UNIVERSIDAD AUTÓNOMA DE TAMAULIPAS ESCUELA DE ENFERMERÍA DR. JOSÉ ÁNGEL CADENA Y CADENA INCORPORADA
TESIS PARA OBTENER EL TÍTULO DE ENFERMERA GENERAL
TEMA: HEPATITIS B
PRESENTADO POR: MAYRA MAY RA ALEJANDRA FL ORES MAYRA ALEJANDRA PULIDO PULIDO FLORES FLORES JORGE LUIS PINEDA LOPEZ CESAR ADRIAN IZAGUIRRE ZAVALA LUIS ENRIQUE LANDEROS HERRERA
CD. REYNOSA TAM. TAM.
FEBRERO 2015
ÍNDICE INTRODUCCIÓN………………………………………………………………….…..3 JUSTIFICACIÓN………………………………………………………………………. 4 OBJETIVOS……………………………………………………………………………5 ANATOMIA ANATOMIA DEL HÍGADO………………………………….. …………………………………………….6 AGENTE CAUSAL DE LA HEPA HEPATITIS B………………………………….………..7 DATOS EPIDEMIOLÓGICOS DE LA HEPATITIS B……………………………....8 TRASMISIÓN PREVENCIÓN DEL VHB…………………………….………….!" MANIFESTACIONES MANIFESTACIONES DE LA ENFERMEDAD………………………......………..!# PROGRESIÓN DE LA ENFERMEDAD POR EL VHB…………………………..!3 DIAGNÓSTICO MONITORI$ACIÓN DEL VHB……….……………………….!6 PAUTAS DE PREVENCIÓN DEL VHB……………………………………………!% VACUNACIÓN CONTRA EL VHB LA PROFILA&IS POST'ESPOSICIÓN POST'ESPOSICIÓN…………………….…………………………..#" …………………….…………………………..#" TRATAMIENTO DEL VHB……………………………..……………………………#! HEPATOCARCINOMA (C)NCER DE HÍGADO* EN PORTADORE PORTADORES S CRÓNICOS…………...………………………………………#4 RECOMENDACIONES PARA PACIENTES CON HEPATITIS B……………………………………..……………#5 CUIDADOS DE ENFERMERÍA…………………….…………………………...…#8 CONCLUSIONES…………………………………………………………………….3 "
BIBIOGRAFÍA……………………………………………………………………...…3!
INTRODUCCIÓN El VHB VHB es un !"u !"uss #e $"%ns $"%ns&!s &!s!' !'n n (e&) (e&)$!* $!*%. %. Se !n$"+ !n$"+#u #u*e *e en el *ue" *ue",+ ,+ &e#!%n$e l% e-,+s!*!'n #!"e*$% % l% s%n"e / % $"%0s #el *+n$%*$+ se-u%l. L% ,"+,+"*!'n #e %#ul$+s !n1e*$%#+s *+n el VHB 2ue se *+n!e"$en en ,+"$%#+"es / ,e"&%ne*en !n1e*$%#+s #u"%n$e &)s #e se!s &eses es #e &en+s #el 34. P%"% 2u!enes se !n1e*$%n *+n el VHB en el n%*!&!en$+ + en l% ,"!&e"% !n1%n*!%5 el "!es+ #e *+ne"$!"se en ,+"$%#+"es #el !"us ,ue#e %l*%n6%" el 784. Se *%l*ul% 2ue e-!s$en 938 &!ll+nes #e ,e"s+n%s % es*%l% &un#!%l !n1e*$%#%s *"'n!*%&en$e *+n el VHB5 #e l%s *u%les el :34 $e"&!n% su1"!en#+ "%es #%;+s (e,)$!*+s. El VHB es el *%us%n$e #e (%s$% el <84 #e l+s *%s+s #e *)n*e" #e (=%#+ en $+#+ el &un#+. En el %;+ :88>5 l+s Cen$"+s ,%"% el C+n$"+l / l% P"een*!'n #e En1e"&e#%#es #e l+s EE.UU. ?CDC@ *%l*ul%"+n 2ue >.888 es$%#+ es$%#+un! un!#en #ense sess se !n1e*$ !n1e*$%"+ %"+n n *+n el VHB / 2ue en$"e 5 5 &!ll+n &!ll+nes es #e ,e"s+n%s $!enen !n1e**!'n *"'n!*% *+n el VHB. He%l$( C%n%#% *%l*ul% 2ue *%#% %;+ se !n1e*$%n %l &en+s 3.888 *%n%#!enses *+n el VHB / 2ue (%/ %l"e#e#+" #e :8. :8.88 888 8 *%n% *%n%#! #!en ense sess *+n *+n l% !n1e !n1e** **!' !'n n *"'n *"'n!* !*%. %. L+s L+s %s!) %s!)$!$!*+ *+ss / l+s l+s !n&!"%n$es #e +$"%s 6+n%s #el &un#+ #+n#e l% (e,%$!$!s B es en#0&!*% &ues$"%n $%s%s #e !n1e**!'n &)s ele%#%s l% &%/+"=% se !n1e*$% %l n%*e" + en l+s ,"!&e"+s %;+s #e su !n1%n*!%. C%s! $+#+s l+s %1e*$%#+s ,+" el VHB es$)n l!"es #e s=n$+&%s / lle%n un% !#% n+"&%l. S!n e&%"+5 en *e"*% #el :34 #e l+s *%s+s5 el VHB ,ue#e ,"++*%" "%es #%;+s en el (=%#+ en$"e ell+s 1!"+s!s 1! "+s!s / *!""+s!s *+n el ,%s+ #e l+s %;+s5 e !n*lus+ #es,u0s #e #0*%#%s #e !n1e**!'n. En l+s *%s+s "%es5 l% (e,%$!$!s B ,ue#e +*%s!+n%" !nsu1!*!en*!% (e,)$!*% / "esul$%" &+"$%l. E-!s$e un% %*un% e1!*%6 ,%"% ,"een!" el VHB. %&!0n (%/ #!s$!n$+s $"%$%&!en$+s 2ue ,ue#en "e#u*!" + #e$ene" l% ,"+"es!'n #e l% en1e"&e#%#.
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JUSTIFICACIÓN L% (e,%$!$!s B es un% en1e"&e#%# 1)*!l&en$e $"%ns&!s!le5 ,+" =% ,%"en$e"%l + se-u%l5 + ,+" l% s!&,le *+n!en*!% es$"e*(% *+n un ,+"$%#+". L+s ,+"$%#+"es *"'n!*+s + l+s %1e*$+s #e (e,%$!$!s %u#% s+n *%,%*es #e $"%ns&!$!" l% !n1e**!'n % ,%"$!" #e *u%l2u!e" se*"e*!'n *+",+"%l / s%n"e. L% en$"%#% #el !"us $!ene lu%" ,+" %"%s!+nes #e ,!el + #e &u*+s%s. En el *%s+ #e l+s n!;+s5 e-!s$e %#e&)s l% ,+s!!l!#%# #e !n1e**!'n ,e"!n%$%l s! l% &%#"e es ,+"$%#+"%. Al"e#e#+" #e l% &!$%# #e l+s *%s+s se %#2u!e"en en l% !n1%n*!% ,+" *+n!en*!% *+n un ,+"$%#+" +5 &)s "%"+5 ,+" $"%ns&!s!'n e"$!*%l. C+n es+s #%$+s5 l+s ,%=ses *+n *%,%*!#%# e*+n'&!*% (%n %#+,$%#+ &e#!#%s #e ,"een*!'n *+n %*un% un!e"s%l en l% !n1%n*!%5 / % "u,+s %#ul$+s #e "!es+ ?$"%%%#+"es s%n!$%"!+s5 %1e*$+s #e en1e"&e#%#es 2ue (%*en ne*es%"!+ $"%ns1us!+nes + (e&+#!)l!s!s5 *+n!!en$es *+n ,+"$%#+"es5 e$*.@. El es$u#!+ #e l%s (e,%$!$!s ="%les *+ns$!$u/e un (e*(+ #e $"%s*en#en$%l !&,+"$%n*!% 1"e*uen*!% *+&+ &+"!&+"$%l!#%# en $+#+ el !&,+"$%n*!% ,+" ,+" su 1"e*uen*!% *+&+ *%us% #e &+"!&+"$%l!#%# &un#+. Su #!s$"!u*!'n es &un#!%l5 +*u""e 1"e*uen$e&en$e en 1+"&% #e e,!#e&!%s / en %lun%s #e sus %"!e#%#es *+&+ !n1e**!'n en#0&!*% en n!;+s #e #!e"s%s "e!+nes #el +"e5 *+&+ ,+" ee&,l+ As!% / A1"!*%. Du"%n$e l+s l$!&+s 8 %;+s se (%n ,"+#u*!#+ n+$%les ,"+"es+s en el #!%n's$!*+5 $"%$%&!en$+ / ,"+1!l%-!s #e es$% en1e"&e#%# *+&+ ,+" ee&,l+ l% +$en*!'n #e %*un%s *+n$"% l% (e,%$!$!s A / B5 l% !#en$!1!*%*!'n / *l+n%*!'n #el !"us C / +$"+s %en$es / en el us+ #el !n$e"1e"'n *+&+ $"%$%&!en$+ #e l%s (e,%$!$!s B5 C / Del$%.
P+" $+#+ l+ %n$e"!+" / +$"%s s+"%#%s "%6+nes 1u!&+s &+$!%#+s % l% "e%l!6%*!'n #e es$e $"%%+.
OBJETIVOS
O+,--/ 012 +12-2 1-,10-2 2+/- 01 H-1,9,92 B: 2 9;9-;91: -;1922 - ,/12929< = -912 /->-,9>12
Objetivos específicos
D-,-/91/ 01 /->10-;91 - 01 ?-1,9,92 B - M@9;.
