目的 了解托幼机构及中小学发生诺如病毒(Norovirus,NoV)聚集性疫情期间集体机构及家庭中的密切接触者病毒感染及环境污染情况.方法 2017-2019年在上海市徐汇区托幼机构及中小学发生的NoV聚集性疫情期间,通过现场流行病学方法分析机构密切接触者NoV感染率和环境检出率.选取疫情中NoV确诊病例的家庭,经知情同意采集家庭密切接触者的粪便,并上门采集环境标本,计算家庭密切接触者NoV感染率和环境检出率.采用SPSS 18.0软件进行x2检验和Fisher确切检验,使用GraphPad Prism 8绘制率的比较图.结果 76起机构疫情中共采集密切接触者标本405份,NoV感染率为20.25％(82/405),41个确诊病例家庭中采集密切接触者标本119份,NoV感染率为9.24％(11/119),两组差异有统计学意义(x2=7.63,P=0.01).采集集体机构环境标本372份,NoV检出率为4.03％(15/372),采集家庭环境标本123份,NoV检出率为8.94％(11/123),两组差异有统计学意义(x2=4.48,P=0.03).集体机构环境标本NoV检出率场所从高到低分别为马桶(10.17％)、呕吐地面(9.68％)、洁具(8.00％)、教室门把手(5.88％)和厕所水龙头(5.41％).家庭环境标本NoV检出率场所从高到低分别为马桶(14.63％)和洁具(12.20％),未在手接触部位检出NoV.结论 在集体机构发生NoV聚集性疫情时,可导致机构和家庭中一定比例的密切接触者感染NoV,且均可在环境中检出NoV,马桶和洁具污染尤为严重.应加强校内密切接触者管理和家庭成员的健康教育,规范机构消毒并指导家庭消毒.

ObjectiveBased on a demand survey， to put forward the idea of family doctor service health service packages for people in functional communities， and provide suggestions for the implementation of family doctor health service in such communities.MethodsThrough the stratified cluster sampling survey of a science and innovation bearing functional community， combined with literature research， current situation survey， case analysis and interviews， this paper proposes the service content of the service packages.ResultsOn the basis of demand survey， the mode of "specified action + optional action" should be adopted. Community health service center should first provide basic service， and then expand their services in diagnosis， treatment， and health management in line with local demand， and provide optional multi-level health service packages for scientific and innovative functional community residents， which should be divided into basic health service， value-added health service and high-end health service.ConclusionSorting out the content of health service packages of family doctor service in functional communities can provide the basis for further improving the allocation of medical service resources， further optimizing the design of the financing and compensation mechanism， and further standardizing the contract service of family doctors.

目的 从家庭医生的角度了解肺癌医联体的实践效果与存在的问题,从而提升家庭医生签约服务内涵.方法 对上海市胸科—徐汇肺癌医联体内的191名家庭医生进行问卷调查与访谈,了解其对医联体的认知与评价,发现医联体运行中的问题.结果 家庭医生对肺癌医联体的知晓度为88.5％,总体满意度为60.9％,其中,对"社区肺癌高危人群筛查"工作的满意度和参与度最高,认为医联体的最大成效是"优化医疗资源配置、促进分级诊疗",但是上转比例明显高于下转.结论 医联体内基层医疗服务水平和工作积极性有待进一步提高,从流程优化、资源共享、制度落实等方面完善改进,推动医联体的可持续发展.

目的 了解居民对肺癌医联体的评价与需求,为完善医联体运行提出对策建议.方法 以上海市胸科—徐汇肺癌医联体内的社区居民为研究对象,选取520名居民进行问卷调查,分析居民对医联体的认知度、满意度、需求度以及参与度.结果 居民对社区首诊的认可度较高,对肺癌医联体的知晓度为51.9％,总体满意度为82.6％,对"社区完成一键支付"和"三级医院专家下沉社区"两项的服务需求比例大于60％,能够积极参加医联体内的健康讲座和高危筛查,超过60％的居民没有参与过双向转诊,主要原因是病情无转诊需要.结论 肺癌医联体的专病管理模式得到居民认可,要进一步扩大社区宣传、促进资源下沉、加强政策支持,以期增强群众基础,促进专病医联体建设.

