Hepatitis a,D,E.completa1pptx

8/18/2019 Hepatitis a,D,E.completa1pptx

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Hepatitis A,D,E

HEPATITIS VIRAL: ES UN SÍNDROME, QUE SE CARACTERIZA POR ICTERICIA,COLURIA, ACOLIA, ASTENIA, ADINAMIA Y ANOREXIA, RARA VEZ FIERE, A VECESFERÍCULA


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Hepatitis A

es !"a e"#e$%e&a& &e' ()*a&+ a!sa&a p+$ e' -i$!s &e 'a(epatitis A .VHA/0

La (epatitis A p!e&e a#eta$ a !a'1!ie$a0

P!e&e s!e&e$ e" as+s ais'a&+s &e i"&i-i&!+s + e" epi&e%ias1!e !2$e" *$a"&es 3$eas0


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Hepatitis D

es !" -i$!s &e#et!+s+ 1!e "eesita e' -i$!s &e (epatitis pa$ae4isti$0

E' -i$!s &e 'a (epatitis D .VHD/ se e"!e"t$a e" 'a sa"*$e &e 'aspe$s+"as i"#eta&as +" e' -i$!s0


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Hepatitis E

es !" -i$!s .VHE/ 1!e se t$a"s%ite e" #+$%a %!5 si%i'a$ a' -i$!s&e (epatitis A0

Si" e%2a$*+, 'a (epatitis E "+ +!$$e +" #$e!e"ia


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La (epatitis A es !"a -i$+sis (ep3tia 1!e p!e&ea!sa$ %+$2i'i&a& %+&e$a&a a *$a-e0

E' -i$!s &e 'a (epatitis A se t$a"s%ite p+$ 'ai"*esti6" &e a'i%e"t+s + 2e2i&as +"ta%i"a&+s +p+$ +"tat+ &i$et+ +" !"a pe$s+"a i"#eta&a p+$e' -i$!s0

La (epatitis A se as+ia a #a'ta &e a*!a sa'!2$e 5 a!" sa"ea%ie"t+ &e7ie"te0

Las epi&e%ias se p!e&e" p$+pa*a$ &e %a"e$ae4p'+si-a 5 a!sa$ p8$&i&as e+"6%ias+"si&e$a2'es0

Las %e9+$as &e' sa"ea%ie"t+ 5 'a -a!"a +"t$a 'a(epatitis A s+" 'as %e&i&as %3s e7aes pa$a+%2ati$ 'a e"#e$%e&a&0


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A &i#e$e"ia &e 'as (epatitis 5 C, 'a (epatitis A "+a!sa (epat+pat)a $6"ia 5 $a$a -e es %+$ta',pe$+ p!e&e a!sa$ s)"t+%as &e2i'ita"tes 5(epatitis #!'%i"a"te .i"s!7ie"ia (ep3tia

a*!&a/, 1!e se as+ia a !"a a'ta %+$ta'i&a&0 Zonas con altos niveles de infección: E" '+s

pa)ses e" &esa$$+''+ +" +"&ii+"es &esa"ea%ie"t+ 5 p$3tias &e (i*ie"e &e7ie"tes

Zonas con niveles intermedios de infección:E" '+s pa)ses e" &esa$$+''+, '+s pa)ses +"e+"+%)as e" t$a"sii6" 5 'as $e*i+"es +" "i-e'es&esi*!a'es &e sa"ea%ie"t+


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Z+"as +" 2a9+s "i-e'es &e i"#ei6": E" '+spa)ses &esa$$+''a&+s +" 2!e" "i-e' &esa"ea%ie"t+ e (i*ie"e 'as tasas &e i"#ei6"s+" 2a9as0 La e"#e$%e&a& p!e&e apa$ee$ e"a&+'ese"tes 5 a&!'t+s &e '+s *$!p+s &e a't+$ies*+, +%+ '+s +"s!%i&+$es &e &$+*asi"5eta2'es, '+s (+%2$es +" $e'ai+"es(+%+se4!a'es 5 'as pe$s+"as 1!e -ia9a" a+"as &e a'ta e"&e%ii&a&, as) +%+ e"a'*!"as p+2'ai+"es ais'a&as, +%+ 'as+%!"i&a&es $e'i*i+sas e$$a&as0


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T$a"s%isi6"