D-,-/91/ 02 1;,/-2 - /9-2 - 01 +01;9< --/10
C;-/ 012 -912 /->-,9>12
D-,-/91/ 01 9/,1;91 - 01 >1;1;9< ;,/1 01 H-1,9,92 B
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ANATOMÍA DEL HÍGADO El (=%#+ es el '"%n+ !n$e"n+ &)s "%n#e #el *ue",+. Es$) s!$u%#+ #e$")s #e l%s *+s$!ll%s en l% ,%"$e #e"e*(% #el %#+&en. El (=%#+ se en*%"% #e *e"*% #e 388 1un*!+nes +")n!*%s. P"+*es% *%s! $+#+ l+ 2ue *+&e&+s5 "es,!"%&+s / %s+"e&+s % $"%0s #e l% ,!el. L%s *0lul%s (e,)$!*%s ,"+#u*en l% !l!s5 l% *u%l ,e"&!$e %l *ue",+ #!e"!" l% *+&!#% / %s+"e" l+s nu$"!en$es. El (=%#+ #ese&,e;% un !&,+"$%n$e ,%,el en el &e$%+l!s&+5 l+ 2ue !n*lu/e el %l&%*en%&!en$+ #e !$%&!n%s5 &!ne"%les / %6*%"es. S!n$e$!6% %"!%s ,"+$e=n%s esen*!%les5 en$"e ell%s (+"&+n%s5 ,"+$e=n%s #e l% s%n"e / 1%*$+"es #e *+%ul%*!'n. A#e&)s5 el (=%#+ #ese&,e;% un !&,+"$%n$e ,%,el #e #es!n$+-!*%*!'n5 1!l$"%n#+ 1)"&%*+s5 #"+%s / $+-!n%s ?enen+s@ / el!&!n%n#+ l+s #e"!%#+s $'-!*+s #el &e$%+l!s&+ n+"&%l. He,%$!$!s es un n+&"e ene"%l ,%"% "e1e"!"se % l% !n1l%&%*!'n #el (=%#+. Pue#e es$%" +*%s!+n%#% ,+" #!s$!n$+s !"us5 sus$%n*!%s 2u=&!*%s $'-!*%s5 %l*+(+l5 1)"&%*+s + #"+%s u +$"+s 1%*$+"es. El VHB %$%*% l%s *0lul%s (e,)$!*%s / se "e,"+#u*e en l%s &!s&%s. A &e#!#% 2ue %%n6% el #%;+ (e,)$!*+5 el '"%n+ ,!e"#e l% *%,%*!#%# #e #ese&,e;%" sus %*$!!#%#es n+"&%les. D%#+ 2ue el (=%#+ se en*%"% #e $%n$%s 1un*!+nes !&,+"$%n$es5 l% en1e"&e#%# (e,)$!*% ,ue#e ,"++*%" un% "%n %"!e#%# #e s=n$+&%s / #+len*!%s #!1e"en$es. L% (e,%$!$!s B es un+ #e l+s $"es $!,+s &)s *+&unes #e (e,%$!$!s ="!*% l+s +$"+s #+s s+n l% (e,%$!$!s A / l% (e,%$!$!s C. L% (e,%$!$!s A es l% &)s 1"e*uen$e. El !"us #e l% (e,%$!$!s A ?VHA@ suele $"%ns&!$!"se &e#!%n$e %l!&en$+s + %u% *+n$%&!n%#+s *+n (e*es !n1e*$%#%s5 ,e"+ $%&!0n ,ue#e *+n$"%e"se % $"%0s #e *+n$%*$+s #+&0s$!*+s / se-u%les ?%n%les+"%les@. N+ e-!s$e $"%$%&!en$+ *+n$"% l% (e,%$!$!s A5 ,e"+ n+"&%l&en$e el *ue",+ el!&!n% el !"us / 0s$e n+ lle% % ,"++*%" !n1e**!'n *"'n!*%. L% (e,%$!$!s C ?%n$e"!+"&en$e *+n+*!#% *+&+
(e,%$!$!s n+ An+ B@ es$) *%us%#% ,+" un !"us 2ue se $"%ns&!$e ,+" l% s%n"e5 %l !u%l 2ue l% (e,%$!$!s B. El VHC $!ene &u*(%s &)s ,"+%!l!#%#es #e *+ne"$!"se en *"'n!*+ 2ue el VHB5 / $%&!0n $!ene &)s 1%*!l!#%# ,%"% ,"++*%" #%;+s (e,)$!*+s. >
AGENTE CAUSAL DE LA HEPATITIS B L% (e,%$!$!s B es$) ,"+#u*!#% ,+" !"us ADN5 #e : n&. #e l% 1%&!l!% #e l+s H-11>9/91-5 +"!!n%l&en$e *+n+*!#+ *+&+ ,%"$=*ul% #e D%ne5 2ue $!ene un es,e*!%l $"+,!s&+ ?,"e#!le**!'n@ ,+" el (=%#+ ?!"us (e,%$+$"+,+@. El VHB es un% ,%"$=*ul% *+n un% #+le en+l$u"%. En un% su,e"1!*!e &)s e-$e"n% se en*uen$"% el %n$=en+ #e su,e"1!*!e #e l% (e,%$!$!s B ?HBs A@ 2ue es !n&un+l'!*%&en$e #!s$!n$+ #e l% ,+"*!'n *en$"%l / 2ue $!ene 1+"&% es10"!*% / $uul%". En l% "e!'n *en$"%l es #+n#e es$) el %n$=en+ *+"e #e l% (e,%$!$!s B ?HBs A@5 el %n$=en+ e ?HBe A@ / l% DNA ,+l!&e"%s%. Es$+s %n$=en+s s+n *%,%*es #e #%" lu%" % sus es,e*=1!*+s %n$!*ue",+s %n$!HBs5 %n$!HB* / %n$! HBe5 "es,e*$!%&en$e.
DATOS EPIDEMIOLÓGICOS DE LA HEPATITIS B
L% (e,%$!$!s B es un% #e l%s en1e"&e#%#es !n1e**!+s%s &)s #!1un#!#%5 /% 2ue se *%l*ul% 2ue en el &un#+ el 34 #e l% ,+l%*!'n es$) !n1e*$%#%5 l+ 2ue su,+ne un+s 988 &!ll+nes #e ,e"s+n%s. Es$%s ,e"s+n%s !n1e*$%#%s s+n l+s ll%&%#+s ,+"$%#+"es *"'n!*+s. P+" +$"% ,%"$e5 *%#% %;+ &ue"en en el &un#+ en$"e / : &!ll+nes #e !n#!!#u+s *+&+ *+nse*uen*!% #e l% (e,%$!$!s B. L% ,"e%len*!% #e l% (e,%$!$!s B es #!1e"en$e sen l%s #!s$!n$%s )"e%s e+")1!*%s *+ns!#e"%#%s5 #e $%l &%ne"% 2ue ,+#e&+s es$%le*e" )"e%s #e en#e&!% %l$%5 !n$e"&e#!% / %%5 sen el ,+"*en$%e #e ,+"$%#+"es #el VHB. En l%s )"e%s #e %% en#e&!% &en+s #el :4 #e l% ,+l%*!'n s+n ,+"$%#+"es #el !"us #e l% (e,%$!$!s B5 es #e*!"5 ,"esen$%n el ll%&%#+ K%n$=en+ Aus$"%l!% + l+ 2ue es l+ &!s&+ s+n HBs A ?@. Se *%l*ul%n 2ue 5 &!ll+nes #e es$%#+un!#enses es$)n *"'n!*%&en$e !n1e*$%#+s *+n el VHB5 +$"+s !nes$!%#+"es su!e"en 2ue s! se !n*lu/e"% % l+s !n&!"%n$es !n#+*u&en$%#+s / % +$"+s "u,+s #e ,+l%*!'n5 l% *%n$!#%# "e%l se %*e"*%"=% % l+s : &!ll+nes. A,"+-!&%#%&en$e :.888.888 es$%#+un!#enses &ue"en *%#% %;+ % *+nse*uen*!% #e *+&,l!*%*!+nes #e"!%#%s #e l% (e,%$!$!s B. He%l$( C%n%#% *%l*ul% 2ue :8.888 *%n%#!enses es$)n !n1e*$%#+s *"'n!*%&en$e *+n el VHB. L+s !n&!"%n$es ,"+*e#en$es #e As!%5 O"!en$e Me#!+ / *!e"$%s 6+n%s #e Á1"!*% %s= *+&+ sus (!+s *+""en un "!es+ &)s ele%#+ #e !n1e*$%"se *+n el VHB.
<
L% O"%n!6%*!'n Mun#!%l #e l% S%lu# "e*+&!en#% l% %*un% *+n$"% l% (e,%$!$!s B #e 1+"&% un!e"s%l (+/ en #=%5 l+s %#+les*en$es "e*!en "u$!n%"!%&en$e l% %*un% *+n$"% el VHB5 ,e"+ l% %*un% !n1%n$!l s!ue s!en#+ +,*!+n%l en %"!+s es$%#+s. L% A*%#e&!% Es$%#+un!#ense #e Pe#!%$"=% "e*+&!en#% %#&!n!s$"%" l% %*un% *+n$"% el VHB % $+#+s l+s l%*$%n$es.
P/;-,1-2 - +01;9< ; 9-;;9< ;/<9;1 / -0 >9/2 - 01 H-1,9,92 B.