背景 上海市作为国家科技创新中心重要承载区,除了满足创新创业的政策支持、创业环境、资金投入等需求外,满足各类人才在健康保健等方面的延伸需求对于促进"产城融合"至关重要.发展功能社区卫生服务是完善功能配套、促进"产城融合"的关键环节,但当前功能社区服务存在短板,无法为"产城融合"提供支撑,亟须突破.目的 分析科创承载型功能社区人群多样化的健康服务需求,并为家庭医生健康服务在功能社区的拓展提供建议.方法 2019年3—11月,通过对上海市科创承载型功能社区进行分层随机抽样调查,共发放1500份问卷,获得功能社区人群基本情况及生活方式、心理健康状况、卫生服务需求与利用等相关数据,了解功能社区人群的健康状况、卫生服务需求与利用情况,并分析功能社区家庭医生服务需求的影响因素;并参考文献研究结果,对比与其他类型功能社区人群的主要健康问题与卫生服务需求的差异.结果 共回收有效问卷1487份(99.13％),其中调查对象两周患病率〔5.92％(88/1487)〕、慢性病患病率〔5.98％(89/1487)〕较低;功能社区人群健康服务主观需求主要是常见疾病处理(1251人,84.13％)、健康管理(858人,57.70％)、健康体检(699人,47.01％)、健康咨询(586人,39.41％)、心理咨询(470人,31.61％).功能社区人群家庭医生签约服务知晓率为57.03％(848/1487),45.73％(680/1487)有签约意愿,且性别、年龄、文化程度、自我感觉健康状况、慢性病患病情况对家庭医生签约意愿产生影响(P<0.05);就诊意愿调查中,患病后想去的卫生机构前3位分别是市级医院(620人,41.69％)、区级医院(404人,27.17％)、门诊部(所)/卫生室/卫生服务站(153人,10.29％),其中质量(734人,25.41％)、距离(732人,25.34％)和有可信赖的医生(391人,13.48％)是主要影响因素;卫生服务实际利用情况与就诊意愿基本一致.结论 在科创承载型功能社区中开展健康保健服务具现实意义和可操作性.不同类型功能社区卫生服务需求可能存在差异,应针对不同需求提供差异化的健康服务方案,并吸取其他类型功能社区健康服务发展的优秀经验.建议从明确覆盖人群与服务内容、丰富供给方式、优化筹资来源、加强统筹协调等角度完善功能社区家庭医生服务的推进工作.

医联体通过信息的跨组织协同特征,有利于充分整合医疗资源.采用新兴古典经济学理论的超边际分析方法,解析医联体的网络形态和信息协同的演变趋势,并进行肺癌早筛医联体的具体案例研究.随着大数据及5G等技术的高速发展,建设信息平台的边际效益得到提高,助推了医联体的闭环健康管理流程.

目的 了解上海市徐汇区手足口病(hand-foot-mouth disease,HFMD)病原学及其流行特征,为其防控提供参考依据.方法 采用实时荧光定量聚合酶链式反应(polymerase chain reaction,PCR)对2009-2019年上海市徐汇区采集的上海市徐汇区HFMD病例标本进行肠道病毒检测,并对病原学检测数据进行整理分析.结果 2009-2019年上海市徐汇区共报告现住址在上海市徐汇区HFMD普通病例10 909例,年均报告发病率为84.79/10万(31.32/10万～135.53/10万),累计报告重症病例47例,重症率为0.43％.2009-2012年报告普通病例发病率呈现升高趋势,2013年始,发病率呈现隔年高发.HFMD发病呈现双峰模式,全年发病有2个高峰:4-7月(春夏高峰)占52.38％和9-11月(秋冬高峰)占26.17％,男性发病率(127.60/10万)高于女性发病率(83.58/10万).实验室检测病例共1 239例,阳性标本1 029例(占83.05％).其中,柯萨奇病毒A组6型(CA6)为29.78％、肠道病毒71型(EV71)为21.55％、柯萨奇病毒A组16型(CA16型)为21.23％和其他肠道病毒为10.09％、柯萨奇病毒A组10型(CA10)为0.32％、EV71/CA16混合感染0.08％.上海市徐汇区全年均有HFMD病例报告,发病高峰期为每年3-11月.每年HFMD病毒的型别特征各不相同.病毒核酸检测阳性病例以＜18岁青少儿童为主(99.19％),男性病例阳性检出率(83.24％)略高于女性(82.75％),差异无统计学意义(x2=0.051,P＞0.05).47例重症患者标本中,重症病例EV71型阳性率为16.10％,CA16型为0.38％和其他类型EV为0.80％.结论 2009-2019年上海市徐汇区HFMD病原谱以CA6型为主,除了 EV71和CA16型,还有其他新型肠道病毒,且近年占比呈上升趋势,应予以重视和加强监测.