E' -i$!s &e (epatitis A se t$a"s%ite p$i"ipa'%e"te p+$ -)a #ea';+$a', est+es, !a"&+ !"a pe$s+"a "+ i"#eta&a i"*ie$e a'i%e"t+s + a*!a+"ta%i"a&+s p+$ 'as (ees &e !"a pe$s+"a i"#eta&a0

S)"t+%as &e 'a (epatitis A

Tie"e" a$3te$ %+&e$a&+ + *$a-e 5 +%p$e"&e" 7e2$e, %a'esta$, p8$&i&&e apetit+, &ia$$ea, "3!seas, %+'estias a2&+%i"a'es, +'+$ai6" +s!$a &+$i"a e ite$iia .+'+$ai6" a%a$i''e"ta &e 'a pie' 5 'a es'e$6tia +!'a$/0i"#eta&+s "+ sie%p$e p$ese"ta" t+&+s es+s s)"t+%as0


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Fisi+pat+'+*ia E' -i$!s A "+ p$+&!e e#et+s it+')ti+s e" 'as 8'!'as i"#eta&as

e4pe$i%e"ta'%e"te, '+ 1!e s!*ie$e 1!e p$+2a2'e%e"te ?i" -i-+? 'a $es

&e 'a &est$!i6" &e '+s (epat+it+s i"#eta&+s $eae p$i"ipa'%e"te 'i"#+it+s T it+t64i+s0

E' -i$!s A pe"et$a e" e' +$*a"is%+ (a2it!a'%e"te p+$ -)a +$a', a'a"ase $ep'ia e" e' i"te$i+$ &e '+s (epat+it+

E' -i$!s A se e'i%i"a p+$ 'as (ees &!$a"te '+s @'ti%+s &)as &e' pe$i+&+i"!2ai6" 5 &!$a"te '+s p$i%e$+s &e' pe$i+&+ &e esta&+, 1!e +"stit!%34i%a +"ta*i+si&a&0 A' pa$ee$ 'a p$ese"ia &e' -i$!s e" 'as (ees a s! ''e*a&a a' i"testi"+ &es&e e' ()*a&+ 5 "+ a 'a e4iste"ia &e $ep'ia'as 8'!'as &e 'a %!+sa i"testi"a'0


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Dia*"6sti+ L+s as+s &e (epatitis A s+" ')"ia%e"te i"&isti"*!i2'es &e +t$+

(epatitis -)$ias a*!&as0

E' &ia*"6sti+ se esta2'ee %e&ia"te 'a &etei6" e" 'a sa"*$e &a"ti!e$pp+s I*M e I* &i$i*i&+s espe)7a%e"te +"t$a e' VHA0

Ot$a p$!e2a es 'a $eai6" e" a&e"a &e 'a p+'i%e$asa +"$et$+t$a"s$iptasa .RT;PCR/, 1!e &eteta e' RNA &e' -i$!s &e 'a (pe$+ p!e&e "eesita$ 'a2+$at+$i+s espeia'ia&+s0

BBID i"#ei6" a*!&a p+$ e' VHA +"siste e" 'a &etei6" &e 'a

i"%!"+*'+2!'i"a M .I*M/ a"ti;VHA %e&ia"te !" ELISA==


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T$ata%ie"t+

N+ (a5 "i"*@" t$ata%ie"t+ espe)7+ pa$a 'a (epatitis A0

L+s s)"t+%as p!e&e" $e%iti$ 'e"ta%e"te, a '+ 'a$*+ &e -a$iasse%a"as + %eses0

E' t$ata%ie"t+ pe$si*!e e' 2ie"esta$ 5 e' e1!i'i2$i+ "!t$ii+"a' &epaie"te, i"'!i&a 'a $e(i&$atai6" t$as '+s -6%it+s 5 &ia$$eas0


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VHD .a*e"te &e'ta/, sie"&+ este -i$!s e' $esp+"sa2'e &e' &e 'as (epatitis #!'%i"a"tes

C+i"#ei6" A*!&a: 1!e +!$$e t$as 'a e4p+sii6" a s!e$+ 1!e+"tie"e ta"t+ e' VHD +%+ e' VH0 E' VH &e2e

esta2'ee$se p$i%e$+ pa$a p$+p+$i+"a$ e' HsA* "eesa$i+spa$a &esa$$+''a$ -i$i+"es +%p'et+s &e VHD0