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TRANSMISIÓN PREVENCIÓN DEL VHB El VHB se $"%ns&!$e &e#!%n$e *+n$%*$+ #!"e*$+ #e s%n"e % s%n"e. Un% #e l%s ,"!n*!,%les =%s #e *+n$%!+ es el us+ *+&,%"$!#+ #e &%$e"!%l ,%"% #"+%s5 $%n$+ !n$"%en+s%s *+&+ #e +$"+ $!,+ ?,+" ee&,l+5 e"!n%s5 *u*(%"%s5 $+"n!2ue$es5 ,%%s ,%"% esn!1%" *+*%=n% / ,!,%s ,%"% *"%*@. L%s %u%s u$!l!6%#%s ,%"% (%*e" $%$u%es / ,e"1+"%*!'n #el *ue",+ $%&!0n ,ue#en $"%ns&!$!" el !"us. El us+ *+&,%"$!#+ #e +e$+s ,e"s+n%les $%les *+&+ *u*(!ll%s #e %1e!$%"5 *e,!ll+s #e #!en$es / *+"$%;%s es &en+s ,el!"+s+5 ,e"+ %un %s= s+n =%s ,+$en*!%les #e $"%ns&!s!'n. Es$+ su*e#e *u%n#+ un% ,e2ue;% *%n$!#%# #e s%n"e !n1e*$%#% *+n el VHB ,e"&%ne*e en un %"$=*ul+ #es,u0s #e us%"l+ / 0s$e ,%s% % se" u$!l!6%#+ ,+" +$"% ,e"s+n%. En el ,%s%#+ &u*(%s ,e"s+n%s *+n$"%e"+n (e,%$!$!s B % $"%0s #e $"%ns1us!+nes s%nu=ne%s s!n e&%"+5 % ,%"$!" #e 7: se e&,e6' % %n%l!6%" l% s%n"e #+n%#% ,%"% #e$e*$%" el VHB5 / #es#e 77: se "e%l!6% +$"% ,"ue% ,%"% #e$e*$%" el VHC. H+/ en #=%5 l%s $"%ns1us!+nes #e s%n"e se *+ns!#e"%n seu"%s. L+s $"%%%#+"es #e l% s%lu# ,ue#en !n1e*$%"se *+n el VHB %l ,!n*(%"se *+n e"!n%s + &e#!%n$e +$"%s e-,+s!*!+nes %**!#en$%les % l% s%n"e en el lu%" #e $"%%+. El VHB es$) ,"esen$e en el se&en / l%s se*"e*!+nes %!n%les5 ,+" l+ 2ue l% (e,%$!$!s B ,ue#e $"%ns&!$!"se % $"%0s #e l% %*$!!#%# se-u%l. El VHB $!ene &u*(%s &)s ,"+%!l!#%#es #e *+n$%!%"se ,+" =% se-u%l 2ue el VHC. L+s CDC *%l*ul%n 2ue l% &%/+"=% #e l%s nue%s !n1e**!+nes en l+s Es$%#+s Un!#+s ,ue#en (%e"se $"%ns&!$!#+ ,+" =% se-u%l. El *+n$%!+ ,ue#e se" &)s ,"+%le #u"%n$e el ,e"=+#+ &ens$"u%l 1e&en!n+. L%s $%s%s #e $"%ns&!s!'n #el VHB s+n ,%"$!*ul%"&en$e ele%#%s en$"e (+&"es 2ue $!enen "el%*!+nes se-u%les *+n +$"+s (+&"es.
L% $"%ns&!s!'n ,e"!n%$%l #e &%#"es !n1e*$%#%s ,+" el VHB % sus (!+s %n$es + #u"%n$e el ,%"$+ "e,"esen$% l% &%/+" ,%"$e #e l%s !n1e**!+nes #e %2uell%s 6+n%s #+n#e el VHB es en#0&!*+. 8
El *+n$%!+ es &)s ,"+%le s! l% &%#"e $!ene un% *%"% !"%l #e VHB ele%#% en l% s%n"e l%s &%#"es *+!n1e*$%#%s *+n el VHC + el VIH %#e&)s #el VHB $%&!0n $!enen &)s ,"+%!l!#%#es #e $"%ns&!$!" l% (e,%$!$!s B % su (!+s. Aun2ue el %n$=en+ #e su,e"1!*!e #el VHB5 un% ,%"$=*ul% #el !"us5 es$) ,"esen$e en l% le*(e &%$e"n%5 n+ e-!s$en !n#!*!+s #e 2ue l% (e,%$!$!s B se *+n$%!e % $"%0s #e l% l%*$%n*!% &%$e"n% s! el l%*$%n$e es$) %*un%#+. L+s es$u#!+s !n#!*%n 2ue l% $"%ns&!s!'n #el VHB es *+&n en$"e n!;+s ,e2ue;+s en %2uell%s 6+n%s en 2ue el !"us es en#0&!*+5 ,"+%le&en$e &e#!%n$e %"%;%6+s / &+"#!s*+s. Aun2ue el VHB es #e$e*$%le en l% s%l!%5 n+ se *+n+*en *%s+s #e *+n$%!+ ,+" es$+"nu#+s5 $+ses5 n! ,+" *+&,%"$!" u$ens!l!+s #e *+&!#% + %s+s l% $"%ns&!s!'n #el VHB en el en$+"n+ #+&0s$!*+ #e *+n$%!+ #el VHB % $"%0s #e +"!n%5 (e*es5 su#+"5 l)"!&%s n! '&!$+s. En %l &en+s un% $e"*e"% ,%"$e #e l+s *%s+s5 l+s ,%*!en$es n+ ,"esen$%n 1%*$+"es #e "!es+ !#en$!1!*%les / n+ lle% % *+n+*e"se l% =% #e $"%ns&!s!'n #e l% (e,%$!$!s B.
Personas que tenen !a"or res#o $e %ontraer &a 'e(atts B: A2uell+s 2ue ,+" "%6+nes ,"+1es!+n%les $!enen un &%/+" "!es+ #e en$"%" en *+n$%*$+ *+n l=2u!#+s +")n!*+s *+n$%&!n%#+s *+n el VHB. Es #e*!" ,e"s+n%l s%n!$%"!+5 ,+l!*=%s5 +&e"+s5 1un*!+n%"!+s #e ,"!s!+nes5 &!l!$%"es5 e$*. %&!0n s+n ,e"s+n%s *+n "!es+ &u/ ele%#+ l+s %#!*$+s % #"+%s ,+" =% ,%"en$e"%l %l *+&,%"$!" %u%s5 e"!nu!ll%s5 e$*.5 l+s ,%*!en$es s+&e$!#+s % (e&+#!)l!s!s5 l%s ,e"s+n%s se-u%l&en$e ,"+&!s*u%s $%n$+ (+&+ *+&+ (e$e"+se-u%les5 l%s 2ue *+n!en *+n ,+"$%#+"es *"'n!*+s #el VHB / &u/ es,e*!%l&en$e l+s (!+s #e &%#"es ,+"$%#+"es #el VHB. %&!0n $!enen un &%/+" "!es+ l%s ,e"s+n%s 2ue !%%n % 6+n%s *+n %l$% en#e&!% #e !n1e**!'n #e VHB ?Á1"!*%5 As!%5 A&%6+n%s5 e$*.@.
MANIFESTACIONES DE LA ENFERMEDAD
El ,e"!+#+ #e !n*u%*!'n #e l% HB es l%"+5 en$"e 3>8 #=%s ?,"+&e#!+ :8 #=%s@. L% &%/+" ,%"$e #e l+s *%s+s #e !n1e**!'n ,+" el VHB s+n %s!n$+&)$!*+s. O$"%s e*es *u"s% *+n un *u%#"+ ,+*+ es,e*=1!*+ #e 1!e"e ?+*%s!+n%l@5 &%les$%" ene"%l5 *%ns%n*!+5 %n+"e-!%5 n)use%s5 '&!$+s5 #+l+" %#+&!n%l. S'l+ un 98384 #e %#ul$+s ,"esen$%n !*$e"!*!% ?*+l+"%*!'n %&%"!ll% #e ,!el / ++s@ / en n!;+s es %n &en+s 1"e*uen$e5 /% 2ue s'l+ &en+s #el 84 *u"s%n *+n !*$e"!*!%. O*%s!+n%l&en$e (%/ +$"%s &%n!1es$%*!+nes *l=n!*%s5 $%les *+&+ •
E-%n$e&%5 %"$"!$!s5 l+&e"ul+ne1"!$!s5 e$*. A,"+-!&%#%&en$e el :4 #e l+s *%s+s ,ue#en $ene" un *u"s+ 1ul&!n%n$e *+n 1%ll+ (e,)$!*+ %u#+ 2ue #e n+ "e*u""!" %l $"%ns,l%n$e *+n#u*e % l% &ue"$e en &u*(%s +*%s!+nes. Jun$+ % es$%s &%n!1es$%*!+nes *l=n!*%s (%/ %u&en$+ #e l% *!1"% #e $"%ns%&!n%s%s ?SGO5 SGP@5 #e l% !l!""u!n% en *%s+ #e !*$e"!*!%5 e$*. En l% 1%se %u#% #e l% en1e"&e#%# ,+#e&+s #e$e*$%" HBs A en sue"+ ?su ,"esen*!% #es,u0s #e > &eses !n#!*% es$%#+ #e ,+"$%#+"@ / ,"esen*!% #e IM %n$!HB*.