目的 分析肺癌医联体的实践效果与存在的问题,为构建以项目为载体的专病医联体提供循证依据与政策参考.方法 以Donabedian模型为理论框架,从结构、过程、结果3个维度对上海市胸科医院与徐汇区共建的肺癌医联体实践效果进行综合分析.结果 肺癌医联体的组织架构清晰合理、分工明确、区域全覆盖,建成肺癌专病防治信息系统,制定具有可操作性的双向转诊流程,形成肺癌高危人群的防治一体化闭环式管理,减少患者就诊次数,缩短就医等候时间,节省一定的就医费用;但考核激励机制尚未健全,医联体内上下帮扶不密切,基层医疗服务水平仍需提高.结论 该医联体实现肺癌防治闭环管理,形成专病分级诊疗新模式,但在落实绩效考核、促进资源下沉、加强专科建设等方面仍需改进.

[目的]评估托幼机构和中小学诺如病毒疫情期间,感染诺如病毒儿童排毒时长及影响排毒时长的可能因素,为疫情防控提供科学依据.[方法]2017—2019年,采集上海市徐汇区托幼机构和中小学校诺如病毒疫情疑似病例及密切接触者标本,应用实时荧光定量逆转录聚合酶链反应(real-time RT-PCR)方法检测样本诺如病毒带毒情况.对感染诺如病毒儿童经知情同意后每隔3～7 d采样,直至样本检测阴性.[结果]研究期间,共报告76起诺如病毒感染聚集性疫情,涉及1014例疑似病例,对421名疑似病例标本检测,诊断出311名确诊病例.经知情同意后,共有58名确诊病例参与排毒研究,参与率为18.65％.诺如病毒感染者平均排毒时间为(16.24±13.80)d,排毒时间超过7 d病例占79.31％,超过14 d占37.93％,超过21 d占17.24％.Cox比例风险模型结果显示,症状较严重者(HR=2.06,P=0.040)、托幼儿童病例(HR=4.13,P=0.012)和2019年确诊病例(HR=0.11,P<0.001)排毒时间更长.[结论]感染诺如病毒的学龄儿童返校后的一段时间内仍存在持续排毒,从而导致疫情传播风险,建议在病例返校后做好排泄物的消毒处理,避免疫情的二次传播和蔓延.

[目的]了解上海市徐汇区社区血糖异常人群情况及相关因素,为糖尿病早期干预提供依据.[方法]采用多阶段人口规模比例(PPS)随机抽样方法,分别于2010年、2015年对同一地区15岁及以上约5000户居民开展调查,分别调查10130、9085人,并进行血糖检测.单因素分析采用t检验和x2检验,用logistic回归分析相关因素.[结果]2010和2015年所涉社区糖尿病发病率分别为2.21％、1.93％,高血糖发生率分别为12.63％、15.28％,两者均随年龄增长和BMI值增加呈上升趋势,2015年高血糖发生率较2010年上升.文化程度较低者、血压值异常者、自报高血压患者、自报冠心病患者和吸烟者糖尿病和高血糖发生率较高;logistic回归分析结果显示,糖尿病的发病率与年龄、BMI、血压值异常、吸烟呈正相关;高血糖的发生与调查年份、性别、年龄、BMI、血压值异常呈正相关;两者均与文化程度呈负相关.[结论]高血糖发生率较高,应着力开展糖尿病高危筛查,重点干预文化程度较低、超重和肥胖、合并高血压以及具有不良生活行为的重点人群.

健康中国行动要求实施慢性病综合防控,强化癌症筛查和早期发现.癌症已经纳入社区慢病管理的研究范围,采取积极预防、早期筛查、规范治疗等措施,对于降低癌症的发病率和死亡率具有显著效果.以上海市胸科医院的学科项目型医联体为例,依托于肺癌早期筛查项目,通过流程优化与整合,建立社区肺癌防治一体化的闭环式管理,通过加大政府财政支持、建立分层培训制度、完善考核激励机制,进一步推动医联体的可持续发展.

目的 利用信息化手段进行疾病早筛的流程重构,建立项目型专科医联体的新模式.方法 以上海市胸科医院与徐汇区卫生健康委合作的肺癌早筛2.0项目为研究背景,通过流程优化后的居民感知,实证分析资源整合的能效.结果 常态化运行减少了居民的就医次数和等候时间,有利于闭环的全程健康管理.结论 基于信息互联互通的医联体模式实现了合理有序的分级诊疗,具有可复制和可推广的应用前景.