S+2$ei"#ei6": &e !" p+$ta&+$ $6"i+ &e' VH 1!e $ei2e !""!e-+ i"6!'+ &e VHD .5 VH/ p$+&!ie"&+ !"a e"#e$%e&a&

&esp!8s &e ap$+40 ;G &)as0

!ti'ia e' VH 5 'as p$+te)"as &e 'as 8'!'as &ia"a pa$a$ep'ia$se 5 si"tetia$ s!s p$+pias p$+te)"as0 Es !" pa$3sit+-)$i+


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se t$a"s%ite a t$a-8s &e 'a sa"*$e, e' se%e" 5 'asse$ei+"es -a*i"a'es0 Si" e%2a$*+, @"ia%e"te sep!e&e $ep'ia$ 5 p$+-+a$ e"#e$%e&a&es e" i"&i-i&!+s+" i"#ei+"es ati-as p+$ e' VH

!" i"&i-i&!+ se p!e&e i"#eta$ si%!'t3"ea%e"te +" e'VH 5 e' a*e"te &e'ta

E" '+s p+$ta&+$es &e' VH i"#eta&+s se!"&a$ia%e"tep+$ e' VHD tie"e '!*a$ !"a e-+'!i6" %3s $3pi&a 5*$a-e

La $ep'iai6" &e' a*e"te &e'ta p$+-+a it+t+4ii&a& 5'esi+"es (ep3tias

'as 'esi+"es (ep3tias apa$ee" +%+ +"se!e"ia &e!" e#et+ it+pat+'6*i+ &i$et+ &e' a*e"te &e'ta+%2i"a&+ +" 'a i"%!"+pat+'+*)a s!25ae"te &e 'ae"#e$%e&a& as+ia&a a' VH0


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E' a*e"te &e'ta i"#eta a '+s "i>+s 5 a&!'t+s 1!e p$ese"ta"!"a i"#ei6" s!25ae"te p+$ e' VH

Hepatitis a*!&a se*!i&a &e $es+'!i6"

Hepatitis $6"ia 1!e p!e&e e-+'!i+"a$ a i$$+sis

Hepatitis #!'%i"a"te +" "e$+sis (ep3tia %asi-a

O$i*i"a a'te$ai+"es &e 'a #!"i6" e$e2$a' .e"e#a'+pat)a (ep3tiaite$iia a%p'ia 5 "e$+sis (ep3tia %asi-a, 'a !a' es %+$ta' e" e' '+s as+s

C+%a Hep3ti+

Hepat+a$i"+%a Ci$$+sis

I"s!7ie"ia (ep3tia

Hipe$te"si6" p+$ta'


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Dia*"+sti+

Detei6" &e' *e"+%a &e ARN, e' a"t)*e; "+ &e'ta + a"ti!e$p+s#$e"te a' VHD

ELISA 5 $a&i+i"%!"+a"3'isis

Las t8"ias &e PCR;TI se e%p'ea" pa$a &eteta$ e' *e"+%a &e'-i$i6" e" %!est$as s8$ias

i+psia &e' ()*a&+

E"i%as (ep3tias .e4a%e" &e sa"*$e/


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T$ata%ie"t+

M!(+s &e '+s %e&ia%e"t+s !ti'ia&+s pa$a t$ata$ 'a (epatitis "+ si$-e" pa$a e' t$ata%ie"t+ &e 'a (epatitis D0

Las pe$s+"as +" i"#ei6" p+$ e' VHD p$+'+"*a&a p!e&e" $ei2i!" %e&ia%e"t+ ''a%a&+ i"te$#e$6" a'#a (asta p+$ J %eses0 U"t$asp'a"te &e ()*a&+ e" as+ &e (epatitis $6"ia te$%i"a'

p!e&e se$ e#eti-+0


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E' VHE .HNAN;E/ .'a E si*"i7a e"t8$i+ +epi&8%i+/ se t$a"s%ite p$e&+%i"a"te%e"tep+$ -)a #e+;+$a', espeia'%e"te e" a*!as

+"ta%i"a&as E' -i$!s p$+2a2'e%e"te es apa &e i"#eta$

e$&+s, p+$ '+ 1!e se (a espe!'a&+ 1!e e4iste!" $ese$-+$i+ a"i%a' &e 'a e"#e$%e&a&0

