size of HCC, model for end-stage liver disease score, Child-Pugh score were not statistically significant in the crude and net survival. In both survival, time on waiting list and number of HCC ≥2 were independent factor of mortality after LT for HCC (P = 0.009 and 0.001, respectively, and P = 0.03 and 0.02, respectively).

CONCLUSIONS

EDI does not impact overall survival after LT for HCC. Number of HCC and time on waiting list are independent prognostic factors of survival after LT for HCC.

Development and Evaluation of the Supportive Needs Assessment Tool for Cirrhosis (SNAC)

BACKGROUND

We report the development and psychometric testing of a Supportive Needs Assessment tool for Cirrhosis (SNAC).

METHODS

The 50-item SNAC was administered to patients (n=465) diagnosed with cirrhosis recruited from five metropolitan hospitals in Queensland, Australia. Items were assessed for ceiling and floor effects, and exploratory factor analysis was used to assess the factor structure. Identified factors were assessed for internal consistency and convergent validity to validated psychosocial tools.

RESULTS

Exploratory factor analysis identified 4 factors (39 items), which together accounted for 49.2% of the total variance. The 39-item SNAC met the requirements of a needs assessment tool and identified a range of needs important to patients with cirrhosis that were grouped in four subscales: "Psychosocial issues", "Practical and physical needs", "Information needs", and "Lifestyle changes". Cronbach's alpha values for the four subscales ranged from 0.64 to 0.92. Convergent validity was supported by a strong correlation between the total SNAC score and that of the Chronic Liver Disease Questionnaire (CLDQ; Spearman rho -0.68; p<0.001), and moderate correlations with the Distress Thermometer (Spearman rho 0.53; p<0.001) and seven subscales of a generic health-related quality of life instrument (Short Form 36; Spearman rho ranged from -0.48 to -0.57; p<0.001). The SNAC discriminated patient groups with respect to sex (p=0.013), age group (p<0.001), and hospital admission status (admitted vs not; p<0.001).

CONCLUSION

These data provide initial evidence for the validity and reliability of the SNAC, an instrument designed to measure type and amount of perceived unmet practical and psychological needs of people diagnosed with cirrhosis.

Global Trends in Incidence Rates of Primary Adult Liver Cancers: A Systematic Review and Meta-Analysis

Background: Primary liver cancer is a leading cause of cancer deaths worldwide. Global burden varies, reflecting geographical distribution of viral hepatitis. Our objective was to perform a systematic review and meta-analysis of published current trends in incidence of adult liver cancers and histological types worldwide.

Methods: This study used systematic searches of PubMed, Embase, CINAHL, and Web of Science databases for English-language peer-reviewed articles published from 1 January 2008 to 01 September 2019. Inclusion criteria were population-based studies of adult liver cancer patients with quantitative estimates of temporal trends in incidence for liver cancers and/or histological types. For multiple studies from the same geographical area, only the publication that reported the most recent trends for the same cancer type and population subgroup was included. Review was conducted per PRISMA guidelines. Two authors independently extracted data and critically assessed studies. Proposed contributors to observed trends were extracted from included articles. Study-specific estimates of the annual percentage change (APC) in incidence rates with 95% confidence intervals (CIs) were pooled using random-effects meta-analysis models. Heterogeneity was measured using the I² statistics and publication bias evaluated using funnel plots and Egger's tests.

Results: Overall, 53 studies met the inclusion criteria, of which 31 were included in the meta-analysis. Overall, pooled APC estimates were +0.8 (95% CI −0.3, +2.0) for liver cancers combined, +2.6 (95% CI +1.2, +4.0) for hepatocellular carcinoma (HCC), and +4.3 (95% CI +2.5, +6.1) for intrahepatic cholangiocarcinoma. Subgroup analyses indicated increasing trends for liver cancers (APC +3.2, 95% CI +2.5, +3.9) and HCC (APC +3.6, 95% CI +2.9, +4.4) in the region of North America/Europe/Australia, whereas corresponding trends were decreasing (APC −1.7, 95% CI −2.2, −1.1) and stable (APC −0.7, 95% CI −1.9, +0.5) in Asia, respectively.

Conclusions: Incidence is increasing for adult liver cancers and HCC in Western countries, whereas trends are decreasing in the Asian region, although still remaining high. Our findings highlight the importance of viral hepatitis control and lifestyle interventions to reduce global liver cancer burden. Ongoing surveillance is also vital to detect early shifts in incidence trends.

The impact of socioeconomic status on outcomes in hepatocellular carcinoma: Inferences from primary insurance

Background

To investigate the impact of insurance status on outcomes in patients with hepatocellular carcinoma (HCC).

Methods

Patients diagnosed with HCC in the cancer registry from 2005 to 2016 were retrospectively stratified by insurance group. Overall survival was assessed via Kaplan‐Meier curves and Cox proportional hazard models including potential confounders in multivariable analyses.