:
PROGRESIÓN DE LA ENFERMEDAD POR EL VHB
V)B A#u$o " Cr*n%o Des,u0s #e l% e-,+s!*!'n %l VHB5 el ,e"=+#+ #e !n*u%*!'n +s*!l% en$"e 98 / 78 #=%s. L% 1%se !n!*!%l #e l% (e,%$!$!s B se #en+&!n% !n1e**!'n %u#%. L% el!&!n%*!'n #el !"us #es,u0s #e l% !n1e**!'n %u#% suele lle%" #e : % : &eses5 #u"%n$e l+s *u%les se ,ue#e sen$!" 1%$!% / #+l+" %#+&!n%l. En l% &%/+" ,%"$e #e l+s !n1e*$%#+s *+n el VHB5 el s!s$e&% !n&un!$%"!+ es *%,%6 #e el!&!n%" el !"us. Pe"+ %lun+s %#ul$+s se *%l*ul% 2ue &en+s #el >4 2ue#%n *"'n!*%&en$e !n1e*$%#+s5 l+ 2ue s!n!1!*% 2ue el !"us ,e"&%ne*e en el *ue",+ ,%s%#+s se!s &eses. En$"e l%s ,e"s+n%s !n1e*$%#%s *+n el VHB *u%n#+ e"%n e0s + n!;+s5 es$% *!1"% es &u*(+ &)s ele%#% (%s$% el 784 #e l+s e0s / el 984 #e l+s n!;+s en$"e / 3 %;+s. El &%$e"!%l en0$!*+ ?ADN@ #el VHB ,e"&%ne*e en el n*le+ #e l%s *0lul%s #e $+#+s l+s sue$+s !n1e*$%#+s5 !n*lus+ s! el !"us n+ es #e$e*$%le en l% s%n"e. En *+nse*uen*!%5 el VHB ,ue#e "e%*$!%"se s! el s!s$e&% !n&un!$%"!+ es$) #e$e"!+"%#+ + s! se u$!l!6%n !n&un+su,"es+"es5 *+&+ l+s es$e"+!#es + l% 2u!&!+$e"%,!%. L% &%/+" ,%"$e #e l%s ,e"s+n%s *+n (e,%$!$!s B *"'n!*% ?el 34@ n+ &ues$"%n s=n$+&%s #e en1e"&e#%# (e,)$!*%5 ,e"+ es$% s!$u%*!'n ,ue#e *%&!%" en *u%l2u!e" &+&en$+ #e l% !#% #e un ,+"$%#+".
S+nto!as $e &a )e(atts B L% &%/+"=% #e l+s %1e*$%#+s ,+" el VHB e-,e"!&en$%n ,+*+s + n!nn s=n$+&% #e (e*(+5 &u*(+s n+ s%en 2ue s+n ,+"$%#+"es #el !"us. Se *%l*ul% 2ue el 984 #e l%s ,e"s+n%s *+n (e,%$!$!s B %u#% n+ &%n!1!es$%n s=n$+&%s5 / l% &%/+" ,%"$e #e 2u!enes $!enen el VHB *"'n!*+ $%&,+*+ $!enen s=n$+&%s.
Cu%n#+ s= %,%"e*en5 l+s s=n$+&%s #e l% (e,%$!$!s B ,ue#en !n*lu!" 1%$!% ?*%ns%n*!+ ,"+l+n%#+ !nusu%l@5 1!e"e5 &%les$%" ?un% sens%*!'n "!,%l@5 n)use%s5 '&!$+s5 ,0"#!#% #el %,e$!$+ ?%n+"e-!%@5 #+l+" + (!n*(%6'n %#+&!n%l5 !n#!es$!'n5 *e1%le%s5 ,!*+"es ?,"u"!$+@ / #+l+"es &us*ul%"es + %"$!*ul%$+"!+s. 9
C!e"$%s ,e"s+n%s *+n (e,%$!$!s B %u#% + *"'n!*% ,ue#en &+s$"%" !*$e"!*!% ?2ue se &%n!1!es$% *+n *+l+" %&%"!llen$+ en l% ,!el / el l%n*+ #e l+s ++s@5 %*l%"%*!'n #e l%s (e*es / +s*u"e*!&!en$+ #e l% +"!n%5 #e!#+ %l %u&en$+ en l% s%n"e #e un ,!&en$+ ll%&%#+ !l!""u!n%.
En,er!e$a$ A-an.a$a En un% &!n+"=% #e l%s ,e"s+n%s *+n (e,%$!$!s B5 l% en1e"&e#%# ,"+"es% *+n el ,%s+ #e l+s %;+s + !n*lus+ #0*%#%s5 ,"++*%n#+ *"e*!en$es #%;+s (e,)$!*+s. Se *%l*ul% 2ue el :8984 #e l+s !n1e*$%#+s *+n el VHB *"'n!*+ $e"&!n%n ,%#e*!en#+ *!""+s!s. En l+s *%s+s "%es5 ,ue#e %,%"e*e" !nsu1!*!en*!% (e,)$!*% / se (%*e ,"e*!s+ "e%l!6%" un $"%s,l%n$e #e (=%#+. L+s #%;+s (e,)$!*+s ,ue#en se"
In,&a!a%*n/ Un%
"es,ues$% !n&un!$%"!% % l% !n1e**!'n + l%s les!+nes5
*%"%*$e"!6%#% ,+" !n1!l$"%*!'n #e l'ul+s l%n*+s5 (!n*(%6'n / %l$e"%*!'n 1un*!+n%l #e l%s *0lul%s (e,)$!*%s. Cu%n#+ e-!s$e !n1l%&%*!'n (e,)$!*% es ,+s!le $ene" ele%#%s l%s $"%ns%&!n%s%s5 ,e"+ n+ s!e&,"e es %s=.
Ne%ross #es$"u**!'n #e l%s *0lul%s (e,)$!*%s ?(e,%$+*!$+s@. F0ross #es%""+ll+ #e *!*%$"!*es en el (=%#+ 2ue5 s! es$) &u/ e-$en#!#+5 ,ue#e +s$%*ul!6%" l% *+""e*$% *!"*ul%*!'n #e l% s%n"e % $"%0s #el (=%#+.
Crross un ,"+*es+ ,+" el *u%l l%s *0lul%s (e,)$!*%s se #es$"u/en / se en "ee&,l%6%#%s ,+" $e!#+ *!*%$"!6%#+. L% 1+"&%*!'n #e 6+n%s e-$ens%s #e $e!#+ *!*%$"!6%#+ ,ue#e !&,e#!" 2ue l% s%n"e 1lu/% % $"%0s #el (=%#+.
En l% *!""+s!s *+&,ens%#%5 el (=%#+ ,"esen$% &u*(%s *!*%$"!*es ,e"+ 1un*!+n% n+"&%l&en$e l+s ,%*!en$es *+n *!""+s!s *+&,ens%#% suelen &+s$"%" ,+*+s s=n$+&%s.
En l% *!""+s!s #es*+&,ens%#%5 el (=%#+ es$) #e&%s!%#+ #%;%#+ / n+ ,ue#e 1un*!+n%" *+""e*$%&en$e. L+s ,%*!en$es *+n *!""+s!s #es*+&,ens%#% ,ue#en $e"&!n%" su1"!en#+ *+&,l!*%*!+nes $%les *+&+ %"!*es s%n"%n$es ?%s+s s%nu=ne+s "+$+s en el es'1%+5 el es$'&%+ / el s!s$e&% #!es$!+@5 %*u&ul%*!'n #e l=2u!#+s en el %#+&en ?%s*!$!s@5 1%*!l!#%# ,%"% su1"!" (e&+""%!%s + "%su;+s5 %l$e"%*!+nes &en$%les ?en*e1%l+,%$=% (e,)$!*%@ / *+&%.
Car%no!a 'e(ato%e&u&ar . Un $!,+ #e *)n*e" #e (=%#+ 2ue ,ue#e %,%"e*e" en ,e"s+n%s *+n (e,%$!$!s *"'n!*%. El *)n*e" #e (=%#+ suele #es%""+ll%"se en ,e"s+n%s *+n *!""+s!s5 ,e"+ %lun+s ,%*!en$es *+n (e,%$!$!s B $!enen *)n*e" #e (=%#+ s!n *!""+s!s.
Crteros 0o&*#%os se 0asa e& $a#n*st%o $e )e(atts B C+&+ +*u""e *+n &u*(%s en1e"&e#%#es !n1e**!+s%s5 l% *l=n!*% n+s #ee sue"!" el #!%n's$!*+ #e l% en1e"&e#%#5 %un2ue su *+n1!"&%*!'n #e1!n!$!% #ee %s%"se en *"!$e"!+s se"+l'!*+s. H%/ un% se"!e #e %n$=en+s ?A@ 2ue !n$e"%n l% *+&,+s!*!'n #el ,"+,!+ !"us / #e %n$!*ue",+s ?A*@ 2ue 1+"&% el +"%n!s&+ en "es,ues$% % l% ,"esen*!% #e %n$=en+s. L% ,"esen*!% #e A / #e A* %n % #e,en#e" #e l% 1%se #e l% en1e"&e#%# / $!enen un% %,%"!*!'n se*uen*!%l5
3
DIAGNÓSTICO MONITORI$ACIÓN DEL VHB E-!s$en #!s$!n$%s ,"ue%s 2ue se u$!l!6%n ,%"% #!%n+s$!*%" l% (e,%$!$!s B / e%lu%" l% e$%,% #e l% en1e"&e#%# / el "%#+ #e #%;+ (e,)$!*+.