Se (a &e%+st$a&+ #$e!e"te t$a"s%isi6"-e$tia' .&e %a&$e a (i9+/ e" %!9e$ese%2a$aa&as 1!e se i"#eta" e" e' te$e$t$i%est$e &e' e%2a$a+, p$+&!ie"&+ (epatitisa*!&a *$a-e e" e' $ei8" "ai&+0


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C!a&$+ ')"i+ L+s s)"t+%as 5 'a e-+'!i6" &e 'a e"#e$%e&a& as+ia&a a

p+$ e' VHE s+" si%i'a$es a '+s p$+&!i&a p+$ e' VHAK p$+-

!a&$+ a*!&+

L+s s)"t+%as s+" si%i'a$es a '+s &e +t$as (epatitis a*!&aIte$iia, #ati*a2i'i&a&, "3!seas, &+'+$ e" (ip++"&$i+ &e$2a9a 5 (epat+%e*a'ia0 Me"+s #$e!e"te%e"te (a5 &ia$$e

a$t$a'*ias 5 !$tia$ia0

U" ,G a &e '+s as+s se p$ese"ta" +%+ (epatitis a*#!'%i"a"te0 P+$ $a+"es "+ a'a$a&as, &!$a"te e' e%2a$at$i%est$e/ E" esta p+2'ai6" 'a %+$ta'i&a& es &e' JG0


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Dia*"6sti+ A"tes &e' +%ie"+ &e 'a ')"ia &e 'a e"#e$%e&a&, e' ARN 5 '+s -i$i+"

VHE 5a s+" &eteta2'es e" (ees 5 e" e' ()*a&+0

E' i"ii+ &e' a!%e"t+ &e 'as t$a"sa%i"asas s8$ias, 'a e"#e$%e&a& ')a!%e"t+ &e '+s t)t!'+s &e I*M a"ti;VHE s+" si%!'t3"e+s0

L+s s)"t+%as e&e" e" J; se%, tie%p+ &!$a"te e' !a' 'a I*M se $eep+$ !" t)t!'+ pe$siste"te &e I* a"ti;VHE0

Es p+si2'e &eteta$ a"t)*e"+ &e HEV 5 RNA HEV e" s!e$+ 5 e" ()*a&+est+s e43%e"es "+ se $ea'ia" $!ti"a$ia%e"te0 Las a'te$ai+"es &e'a2+$at+$i+ i"'!5e" e'e-ai+"es &e a%i"+t$a"s#e$asas .ALT 5 AST/ 52i'i$$!2i"a0


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T$ata%ie"t+

E' t$ata%ie"t+ es &e s+p+$te0 E" as+s&e (epatitis #!'%i"a"te, ta"t+ '+ssiste%as &e s+p+$te tip+ MARS +%+ e't$asp'a"te (ep3ti+ p!e&e" se$ &e

!ti'i&a&0


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Hepatitis -i$a' E" *e"e$a' !a'1!ie$ i"a%ai6" &e' ()*a&+ se +"+e +%+ (epatitis0

La (epatitis p!e&e te"e$ &i#e$e"tes +$)*e"es, i"#ei+sa, +2st$!ti-a,%e&ia%e"t+sa, et8te$a0

La (epatitis &e +$i*e" -i$a' .i"#ei+sa/ p!e&e se$ a!sa&a p+$ &i-e$s+sa*e"tes, '+s !a'es at!a'%e"te se (a" $e!"i&+ e" &+s *$!p+s &e -i$!s:

e" e' p$i%e$+ se e"!e"t$a" a1!e''+s 1!e 'a p$+&!e" s+'+ +%++"se!e"ia &e s! &ise%i"ai6" e" e' +$*a"is%+K e"t$e e''+s te"e%+sa '+s

-i$!s &e' &e"*!e, 7e2$e a%a$i''a, Epstei" a$$ 5 it+%e*a'+-i$!s e"t$e+t$+s0

E" e' se*!"&+ *$!p+ se e"!e"t$a" -i$!s 1!e tie"e" +%+

6$*a"+ 2'a"+ e' ()*a&+ .(epat+t$6pi+s/0 Se (a" i&e"ti7a&+

-i$!s p$+&!t+$es &e (epatitis -i$a'

Virus Familia/Género Vía de transmisiónHepatitis tipo A icornaviridae !ro fecal $i