发展医联体是近几年新医改任务的重中之重.结合上海市胸科医院专科医联体建设的实践经验,以肺癌防治一体化管理为依托,探索建立以项目为载体、以疾病为纽带的医联体合作新模式,构建八大体系保障医联体顺畅运行,提出大力发展学科项目型医联体、制订病种分级诊疗规范标准、发挥网络信息技术支撑作用,为推进分级诊疗和医联体建设提供借鉴和参考.

Norovirus (NoV) is recognized as a leading cause of acute gastroenteritis (AGE) outbreaks in settings globally. Studies have shown that employees played an important role in the transmission mode during some NoV outbreaks. This study aimed to investigate the prevalence of NoV infection and duration of NoV shedding among employees during NoV outbreaks, as well as factors affecting shedding duration. Specimens and epidemiological data were collected from employees who were suspected of being involved in the transmission or with AGE symptoms during NoV outbreaks in Xuhui District, Shanghai, from 2015 to 2017. Specimens were detected using real-time RT-PCR to determine whether or not employees had become infected with NoV. Specimens were collected every 3–7 days from NoV-infected employees until specimens became negative for NoV. A total of 421 employees were sampled from 49 NoV outbreaks, and nearly 90% of them (377/421) were asymptomatic. Symptomatic employees showed significantly higher prevalence of NoV infection than asymptomatic ones (70.5% vs. 17.0%, P < 0.01). The average duration of NoV shedding was 6.9 days (95% confidence interval: 6.1–7.7 days) among 88 NoV-infected individuals, and was significantly longer in symptomatic individuals than in asymptomatic ones (9.8 days vs. 5.6 days, P < 0.01). In Cox proportional-hazards model, after adjusting age and gender, symptoms was the only factor associated with duration of NoV shedding. Compared with asymptomatic employees, symptomatic employees had higher prevalence of NoV infection and longer durations of NoV shedding. Since NoV shedding duration among NoV-infected employees tends to be longer than their isolation time during outbreaks, reinforcement of hygiene practices among these employees is especially necessary to reduce the risk of virus secondary transmissions after their return to work.

构建多种形式医联体,是推动分级诊疗制度落地的有效载体.在健康中国背景下探索以项目为载体、以疾病为纽带的专科医联体建设是一种创新尝试.运用PEST模型,从政治、经济、社会和技术4个方面对学科项目型医联体发展的环境条件进行深入分析,探讨学科项目型医联体建设的必要性与可行性,为专科医联体建设提供发展思路.

目的 了解上海市徐汇区急性呼吸道感染病毒病原学现况.方法 2012-2016年收集监测点医院流感样病例咽拭子标本,采用Real-time RT-PCR方法检测.结果 对4 660份标本进行流感检测:flu A 18.80％,flu B 6.78％.对364份标本中进行7种呼吸道病毒PCR阳性率18.68％,其中flu A+flu B 10.44％,HRV 2.75％,ADV、HBoV和PV1型均为0.82％;RSVB 0.55％,PV2、PV4均为0.27％,hmPV未检出.比较一个流行年不同监测点流感检出率无差异.2012-2016年聚集性流感样病例疫情11起,集中在冬春季,流感占90.91％,无暴发疫情.结论 徐汇地区呼吸道病毒多样化,流感病毒最常见,且呈冬春季和夏季双峰流行,B型、季H3型、新HIH1型交替,夏季高峰多以季H3型为优势毒株.流感样病例就诊百分比与流感病毒检出率呈正相关.学校、托幼机构为呼吸道病毒感染聚集疫情重点防控单位.应长期监测主要呼吸道病毒活动水平.