S#n,%a$o %&+n%o $e &os $,erentes !ar%a$ores $e n,e%%*n $e& V)B HB2 A(1,9-2 - 2-/9;9- - 01 H-1,9,92 B*. Es el ,"!&e" &%"*%#+" 2ue %,%"e*e en el ,l%s&% #el sue$+ !n1e*$%#+ ,+" el VHB5 un%s > se&%n%s $"%s l% e-,+s!*!'n %l !"us. Pe"s!s$e #u"%n$e l% 1%se %u#% ? se&%n%s@. Su ,"esen*!% #es,u0s #e > &eses s!n!1!*% !n1e**!'n *"'n!*%. ADN VHB (DNA -0 >9/2 - 01 H-1,9,92 B* Su ,"esen*!% en el sue"+ es el &e+" !n#!*%#+" #e l% "e,l!*%*!'n !"%l %*$!%. HB- A (A,- - -0 V9/2 - 01 H-1,9,92 B* A,%"e*e !n&e#!%$%&en$e #es,u0s #el HBs A. Su ,"esen*!% es$) "el%*!+n%#% *+n l% "e,l!*%*!'n #el !"us5 ,+" l+ 2ue es un =n#!*e #e !n1e*$!!#%#. L% ,"esen*!% s!&ul$)ne% en el ,l%s&% #e HBs A / #e HBe A es s!n'n!&+ #e ele%#% !n1e**!+s!#%#. L% ,"esen*!% #e HBe A su,e"!+" % 8 se&%n%s es &u/ sues$!% #e e+lu*!'n *"'n!*%. HB; A (A,- ;-,/10 -0 V9/2 - 01 H-1,9,92 B* N+ se #+s!1!*% en el ,l%s&%. Pue#e !nes$!%"se en el n*le+ #el (e,%$+*!$+5 &e#!%n$e !+,s!% (e,)$!*%. HB; A; (A,9;-/2 ;-,/10 ;,/1 -0 V9/2 - 01 H-1,9,92 B* Es l% ,"!&e"% se;%l #e "es,ues$% !n&un+l'!*% #el sue$+ % l% !n1e**!'n !"%l. Se #e$e*$% en l% 1%se %u#% #e l% en1e"&e#%#5 ,e"s!s$!en#+ $"%s l% *u"%*!'n. Den$"+ #el HB* A*
#ee&+s *+ns!#e"%" F"%**!'n IM !n#!*% !n1e**!'n "e*!en$e / su ,e"s!s$en*!% $"%#u*e !n1e**!'n *"'n!*% / l% 1"%**!'n IG !n#!*% !n1e**!'n %n$!u%
>
HB- A; (A,9;-/2 - ;,/10 01 H-1,9,92 B* Es el seun#+ %n$!*ue",+ en %,%"e*e" en l% *!"*ul%*!'n / % #!"!!#+ *+n$"% el HBe A. "%#u*e #!s&!nu*!'n #e !n1e*$!!#%#. Pue#e ,e"s!s$!" un+ + &)s %;+s $"%s l% *u"%*!'n #e l% !n1e**!'n. HB2 A; (A,9;-/2 - 2-/9;9- ;,/1 01 H-1,9,92 B* Es el l$!&+ %n$!*ue",+ en %,%"e*e" / l+ (%*e en l% 1%se #e *+n%le*en*!%. Su ,"esen*!% es s!n'n!&+ #e *u"%*!'n / #e !n&un!#%#
Prue0as $e Car#a Vra& L%s ,"ue%s #e *%"% !"%l &!#en l% *%n$!#%# #e ADN ?&%$e"!%l en0$!*+@ #el VHB 2ue *!"*ul% ,+" l% s%n"e. Un% *%"% !"%l #e$e*$%le !n#!*% 2ue el VHB se es$) &ul$!,l!*%n#+ %*$!%&en$e. Cu%n#+ l%s en6!&%s (e,)$!*%s $!enen un n!el %n+"&%l5 l% &%/+" *%"% !"%l #el ADN #el VHB ,%"e*e es$%" %s+*!%#% % un% &%/+" "%e#%# #e l% en1e"&e#%# (e,)$!*%. L%s ,"ue%s #e *%"% !"%l $%&!0n "esul$%n $!les ,%"% !n#!*%" s! el $"%$%&!en$+ es$) s!en#+ e1!*%6.
An1&ss Boqu+!%os $e& )+#a$o L%s ,"ue%s !+2u=&!*%s #el (=%#+ #%n un% !#e% %,"+-!&%#% #el "%#+ #e !n1l%&%*!'n (e,)$!*%. El ,%nel (e,)$!*+ es$) *+&,ues$+ ,+" #e$e"&!n%*!+nes #e #!s$!n$%s sus$%n*!%s #e l% s%n"e. Mu*(%s ,e"s+n%s *+n (e,%$!$!s B %u#% + *"'n!*%5 ,e"+ n+ $+#%s5 e-,e"!&en$%n %u&en$+s #e #+s en6!&%s (e,)$!*%s5 ll%&%#%s %l%n!n%%&!n+$"%ns1e"%s% ?ALA5 #en+&!n%#% %n$e"!+"&en$e SGP@ / %s,%"$%$+%&!n+$"%ns1e"%s% ?ASA5 *+n+*!#% %n$e"!+"&en$e *+&+ SGO@. L% ALA / l% ASA se l!e"%n ,+" l% s%n"e *u%n#+ el (=%#+ es$) #%;%#+. El %u&en$+ #e l%s *+n*en$"%*!+nes #e es$%s en6!&%s es % &enu#+ el ,"!&e" s!n+
#e ,"+le&%s en el (=%#+5 / el #es*ens+ #e l% ALA &u*(%s e*es !n#!*% 2ue el $"%$%&!en$+ es$) "esul$%n#+ e1!*%6. S!n e&%"+5 &u*(%s ,e"s+n%s *+n (e,%$!$!s B $!enen el n!el #e en6!&%s (e,)$!*%s s!e&,"e n+"&%l. A#e&)s5 *!e"$%s ,e"s+n%s &ues$"%n *+n*en$"%*!+nes n+"&%les #e ALA %un *u%n#+ ,%#e*en *!""+s!s #e 1+n#+.
O$"% #e$e"&!n%*!'n *+&n es l% *+n*en$"%*!'n #e !l!""u!n%. L% !l!""u!n% es un ,!&en$+ 2ue se ,"+#u*e *+n$!nu%&en$e *+&+ #e"!%#+ #e l% #es!n$e"%*!'n n%$u"%l #e l+s l'ul+s "++s. L% ele%*!'n #e l+s n!eles #e !l!""u!n% *%us% !*$e"!*!%. El n!el #e !l!""u!n% !n#!*% el "%#+ #e 1un*!'n (e,)$!*%5 #el &!s&+ &+#+ 2ue l% *+n*en$"%*!'n #e %l&!n% en sue"+ / l% #e$e"&!n%*!'n #e l% *+%ul%*!'n s%nu=ne%.
Prue0as Genot+(%as El VHB *+ns$% #e %"!+s en+$!,+s + *e,%s #!1e"en$es 2ue se #en+&!n%n *+n le$"%s #e l% A % l% H. L+s #!s$!n$+s en+$!,+s #el VHB es$)n %s+*!%#+s % n!eles es,e*=1!*+s #e "e,l!*%*!'n !"%l5 ,"+"es!'n #e l% en1e"&e#%# (e,)$!*% / e1!*%*!% $e"%,0u$!*%. En l+s Es$%#+s Un!#+s5 ,ue#en en*+n$"%"se l+s s!u!en$es en+$!,+s en+$!,+ A ?934@5 en+$!,+ B ?::4@5 en+$!,+ C ?94@5 en+$!,+ D ?84@. L% ,"ue% ,%"% #e$e"&!n%" el en+$!,+ #el VHB es$) *%#% e6 &)s e-$en#!#%5 /% 2ue *!e"$+s en+$!,+s "es,+n#en &e+" 2ue +$"+s % %lun+s &e#!*%&en$+s. P+" ee&,l+5 l+s en+$!,+s A / B ,ue#en "es,+n#e" &e+" %l $"%$%&!en$+ *+n !n$e"1e"'n 2ue l+s en+$!,+s C / D. L+s !nes$!%#+"es es$)n +se"%n#+ %#e&)s 2ue l%s &u$%*!+nes ="!*%s5 + el "!es+ #e #%;+s (e,)$!*+s5 ,ue#en #e,en#e" #el en+$!,+ 2ue $en% *%#% ,e"s+n%.
Bo(sa $e '+#a$o L%s !+,s!%s se "e%l!6%n ,%"% e%lu%" l% "%e#%# #e l% !n1l%&%*!'n / el "%#+ #e *!*%$"!6%*!'n #el (=%#+. L% !+,s!% es el !n#!*%#+" &)s 1!%le #el #%;+ (e,)$!*+ / se u$!l!6% ,%"% $+&%" #e*!s!+nes %*e"*% #el $"%$%&!en$+. Mu*(+s &0#!*+s n+ "e*+&!en#%n "e%l!6%" !+,s!%s % l+s ,+"$%#+"es #el VHB 2ue &ues$"en "esul$%#+s n+"&%les en l+s %n)l!s!s !+2u=&!*+s. En el ,"+*e#!&!en$+ &)s *+&n5 se %nes$es!% l% ,!el / se !nse"$% *+n "%,!#e6 un% %u% l%"% en el
(=%#+ ,%"% e-$"%e" un% &ues$"% #e $e!#+ / e-%&!n%"l% %+ el &!*"+s*+,!+. L%s !+,s!%s (e,)$!*%s "%"% e6 ,"++*%n *+&,l!*%*!+nes. S! %un %s= le ,"e+*u,%5 ,ue#e ,e#!"le %l &0#!*+ 2ue le %#&!n!s$"e un $"%n2u!l!6%n$e su%e %n$es #e s+&e$e"se % l% !+,s!% / un %n%l0s!*+ #es,u0s #el ,"+*e#!&!en$+.
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PAUTAS DE PREVENCIÓN DEL VHB
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L+s e0s #e l%s &%#"es !n1e*$%#%s ,+" el VHB #een "e*!!" l% %*un% *+n$"% l% (e,%$!$!s B e !n&un+l+ul!n% %n$!VHB ?HBIG@ el &!s&+ #=% #el n%*!&!en$+.