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Hepatitis tipo A(VHA)

icornaviridaeHeparnavirus

!ro"fecalse#ual (oro"anal)

$i'eno

sencidem

Hepatitis tipo -(VH-)

HepadnaviridaeHepadnavirus

arenteral& se#ual&san'uínea& perinatal&

percut.nea

$i'e

diss

Hepatitis tipo C(VHC)

FlaviviridaeHepacavirus

arenteral& san'uíneaperinatal& se#ual&

percut.nea

$i'eno

sencienm

Hepatitis tipo D(VHD)

$atélites arenteral& se#ual&san'uínea& perinatal&

percut.nea

0sdi.mcircu

virine

distri

Hepatitis tipo 0(VH0)

Caliciviridae !ro"fecal&se#ual (oro"anal)

0sfpro*

di.meca

Hepatitis tipo F o clasi8cado arenteral& se#ual&

san'uíneaHe atitis ti o G elacionado a los arenteral se#ual


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Pat+*e"ia

T+&+s '+s -i$!s &es$it+s a"te$i+$%e"te s+" apaes &e p$+&!i$ #+$%as ')"ias &e (epatitis:

Hepatitis a*!&a

Hepatitis #!'%i"a"te

Hepatitis s!2')"ia

Hepatitis $6"ia0


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HEPATITIS AUDA

0 Periodo de incubación0

Dete$%i"a&+ p+$ e' a*e"te i"#eti-a

Tip+ &e Vi$!sPe$i+&+ &e

i"!2ai6" .&)as/ P$+%e&i+ .&)as/

VHA G ; G J ;

VH G ; ;

VHC G ; ;

VHD G ; ; G

VHE G ; J ; J


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2. Fase prodrómica0

Se a$ate$ia p+$ %a"i#estai+"es ')"ias i"espe)7as +%+%a'esta$ *e"e$a', #ati*a, 'eta$*ia 5 a"+$e4ia0 Oasi+"a'%e"teta%2i8" p!e&e" p$ese"ta$se "a!sea, -6%it+ 5 7e2$e0e"e$a'%e"te esta #ase pe$siste &e a &)as0


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3.Fase ictérica0

E" este pe$i+&+ se p$ese"ta" 'as %a"i#estai+"es '3sias &e'a (epatitis: ite$iia, a+'ia, +'!$ia, p!e&e (a2e$ "a!sea,-6%it+, pe$siste e' %a'esta$ *e"e$a' 5 'a a"+$e4ia0

Las p$!e2as &e 'a2+$at+$i+ pa$a #!"i+"a%ie"t+ (ep3ti+%!est$a" 2i'i$$!2i"as a!%e"ta&as a e4pe"sas &e 'a 2i'i$$!2i"a

&i$eta .%3s &e %*&'/ 5 t$a"sa%i"asas .TO 5 TP/ +"-a'+$es p+$ a$$i2a &e' ')%ite "+$%a'0


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4. Fase de convalecencia0

E' paie"te se $e!pe$a, $e+2$a e' apetit+ 5 &esapa$ee" '+ss)"t+%as, si" e%2a$*+ 'a #ati*a p!e&e pe$sisti$ &!$a"te -a$iasse%a"as0


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Hepatitis fulminante,

Repe"ti"a%e"te, &!$a"te 'a #ase it8$ia, e' paie"te p$ese"ta

si*"+s &e #a''a (ep3tia + &e e"e#a'+pat)a (ep3tia Ca$ate$ia&as p+$ a%2i+s e" 'a +"&!ta, a'te$ai+"es &e'

i'+ s!e>+;-i*i'ia 5 &i7!'ta& pa$a +"e"t$a$se0

Repe"ti"a%e"te e' paie"te e"t$a e" esta&+ &e +%a 5%!e$e0


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Hepatitis su+clínica,

T$a&ii+"a'%e"te 'a (epatitis A se (a +"si&e$a&+ +%+s!2')"ia0

De2i&+ a #at+$es s+i+e+"6%i+s, p$ese"tes e" "!est$+ pa)s, 'i"#ei6" p+$ e' -i$!s &e 'a (epatitis A se +"-ie$te e" !" e-e"t+%!5 #$e!e"te e" "!est$a p+2'ai6", pa$ti!'a$%e"te e" &+"&e