Results

Seven hundred and sixty‐nine patients met inclusion criteria (median age 63 years, 78.8% male, 65.9% Caucasian). 44.5% had private insurance (n = 342), 29.1% had Medicare (n = 224), and 26.4% had Medicaid (n = 203). At diagnosis, Medicaid patients had higher rates of Child‐Pugh B (32.0%) and C disease (23.6%) vs Medicare (28.6% and 9.8%) and private insurance (26.9% and 6.7%, P < 0.0001) and higher MELD scores (median 11.0) vs Medicare (9.0) and private insurance (9.0, P = 0.0266). Across insurance groups, patients had similar distribution of American Joint Committee on Cancer stage, tumor size, and multifocal tumor burden. Patients with private insurance had the highest survival (median OS 21.9 months) vs Medicare (17.7 months) and Medicaid (13.0 months, overall P = 0.0061). On univariate analysis, Medicaid patients demonstrated decreased survival vs private insurance (HR 1.40, 95% CI: 1.146‐1.715, P = 0.0011). After adjustment for liver disease factors, this survival difference lost statistical significance (Medicaid vs private insurance, HR 1.02, 95% CI: 0.819‐1.266, P = 0.8596).

Conclusion

Medicaid was associated with advanced liver disease at HCC diagnosis; however, insurance status is not an independent predictor of HCC survival.

Hepatocellular carcinoma over three decades in Victoria, Australia: epidemiology, diagnosis and trends, 1984-2013

BACKGROUND

Liver cancer continues to be a health priority in Australia, with the majority attributable to preventable causes, and certain populations at higher risk.

AIMS

Epidemiological assessment of incidence, trends and distribution to inform prevention, and reassessment of data in light of recent changes to registry case definitions.

METHODS

Reported cases of hepatocellular carcinoma (HCC) in Victoria, Australia, 1984-2013, were obtained from the Victorian Cancer Registry. Demographic characteristics were examined, incidence and survival assessed using Poisson and Cox regression, and geographic distribution mapped. Incidence was compared before and after inclusion of non-histologically confirmed cases in Registry data to assess impacts on incidence trends.

RESULTS

Diagnoses of HCC rose substantially between 1984 and 2013, increasing sixfold from 0.9 to 5.9 per 100 000. The rate of increase per year accelerated from 5.3% between 1984 and 2003 to 9.5% between 2004 and 2013. Cases were disproportionately male (80%), median age at diagnosis was 66 years and 53% were born overseas. Even during 2004-2013, 5-year survival was only 16%, although higher among younger people, metropolitan residents and people born overseas. Incidence showed strong geographic clustering. The proportion of cases diagnosed clinically increased from 1% during 1984-2004 to 43% in 2009-2013. The revised case definition added 993 cases (27.3% of total).

CONCLUSION

Cases of HCC are becoming increasingly common, and revised incidence estimates highlight the impact of case definitions in the context of changing diagnostic approaches. The ongoing burden, disproportionate population distribution and low survival emphasise the importance of prevention and early detection as a public health imperative.

Use of telehealth to treat and manage chronic viral hepatitis in regional Queensland

For regional and rural Queenslanders, chronic viral hepatitis treatment is a major unmet health need, with restricted access to specialists outside of tertiary, largely metropolitan hospitals. To increase treatment of chronic viral hepatitis in regional Queensland, a team-based telehealth model was expanded. This expansion embedded an initial nursing consultation prior to specialist telehealth consultation. We conducted a retrospective audit of the introduction and expansion of hepatology telehealth services. Activity from July 2014-June 2015 (pre-expansion) was compared with July 2015- June 2016 (post-expansion). Interviews were conducted with key staff to determine factors contributing to success of the service and identify ongoing challenges to the service model. A greater than four-fold increase in clinical consultation was observed (131 telehealth consultations pre-expansion vs 572 post-expansion; p < 0.001). The failure to attend rate decreased (13.0% vs 6.5%, pre vs post-expansion respectively; p = 0.030), suggesting engagement with the service increased. Staff cited nurse-conducted primary assessment prior to specialist consultation and personalised patient treatment packs as key contributors to increased patient flow and engagement. This expanded team approach appears effective in delivering specialised treatment to an underserved area in regional Central Queensland. It may serve as a model to further expand telehealth management of chronic disease for regional Queenslanders.

After accounting for competing causes of death and more advanced stage, do Aboriginal and Torres Strait Islander peoples with cancer still have worse survival? A population-based cohort study in New South Wales

Background

Aboriginal and Torres Strait Islander peoples in Australia have been found to have poorer cancer survival than non-Aboriginal people. However, use of conventional relative survival analyses is limited due to a lack of life tables. This cohort study examined whether poorer survival persist after accounting for competing risks of death from other causes and disparities in cancer stage at diagnosis, for all cancers collectively and by cancer site.

Methods

People diagnosed in 2000–2008 were extracted from the population-based New South Wales Cancer Registry. Aboriginal status was multiply imputed for people with missing information (12.9%). Logistic regression models were used to compute odds ratios (ORs) with 95% confidence intervals (CIs) for ‘advanced stage’ at diagnosis (separately for distant and distant/regional stage). Survival was examined using competing risk regression to compute subhazard ratios (SHRs) with 95%CIs.