•
Rel%*!+nes se-u%les *+n ,"+$e**!'n5 us%n#+ *+n#+nes / %""e"%s #e l)$e-.
•
N+ "eu$!l!6%" e"!n%s
•
L+s ,"+1es!+n%les #el $%$u%e5 l% ,e"1+"%*!'n *+",+"%l / l% %*u,un$u"% #een u$!l!6%" %u%s nue%s *+n *%#% *l!en$e.
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L+s ,"+1es!+n%les #e l% &%n!*u"% / l%s %"e"=%s #een #es!n1e*$%" l+s u$ens!l!+s en$"e un+ / +$"+ *l!en$e + !en e&,le%" %"$=*ul+s #ese*(%les #e un s+l+ us+.
•
N+ *+&,%"$% %"$=*ul+s ,e"s+n%les *+&+ *u*(!ll%s #e %1e!$%"5 *e,!ll+s #e #!en$es5 *+"$%;%s + %"e$es. P"%*$!2ue &e#!#%s #e ,"e*%u*!'n un!e"s%les en l+s *en$"+s #e s%lu#5 !n*lu/en#+ el us+ #e u%n$es #e l)$e-.
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Dese*(%" %#e*u%#%&en$e l%s %u%s5 en#%s / su&!n!s$"+s &ens$"u%les us%#+s l!&,!e / #es!n1e*$e l+s l=2u!#+s *+",+"%les 2ue se #e""%&en.
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Cu"!" $+#+s l+s *+"$es5 (e"!#%s / e"u,*!+nes.
7
LA VACUNA CONTRA EL VHB LA PROFILA&IS POST' E&POSICIÓN L% (e,%$!$!s B ,ue#e ,"een!"se *+n un% %*un%. En l+s %#ul$+s5 l% %*un% se %#&!n!s$"% *+n un% se"!e #e $"es !n/e**!+nes en un ,l%6+ #e se!s &eses ?l% seun#% !n/e**!'n un &es #es,u0s #e l% ,"!&e"%5 / l% $e"*e"% !n/e**!'n *!n*+ &eses &)s $%"#e@. A*$u%l&en$e se (% %,"+%#+ un% %*un% en #+s #+s!s ,%"% %#+les*en$es #e en$"e / 3 %;+s. %&!0n e-!s$e un% %*un% &!-$% *+n$"% el VHA / el VHB ?!n"!-@. L% Aen*!% Es$%#+un!#ense
#el
Me#!*%&en$+
?FDA@
%u$+"!6'
"e*!en$e&en$e
l%
%#&!n!s$"%*!'n %*ele"%#% #e !n"!- ?9 !n/e**!+nes en 98 #=%s5 seu!#%s #e +$"% #+s!s #e "e1ue"6+ %l *%+ #e un %;+@. L% %*un% #e l% (e,%$!$!s B $%&!0n es %*+nse%le ,%"% $"%%%#+"es #e l% s%lu#5 %#ul$+s se-u%l&en$e %*$!+s5 usu%"!+s #e #"+%s !n$"%en+s%s5 ,e"s+n%s 2ue $en%n *+n$%*$+ #+&0s$!*+ *+n ,+"$%#+"es #el VHB5 sue$+s !n1e*$%#+s *+n el VHC / %#+les*en$es 2ue n+ (%/%n s!#+ %*un%#+s en l% !n1%n*!%. S! un% ,e"s+n% (% es$%#+ e-,ues$% "e*!en$e&en$e %l VHB5 l% ,"+1!l%-!s ,+s$ e-,+s!*!'n &e#!%n$e l% %*un% %n$!VHB &)s %n$!*ue",+s !n/e*$%#+s ?!n&un+l+ul!n% *+n$"% el VHB5 + HBIG@ ,ue#e ,"een!" el #es%""+ll+ #e l% (e,%$!$!s B5 + %l &en+s &!$!%" l% #u"%*!'n / "%e#%# #e l+s s=n$+&%s. Es$e ,"+*e#!&!en$+ #ee "e%l!6%"se en un ,l%6+ #e : (+"%s $"%s l% e-,+s!*!'n %l !"us. L% HBIG &)s l% %*un% %n$!VHB $%&!0n ,ue#en ,"een!" l% (e,%$!$!s B en l+s l%*$%n$es 2ue se%n (!+s #e &%#"es VHB ,+s!$!%s.
:8
TRATAMIENTO DEL VHB En l% %*$u%l!#%#5 e-!s$en #+s $!,+s #e $"%$%&!en$+ *+n$"% l% (e,%$!$!s B el !n$e"1e"'n / l+s %n$!!"%les. L%s !nes$!%*!+nes su!e"en 2ue %ln #=% ,+#"=%n u$!l!6%"se $e"%,!%s *+&!n%#%s + se*uen*!%les ,%"% $"%$%" *+n e1!*%*!% l% (e,%$!$!s B. El $"%$%&!en$+ $!ene &)s ,"+%!l!#%#es #e "esul$%" ene1!*!+s+ *u%n#+ l%s en6!&%s (e,)$!*%s es$)n ele%#%s / l% *%"% !"%l es %%. N+ suele "e*+&en#%"se $"%$%" % l+s ,%*!en$es *+n un ADN #el VHB &u/ %+ / l%s en6!&%s #en$"+ #e l+s &)"enes n+"&%les5 /% 2ue es+ #e&ues$"% 2ue n+ se es$)n ,"+#u*!en#+ #%;+s (e,)$!*+s. L% &%/+" ,%"$e #e l+s *%s+s #e !n1e**!'n *"'n!*% ,+" el VHB n+ ,"e*!s%n $"%$%&!en$+5 ,e"+ s= se %*+nse% *+&,"+%" *+n "eul%"!#%# l+s n!eles #e en6!&%s / "e!s%" el es$%#+ ene"%l #e s%lu# *%#% se!s &eses *+&+ &=n!&+. TRATAMIENTOS APROBADOS
La FDA a(ro0* e& nter,er*n (e#&a$o 2(e#nter,er*n a&,a34a5 Pe#as"s6 5 un ,"+#u*$+ #e !nen!e"=% en0$!*% el%+"%#+ % ,%"$!" #e ,"+$e=n%s n%$u"%les #el s!s$e&% !n&un!$%"!+. Su %*$!!#%# en el +"%n!s&+ es el!&!n%" %l !"us #e 1+"&% 2ue el VHB $en% &en+s *%,%*!#%# ,%"% es*%,%"se #e sus e1e*$+s. Es$e !n$e"1e"'n5 ,"+#u*!#+ ,+" R+*(e5 #ee !n/e*$%"se un% e6 % l% se&%n% #u"%n$e se&%n%s. El !n$e"1e"'n ,e!l%#+ (% "ee&,l%6%#+ %l !n$e"1e"'n *+nen*!+n%l ?!n$e"1e"+n%l1% :@5 2ue e"% &en+s e1!*%6 / e-!=% $"es !n/e**!+nes ,+" se&%n%. D%#+ 2ue el !n$e"1e"'n es$!&ul% l% "es,ues$% !n&un!$%"!% #el *ue",+5 es ,+s!le 2ue e&,e+"e $e&,+"%l&en$e l% !n1l%&%*!'n #el (=%#+ ?un% "e*%=#%@. C%s! $+#+s l+s e-,e"$+s "e*+&!en#%n n+ $"%$%" *+n !n$e"1e"'n % l+s ,%*!en$es *+n
*!""+s!s #es*+&,ens%#%. El !n$e"1e"'n ,e!l%#+ $+#%=% n+ (% s!#+ %u$+"!6%#+ ,%"% $"%$%" % n!;+s *+n (e,%$!$!s B.
:
Ant-ra&es La &a!-u$na 2E(-r3)BV6 es un %n$!!"%l 2ue !n(!e l% &ul$!,l!*%*!'n #el VHB. Se $+&% *%#% #=% #u"%n$e < se&%n%s *+&+ &=n!&+5 / l+"% un n!el !n#e$e*$%le #el ADN #el VHB / un% ALA n+"&%l en el 84 #e l+s *%s+s. P+" #es"%*!%5 el $"%$%&!en$+ *+n l%&!u#!n% ,"++*% &u$%*!+nes #e VHB "es!s$en$es %l 1)"&%*+5 % un "!$&+ #el 8:4 %l *%+ #e un %;+5 #el 9<4 en #+s %;+s / #el >8>34 $"%s *u%$"+ %;+s #e $e"%,!%. Un% e6 2ue un% ,e"s+n% #es%""+ll% "es!s$en*!% ="!*% % l% l%&!u#!n%5 $%&!0n ,ue#e *"e%" "es!s$en*!% % +$"+s %n$!!"%les ,%"e*!#+s. Es$e es el n!*+ %n$!!"%l %u$+"!6%#+ ,+" l% FDA ,%"% $"%$%" % l+s n!;+s !n1e*$%#+s.
A$e,o-r 2)e(sera6 ,"+#u*e n+$%les #es*ens+s #e l% *%"% !"%l #el VHB ?#el :4 en l+s ,%*!en$es HeA ,+s!$!+s / #el 34 en l+s HBeAne%$!+s@5 "e#u**!+nes en l% *+n*en$"%*!'n #e ALA / &en+s #%;+s (e,)$!*+s s! n+ se (% $+&%#+ ,"e!%&en$e n!nn +$"+ %n$!!"%l. P%"e*e 1un*!+n%" !en *+n$"% el VHB n%$u"%l ?n+ &u$%#+@ / *+n$"% el "es!s$en$e % l% l%&!un%5 s!e&,"e 2ue se %;%#% %#e1+!" %l $"%$%&!en$+ *+n l%&!u#!n%. En %lun%s ,e"s+n%s +*%s!+n% $+-!*!#%# "en%l.