[Objective] To assess the changes of smoking status and related influencing factors among residents aged above 15 years in Xuhui District of Shanghai between the first and sixth years of the implementation of The Regulations of Shanghai Municipality on Smoking Control in Public Places (hereinafter referred to "the regulations").[Methods] Two household investigations (Health Status and Health Service Utilization Survey 2010 & 2015 in Xuhui District) were carried out using multistage random sampling method with probability proportional to population size.The sample sizes were 11 347 and 10 388 in 2010 and 2015,respectively.Descriptive analysis and logistic regression analysis were used to describe smoking behavior and the influencing factors of smoking or quitting smoking,respectively.[Results] From 2010 to 2015,the standardized current smoking rate of residents aged above 15 years fell from 17.6％ to 14.7％ (from 35.2％ to 29.8％ for men,and from 1.3％ to 1.0％ for women),the standardized quitting smoking rate increased from 17.6％ to 22.8％,and the smokers' age of first cigarette smoking was 0.9 years earlier.The smoking rate,current smoking rate,current daily smoking rate,and heavy smoking rate of residents aged 45 to 59 years were higher than those in other age groups.There was a significant reduction in smoking rate and a significant increase in quitting smoking rate of the respondents aged 30-59 years and 75 years and above (P＜0.01).Male (adjusted OR=51.479),the 45-59 years age group (adjusted OR=1.825),the widowed/ divorced (adjusted OR=1.498),housekeeper (adjusted OR=18.279),the unemployed (adjusted OR=16.625),the retired (adjusted OR=12.057),the employed (adjusted OR=15.453),and drinkers (for those who drink 1-2 times weekly adjusted OR=3.190,and for those who drink ≥ 3 times weekly adjusted OR=5.221) had high risks of smoking;those with college and above educational level (adjusted OR=0.510) and the single (adjusted OR=0.738) had low risks of smoking.Male (adjusted OR=0.336),and those who drink ≥ 3 times weekly (adjusted OR=0.467) tended to keep smoking,while the elderly (for the 60-74 years age group adjusted OR=6.583,and for the 75-years age group adjusted OR=28.521) tended to quit smoking.[Conclusion] The implementation of the regulations is beneficial to the reduction of smoking rate among young and middleaged men,but the tobacco control work is still facing huge challenges,and public health practitioners should adopt more targeted measures.

Objectives Varicella vaccine (VarV) is recommended as effective post-exposure prophylaxis (PEP) within 3–5days to control outbreaks. However, the effectiveness of PEP at >5days after exposure and the administration of a second dose to those with a history of one dose prior to exposure have not been fully examined. This study evaluated the vaccine effectiveness (VE) of PEP in preventing disease during a varicella outbreak in Shanghai, China in 2013. Methods Self-administered questionnaires were used to obtain the students' varicella history, vaccination status, and willingness to receive PEP. One dose of VarV was provided free of charge to eligible students. The VE of PEP was calculated as [1−relative risk (RR)]×100%. Analyses were restricted to grade 8 students, as no students from the other grades or teachers developed varicella during the outbreak. Results Twenty-seven varicella cases were identified, 16 (59%) of which were infected after the PEP campaign. Sixty-five students received one dose of VarV on day 13 or 19 after the index case. Attack rates were 28% (9/32), 16% (15/94), 0% (0/10), and 6% (3/55) among unvaccinated, one-dose Pre-PEP, first dose as PEP, and second dose as PEP recipients, respectively. Cases among second dose as PEP recipients tended to have less fever compared with unvaccinated or one-dose Pre-PEP recipients. Compared with unvaccinated students, the VE of first dose as PEP recipients was 100% and of the second dose as PEP recipients was 60% (95% confidence interval −72% to 91%). Conclusions Post-exposure vaccination should be given as soon as possible after exposure. Nevertheless, vaccination is still recommended even at more than 5days post-exposure to control varicella outbreaks.

Carrying out HIV management and voluntary counseling and testing(VCT)by community health service centers is an important measure for HIV prevention and control.In this study,the strengths,weaknesses,opportunities and challenges of carrying out HIV management and VCT in community health service centers were explored through SWOT analysis method.And targeted strategies were put forward according to the results of the study.

Objective Objective To explore the characteristics and determinants of natural chan-ges in CD4+lymphocyte counts among HIV -infected patients without previous antiviral therapy in two dis-tricts of Shanghai . [ Methods] A retrospective study was conducted on HIV -infected patients reported from 1987 through May 2013 in two districts of Shanghai , who had received at least twice CD 4+lymphocyte counting tests before antiretroviral treatment ( ART) .The characteristics of natural changes in CD 4+lympho-cyte count and the determinants of significant decrease in count were described . [ Results] A total of 365 patients were included in the study .The monthly rate of CD 4+lymphocyte count changes between the first and the last counting tests had a median of -4.4 (IQR:-11.1~0.2).Among them 263(72.1%) showed remarkable decrease in CD 4+lymphocyte counts and 143 ( 39 .2%) presented a significant decrease (≥30%).Multiple logistic regression analysis indicated that the age , the first CD4+lymphocyte counts and the interval between the first and the last counting tests were significantly associated with the significant de -crease of CD4+lymphocyte counts among HIV-infected patients. [Conclusion] Natural changes of CD4+lymphocyte counts were gentle as a whole among untreated patients infected with HIV in central districts of Shanghai and rapid decrease in CD 4+lymphocyte counts among some HIV -infected patients was associated with many factors .It is held that CD 4+lymphocyte count and its changing rate should be regularly monitored so as to estimate the progress of the disease and perform targeted behavior intervention and clinic intervention .