Results

Of the 301,356 cases, 2517 (0.84%) identified as Aboriginal (0.94% after imputation). After adjusting for age, sex, year of diagnosis, socio-economic status, remoteness, and cancer site Aboriginal peoples were more likely to be diagnosed with distant (OR 1.30, 95%CI 1.17–1.44) or distant/regional stage (OR 1.29, 95%CI 1.18–1.40) for all cancers collectively. This applied to cancers of the female breast, uterus, prostate, kidney, others (those not included in other categories) and cervix (when analyses were restricted to cases with known stages/known Aboriginal status). Aboriginal peoples had a higher hazard of death than non-Aboriginal people after accounting for competing risks from other causes of death, socio-demographic factors, stage and cancer site (SHR 1.40, 95%CI 1.31–1.50 for all cancers collectively). Consistent results applied to colorectal, lung, breast, prostate and other cancers.

Conclusions

Aboriginal peoples with cancer have an elevated hazard of cancer death compared with non-Aboriginal people, after accounting for more advanced stage and competing causes of death. Further research is needed to determine reasons, including any contribution of co-morbidity, lifestyle factors and differentials in service access to help explain disparities.

Mailed Outreach Program Increases Ultrasound Screening of Patients With Cirrhosis for Hepatocellular Carcinoma

BACKGROUND & AIMS

Surveillance of patients with cirrhosis increases early detection of hepatocellular carcinoma (HCC) and prolongs survival. However, its effectiveness is limited by underuse, particularly among racial/ethnic minorities and individuals of low socioeconomic status. We compared the effectiveness of mailed outreach strategies, with and without patient navigation, in increasing the numbers of patients with cirrhosis undergoing surveillance for HCC in a racially diverse and socioeconomically disadvantaged cohort.

METHODS

We performed a prospective study of patients with documented or suspected cirrhosis at a large safety-net health system from December 2014 through March 2016. Patients were assigned randomly (1:1:1) to groups that received mailed invitations for an ultrasound screening examination (n = 600), mailed invitations for an ultrasound screening examination and patient navigation (barrier assessment and motivational education for patients who declined screening; n = 600), or usual care (visit-based screening; n = 600). Patients who did not respond to outreach invitations within 2 weeks received up to 3 reminder telephone calls. The primary outcome was completion of abdominal imaging within 6 months of randomization.

RESULTS

Baseline characteristics were similar among groups. Cirrhosis was documented, based on International Classification of Diseases, 9th revision, codes, for 79.6% of patients, and suspected, based on noninvasive markers of fibrosis, for 20.4%. In an intent-to-treat analysis, significantly greater proportions of patients who received the mailed invitation and navigation (47.2%) or the mailed invitation alone (44.5%) underwent HCC screening than patients who received usual care (24.3%) (P < .001 for both comparisons). However, screening rates did not differ significantly between outreach the outreach groups (P = .25). The effects of the outreach program were consistent in all subgroups, including Caucasian vs non-Caucasian race, documented vs suspected cirrhosis, Child-Pugh A vs B cirrhosis, and receipt of gastroenterology care.

CONCLUSIONS

In a prospective study, we found outreach strategies to double the percentage of patients with cirrhosis who underwent ultrasound screening for HCC. However, adding patient navigation to telephone reminders provided no significant additional benefit. ClinicalTrials.gov no: NCT02312817.

Sociodemographic and geographical inequalities in notifiable infectious diseases in Australia: a retrospective analysis of 21 years of national disease surveillance data

BACKGROUND

Australia is a high-income country with a well established and largely publicly funded health-care system. However, some populations within Australia have shorter life expectancy and worse health outcomes than others. We explored geographical variations and sociodemographic inequities in infectious disease notifications in Australia.

METHODS

In this retrospective study, we analysed National Notifiable Diseases Surveillance System (NNDSS) notifications from 1991-2011 (n=2·4 million). We assessed the effect of socioeconomic disadvantage and remoteness of residence on national notification incidence. We calculated Gini coefficients, adjusted relative risks (aRRs), population attributable fractions (PAFs), and attributable notifications. We reported aRRs for Indigenous status in three jurisdictions with more than 75% completeness of Indigenous status reporting from the Northern Territory, South Australia, and Western Australia.

FINDINGS

Of the eight most commonly notified diseases from Jan 1, 1991, to Dec 31, 2011, gonococcal infection was the most geographically unequal and campylobacteriosis was the most evenly distributed across the country. Overall, notification incidence was higher in remote and very remote areas than in major cities (aRR 3·37), and higher in the most socioeconomically disadvantaged quintiles compared with less disadvantaged quintiles (aRR 1·15). The PAF for socioeconomic disadvantage was high for blood-borne viral hepatitis but decreased in other disease groups. In 2011, sexually transmitted infections had 11 093 notifications attributed to remoteness and 5597 notifications attributable to socioeconomic disadvantage. Notification incidence was higher in Indigenous than in non-Indigenous Australians (aRR 5·3).

INTERPRETATION

All diseases had differing geographical concentration and sociodemographic risk. Overall, sociodemographic inequities in infectious disease notifications have decreased, but remain unacceptably high. National communicable disease control is complex, requiring both targeted and population-wide interventions.

FUNDING

None.