Ente%a-r 2Bara%&u$e6 es +$"+ %n$!!"%l 2ue 1un*!+n% &e+" s! l+s ,%*!en$es nun*% (%n s!#+ $"%$%#+s *+n +$"+ %n$!!"%l ?es #e*!"5 s! n+ $!enen e-,e"!en*!% $e"%,0u$!*% ,"e!%@. En l+s ,%*!en$es HeA ,+s!$!+s5 el en$e*%!" "e#u*e l% *%"% !"%l en el >4 #e l+s ,%*!en$es5
Te&0-u$na 2T".e7a6 uele !n#e$e*$%le el ADN #el VHB en el >84 #e l+s ,%*!en$es
HeA
,+s!$!+s
s!n
e-,e"!en*!%
$e"%,0u$!*%5
l+"%
un%
se"+*+ne"s!'n %l HeA #el :>4 / n+"&%l!6% l%s en6!&%s (e,)$!*%s en el 4 #e l+s ,%*!en$es.
Teno,o-r 2Vrea$65 el l$!&+ %n$!!"%l %,"+%#+ ,+" l% FDA. Lle% %;+s u$!l!6)n#+se *+n 0-!$+ *+n$"% el VIH.
L% #+s!s "e*+&en#%#% en *%s+ #e
(e,%$!$!s B *"'n!*% es un *+&,"!&!#+ #e 988 & %l #=%. ::
Tera(as A&ternat-as A#e&)s #e l+s 1)"&%*+s *+nen*!+n%les5 %lun%s ,e"s+n%s u$!l!6%n $e"%,!%s %l$e"n%$!%s / *+&,le&en$%"!%s ,%"% l% (e,%$!$!s B. L%s ,l%n$%s &e#!*!n%les 2ue se e&,le%n *+n &)s 1"e*uen*!% s+n el *%"#+ &%"!%n+ ?s!l!&%"!n%@5 el "e%l!6 ?l!*!""!*!n%@ / l% *(%n*%,!e#"% ?,(/ll%n$(us@. L+s "e&e#!+s (e"%les #een $"%$%"se *+&+ s! 1ue"%n 1)"&%*+s5 /% 2ue ,ue#en +*%s!+n%" e1e*$+s se*un#%"!+s e !n$e"%*$u%" *+n +$"%s ,l%n$%s &e#!*!n%les / *+n l+s &e#!*%&en$+s *+nen*!+n%les. Mu*(%s ,l%n$%s &e#!*!n%les s+n $'-!*%s ,%"% el (=%#+5 en$"e ell%s el *(%,%""%l5 el *%&e#"!+5 l% %% %% / l%s ,l%n$%s 2ue *+n$!enen %l*%l+!#es ,!""+l!6!#=n!*+s.
L+s *+&,le&en$+s nu$"!*!+n%les 2ue se su!e"en ,%"% $"%$%" l% (e,%$!$!s B s+n l% !$%&!n% C5 l% !$%&!n% E5 el lu$%$!'n5 l% N%*e$!l*!s$e=n%5 l% S %#en+s!l&e$!+n!n% ?SAMe@ / l+s 1%*$+"es $=&!*+s.
:9
HEPATOCARCINOMA (C)NCER DE HÍGADO* EN LOS PORTADORES CRÓNICOS DEL VHB
Es !en *+n+*!#+ 2ue l+s !n#!!#u+s %#ul$+s 2ue se *+n!e"$en en ,+"$%#+"es *"'n!*+s #el VHB $!enen "!es+ 38 e*es &%/+" #e #es%""+ll%" un% *!""+s!s (e,)$!*% + un (e,%$+*%"*!n+&% 2ue l+s sue$+s s%n+s. Se es$!&% 2ue en el &un#+ (%/ un+s 988938 &!ll+nes #e ,+"$%#+"es #el VHB / 2ue el <84 #e l+s $u&+"es ,"!&!$!+s (e,)$!*+s es$)n "el%*!+n%#+s *+n el VHB. En As!%5 el <84 #e l+s (e,%$+*%"*!n+&%s s+n se*un#%"!+s % !n1e**!'n ,+" el VHB. Se *+ns!#e"%5 ,+" $%n$+5 % es$e !"us5 #es,u0s #el $%%*+5 el *%"*!n'en+ (u&%n+ #e &%/+" !&,+"$%n*!% / $"%s*en#en*!%. De %2u= el en+"&e !n$e"0s 2ue su,+ne ,"+$ee" % l% ,+l%*!'n *+n$"% l% !n1e**!'n ,+" el VHB.
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RECOMENDACIONES PARA PACIENTES CON HEPATITIS B
C(e2ue+s *+n "eul%"!#%#5 2ue !n*lu/%n ,"ue%s !+2u=&!*%s #e l% 1un*!'n (e,)$!*%. E!$e + l!&!$e el *+nsu&+ #e %l*+(+l / #e #"+%s "e*"e%$!%s.
N+ su,e"%" l%s #+s!s "e*+&en#%#%s #e l+s &e#!*%&en$+s. en% *u!#%#+ % l% (+"% #e *+&!n%" &l$!,les 1)"&%*+s5 ,l%n$%s &e#!*!n%les5 + 1)"&%*+s / (!e"%s *+nun$%&en$e.
D!e$% s%lu#%le / e2u!l!"%#%.
P"%*$!2ue ee"*!*!+ &+#e"%#+ *+n "eul%"!#%#.
In1+"&e % $+#+s sus &0#!*+s s+"e $+#+s l+s 1)"&%*+s5 ,l%n$%s &e#!*!n%les5 su,le&en$+s / $e"%,!%s %l$e"n%$!%s 2ue es$0 $+&%n#+.
In1+"&%" $+#+s sus &0#!*+s / % l+s #e&)s ,"+1es!+n%les #e l% s%lu# s+"e su (e,%$!$!s B5 en es,e*!%l s! ne*es!$% $"%$%&!en$+ *+n$"% el *)n*e" + $e"%,!% #e es$e"+!#es.
Nutr%*n D%#+ 2ue el (=%#+ ,"+*es% $+#+ l+ 2ue *+&e&+s / ee&+s5 es esen*!%l seu!" un% #!e$% s%lu#%le / e2u!l!"%#%. Un% #!e$% s%lu#%le #ee seu!" l%s ,%u$%s ene"%les !n#!*%#%s en l% nue% P!")&!#e #e Al!&en$%*!'n D!*(% #!e$% es %% en "%s%s / en s%l5 "!*% en *%"+(!#"%$+s *+&,le+s / *+n$!ene l%s su1!*!en$es ,"+$e=n%s. H+/ en #=%5 l%s "es$"!**!+nes #!e$0$!*%s n+ ue%n un ,%,el !&,+"$%n$e en el %+"#%e #e l% (e,%$!$!s B *"'n!*%. L+s %l!&en$+s ,"+*es%#+s suelen *+n$ene" %#!$!+s 2u=&!*+s5 ,+" l+ 2ue es %*+nse%le "e#u*!" el *+nsu&+ #e *+&!#%s enl%$%#%s5 *+nel%#%s / en *+nse"%. C+nsu&% 1"u$%s / e"#u"%s #e *ul$!+ !+l'!*+ ,%"% e!$%" ,es$!*!#%s / 1e"$!l!6%n$es. Le% l%s e$!2ue$%s ,%"% 1%&!l!%"!6%"se *+n l+s !n"e#!en$es. Mu*(+s
&0#!*+s %*+nse%n % l%s ,e"s+n%s *+n (e,%$!$!s 2ue e!$en l+s &%"!s*+s *"u#+s + ,+*+ *+*!#+s5 *+&+ l%s +s$"%s / %l&e%s5 /% 2ue ,ue#en *+n$ene" +"%n!s&+s !n1e**!+s+s + $+-!n%s. Un% #!e$% !en e2u!l!"%#% #ee"=% *+n$ene" $+#%s l%s !$%&!n%s / l+s &!ne"%les esen*!%les e!$e $+&%" #+s!s ele%#%s #e su,le&en$+s5 es,e*!%l&en$e s! *+n$!enen !$%&!n% A5 !$%&!n% D + (!e""+5 ,ues 0s$+s s+n n+*!+s ,%"% el (=%#+. :3
A&%o'o&5 F1r!a%os5 Dro#as " To8nas Las (ersonas %on 'e(atts B5 es,e*!%l&en$e s! $!enen *!""+s!s5 #een e!$%" el *+nsu&+ e-*es!+ #e %l*+(+l. Certos ,1r!a%os *+n + s!n "e*e$%5 e !n*lus+ #"+%s "e*"e%$!%s / "e&e#!+s (e"%les ,ue#en se" n+*!+s ,%"% el (=%#+ ?(e,%$+$'-!*+s@5 en es,e*!%l *u%n#+ se $+&%n en #+s!s ele%#%s + se *+&!n%n en$"e s=. L%s ,e"s+n%s *+n el VHB #een !n1+"&%" % sus &0#!*+s s+"e $+#+s l+s 1)"&%*+s5 ,l%n$%s &e#!*!n%les5 su,le&en$+s / $e"%,!%s %l$e"n%$!%s 2ue es$0n $+&%n#+. E!$e + l!&!$e el *+nsu&+ #e #"+%s "e*"e%$!%s. N+ s+"e,%se l%s #+s!s "e*+&en#%#%s #e l+s &e#!*%&en$+s. D%#+ 2ue el (=%#+ #ee ,"+*es%" l%s $+-!n%s5 e!$e l% e-,+s!*!'n % l=2u!#+s / (u&+s $'-!*+s $%les *+&+ #!s+len$es5 $%""+s #e ,!n$u"%5 ,es$!*!#%s / %e"+s+les. S! es ne*es%"!+ u$!l!6%" es$+s ,"+#u*$+s 2u=&!*+s5 $"%%e en un% 6+n% !en en$!l%#%5 *"%se l% ,!el / ,'n%se u%n$es / un% &)s*%"% 1%*!%l ,"+$e*$+"%.