#ea'is%+ a' ai$e 'i2$e 5 'as %a'as +"&ii+"es &e (i*ie"e s+" !"a+"sta"te0

La (epatitis p!e&e p$ese"ta$se &e %a"e$a asi"t+%3tia0


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Hepatitis crónica

L+s a*e"tes p$+&!t+$es &e (epatitis -i$a' s+" apaes &eesta2'ee$ i"#ei+"es $6"ias, e" 'as !a'es e' paie"te+"-i-e +" e' a*e"te -i$a', &e2i&+ a 1!e este pe$%a"ee &e%a"e$a 'ate"te e" e' (epat+it+0

La (epatitis $6"ia se a$ate$ia p+$ 'a p$ese"ia &e

s)"t+%as +%p'eta%e"te i"espe)7+s +%+ s+" #ati*a 5 &+'+$+$p+$a' i"te$%ite"te0 A'*!"as -ees p!e&e p$ese"ta$se"a!sea, a"+$e4ia, p8$&i&a &e pes+ 5 &+'+$ a2&+%i"a'0 La$+"ii&a& -a$ia &es&e ;J pa$a e' VH, (asta ; pa$ae' VHC0


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Dia'nóstico,

Se $ea'ia %e&ia"te 'a &ete$%i"ai6" &e a"ti!e$p+s +"t$a&i-e$s+s %a$a&+$es .a"t)*e"+s/ pe$te"eie"tes a est+s -i$!s0

La &ete$%i"ai6" &e '+s %a$a&+$es se 2asa e" 'a (ist+$ia')"ia, e' tip+ &e -i$!s 5 'as a$ate$)stias epi&e%i+'6*ias &e'a e"#e$%e&a&0


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Control * revención,

De2e e&!a$se a 'a p+2'ai6" s+2$e 'as %e&i&as &e sa"ea%ie"t+23si+ e (i*ie"e pe$s+"a' pa$a 'as (epatitis t$a"s%iti&as p+$ -)a+$+;#ea' .tip+s A 5 E/0

Pa$a '+s +t$+s tip+s &e (epatitis se $e+%ie"&a i&e"ti7a$ '+s+%p+$ta%ie"t+s &e $ies*+ 5 $ea'ia$ 'a 2@s1!e&a &e %a$a&+$ese$+'6*i+s e" 2a"+s &e sa"*$e pa$a 'as (epatitis tip+s 5 C, a+%+ 'a "+ti7ai6" +2'i*at+$ia &e '+s as+s &e (epatitis, pa$a%a"te"e$ !" siste%a &e -i*i'a"ia epi&e%i+'6*ia 1!e pe$%ita 'i&e"ti7ai6" &e 2$+tes0

P+$ +t$a pa$te, e4iste" -a!"as 1!e (a" &e%+st$a&+ e7aia e"'a p$e-e"i6" &e 'a (epatitis -i$a'0


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i'i+*$a#)a

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PITA FERNNDEZ, L0Hepatitis -i$a'esE" e' te4t+: .Pita Fe$"3"&e, i2'i+*$a#)a: Pita Fe$"3"&e, L0 .-i$a'es0 Ma&$i&: P$+&!t+s R+(e

OMS HEPATITIS AE" e' te4t+: .?OMS Hepatitis A?, J/i2'i+*$a#)a: OMS Hepatitis A0 .J/0 (+0i"t0Ret$ie-e& Ap$i' J, #$+%(ttp:0(+0i"t%e&iae"t$e#ats(eets#sJes

CDC EN ESPAOL ; ENFEAFECCIONES, HEPATITIS VE" e' te4t+: .?CDC e" EspE"#e$%e&a&es 5 a#ei+"Vi$a'?, J/i2'i+*$a#)a: CDC e" Espa

E"#e$%e&a&es 5 a#ei+"Vi$a'0 .J/0 C&0*+-0 ReJ, #$+%(ttp:0&0*+-spa"es(epatitis

SOZA, D0 Y CHILE, P0

Hepatitis E ; (epatitis0'E" e' te4t+: .S+a W C(i'e, J/i2'i+*$a#)a: S+a, D0, W C(i'e, P0 .J/0 Hepatitis E; (epatitis0'0 (epatitis0'0 Ret$ie-e& Ap$i' J,#$+% (ttp:(epatitis0'GJ(epatitis;e

Hepatitis a,D,E.completa1pptx

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