E9er%%o/ L% ,")*$!*% #e ee"*!*!+ %e"'!*+ *+n "eul%"!#%# ,ue#e &e+"%" l% 1+"&% 1=s!*% / %/u#%" % "e#u*!" el es$"0s5 l% #e,"es!'n / l% 1%$!%. L% &%/+"=% #e l%s ,e"s+n%s *+n (e,%$!$!s *"'n!*% ,ue#en ,"%*$!*%" ee"*!*!+ &+#e"%#+ #e 1+"&% seu"%. E!$e el ee"*!*!+ s! se s!en$e &u/ en1e"&+%. L+s ,%*!en$es *+n *!""+s!s %%n6%#% #een $ene" *u!#%#+ % l% (+"% #e le%n$%" ,es+s. +#%s l%s ,e"s+n%s *+n (e,%$!$!s *"'n!*% #een *+nsul$%" *+n su &0#!*+ %n$es #e !n!*!%" un ,"+"%&% #e ee"*!*!+.
Contro& $e& estrs/ El *+n$"+l #el es$"0s es un 1%*$+" esen*!%l ,%"% %1"+n$%" *+n 0-!$+ l% en1e"&e#%# ,+" el VHC. El ee"*!*!+5 l% &e#!$%*!'n / un% ,l%n!1!*%*!'n %#e*u%#% #el $!e&,+ ,ue#en %/u#%" % "e#u*!" el es$"0s. "%$e #e &%n$ene" un%
,e"s,e*$!% "e%l!s$% s+"e su s%lu#5 %s= *+&+ un% %*$!$u# ,+s!$!% %n$e su s!$u%*!'n.
Contro& $e &a ,at#a/ L% 1%$!% / l% 1%l$% #e ene"=% s+n ,"+le&%s *+&unes en l%s ,e"s+n%s %1e*$%#%s ,+" el VHC. Res,e$e sus ,"+,!%s l!&!$%*!+nes / $"%$e #e n+ 1+"6%" su *%,%*!#%#. Al$e"ne l%s %*$!!#%#es 1%$!+s%s *+n +$"%s &)s "el%%n$es. :>
Gru(os $e A(o"o " Ps%otera(a Mu*(%s ,e"s+n%s *+n (e,%$!$!s B se s!en$en %!sl%#%s / en*uen$"%n #!1=*!l en1"en$%"se % l+s e1e*$+s #e !!" *+n un% en1e"&e#%# *"'n!*%. L+s "u,+s #e %,+/+ ,ue#en +1"e*e" un es,%*!+ seu"+ ,%"% #!s*u$!" l+s %s,e*$+s e&+*!+n%les "el%*!+n%#+s *+n l% (e,%$!$!s *"'n!*%. A#e&)s5 l% !n1+"&%*!'n 2ue se *+&,%"$e *+n ,e"s+n%s en s!$u%*!+nes s!&!l%"es ,ue#e %/u#%" % $+&%" #e*!s!+nes5 &e+"%" l+s s=n$+&%s / #es%""+ll%" es$"%$e!%s ,%"% s+"elle%" l+s ,"+le&%s. Alun%s ,e"s+n%s $%&!0n *+ns!#e"%n ene1!*!+s% l% $e"%,!% *+n un% ,s!*'l++% + un% $"%%%#+"% s+*!%l.
:
CUIDADOS DE ENFERMERÍA . Se #ee e-,l!*%" % l+s 1%&!l!%"es / %l ,"+,!+ ,%*!en$e sen su e#%# l% !&,+"$%n*!% #el "e,+s+ 1=s!*+ / e"!1!*%" *+ns$%n$e&en$e su *u&,l!&!en$+. :. Res,e*$+ % l% #!e$% / %*l%"%n#+ #e *!e"$+ &+#+ e""+"es 2ue %n se *+&e$en en l% ,+l%*!'n5 0s$% #ee se" n+"&+"%s%5 n+"&+,"+$e=*% / n+"&+*%l'"!*%. 9. En *%s+ #e $"%$%"se #e !"us 2ue se $"%s&!$en ,+" =% 1e*%l+"%l ?!"us A / E @ se "e*+&!en#%
M%n$ene" l+s +e$!+s #e us+ ,e"s+n%l %!sl%#+s #el "es$+ #e l%s ,e"s+n%s s%n%s.
Re%l!6%" l% #es!n1e**!'n *+n*u""en$e *+n %u% / %'n / $e"&!n%" *+n Re%l!6%" %lun% sus$%n*!% 2u=&!*% #e l+s se"!*!+s s%n!$%"!+s.
H%*e" un l%%#+ #e &%n+s &!nu*!+s+ #es,u0s #e &%n!,ul%" (e*es / +"!n% #e l+s ,%*!en$e.
E-,l!*%" %l ,e"s+n%l &0#!*+ / ,%"%&0#!*+ l%s &e#!#%s 2ue $!en#%n % #!s&!nu!" l%s !n1e**!+nes n+s+*+&!%les.
Al e"es%" l+s ,%*!en$es5 (%*e" l%+"es #e e#u*%*!'n ,%"% l% s%lu# / ,"+&+*!'n #e l% s%lu# en el (+%".
. +&%n#+ en *uen$% 2ue l%s (e,%$!$!s 1ue"%n ,+" !"us B / C l%s &e#!#%s %n en*%&!n%#%s %
+&%" ,"e*%u*!+nes *+n l% s%n"e / l%s se*"e*!+nes +")n!*%s ,"+$e!0n#+n+s l%s &%n+s *+n el us+ #e u%n$es % l% (+"% #e l% &%n!,ul%*!'n.
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El us+ #e &%$e"!%l #ese*(%le #e $!,+ ,%"en$e"%l / l% se,%"%*!'n %,%"$e #el &%$e"!%l #e l+s ,%*!en$es 2ue n+ ,%#e6*%n l% en1e"&e#%# *u%n#+ n+ se #!s,+n% #e &%$e"!%l #ese*(%le.
S+&e$e" el &%$e"!%l % s+lu*!'n #e (!,+*l+"!$+ %n$es #e en!%"l+ %l De,%"$%&en$+ #e Es$e"!l!6%*!'n
E!$%" l+s %**!#en$es *+n %u%s *+n$%&!n%#%s *+n es$e !"us
%2uell%s ,e"s+n%s ,e"s+n%s 2ue $en%n $en%n A#&!n!s$"%" l% %*un% ,%"% el !"us B %% %2uell%s "!es+ #e *+n$"%e" l% en1e"&e#%#.
R+$ul%" l%s &ues$"%s s%nu=ne%s #e ,%*!en$es *+n (e,%$!$!s %n$es #e en!%"l%s.
:7
CONCLUSIONES Aun2ue l% (e,%$!$!s B ,ue#e %*%""e%" "%es *+nse*uen*!%s5 l% &%/+"=% #e l+s %1e*$%#+s ,+" el VHB n+ lle%n % #es%""+ll%" l% en1e"&e#%# *"'n!*% / lle%n un% !#% n+"&%l. L+s ,+"$%#+"es !n%*$!+s ,"esen$%n e!#en*!% #e !n1e**!'n ,+" el VHB ,e"+ n+ $!enen s=n$+&%s n! #!s1un*!'n (e,)$!*%. Un% &!n+"=% #e 2u!enes es$)n *"'n!*%&en$e !n1e*$%#+s *+n el VHB e-,e"!&en$% un% ,"+"es!'n #e l% en1e"&e#%# 2ue ,ue#e *%us%" "%es #%;+s en el (=%#+5 $%les *+&+ *!""+s!s5 *)n*e" #e (=%#+ e !nsu1!*!en*!% (e,)$!*%. En l% %*$u%l!#%# se s!uen #es%""+ll%n#+ nue+s &e#!*%&en$+s *+n$"% el VHB. L% %*un% un!e"s%l *+n$"% el VHB su,+ne l% &%/+" es,e"%n6% ,%"% *+n$"+l%" l% ,"+,%%*!'n #e l% (e,%$!$!s B. A,%"$e #el $"%$%&!en$+ &0#!*+5 s! $!ene el VHB ,ue#e $+&%" %"!%s &e#!#%s5 $%les *+&+ +$ene" %$en*!'n &0#!*% *+n "eul%"!#%#5 e!$%" el %l*+(+l / l%s #"+%s5 seu!" un% #!e$% s%lu#%le5 ,"%*$!*%" ee"*!*!+ *+n &+#e"%*!'n5 *+n$"+l%" el es$"0s / l% 1%$!%5 / un!"se % un "u,+ #e %,+/+ $+#+ es$+ le %/u#%") % &%n$ene" s%n+ el (=%#+ / % &e+"%" su *%l!#%# #e !#% en ene"%l.
98
BIBLIOGRAFÍA . B+"$+l+$$! F5 J%"% P5 B%"e"% C5 G"e+"!+ CV5 Venen$e A5 Z%n*%n L5 H!e""+ L5 C"!ell%"+ C5 M!el!Ve"%n! G5 I+"!+ R5 P%*e M5 C+n P5 G%$$% A. L+n$e"& e11e*$ +1 %l,(% !n$e"1e"+n !n *(!l#"en !$( *("+n!* (e,%$!$!s B. Gu$ :888 >3<. :. B+"$+l+$$! F5 J%"% P5 C"!ell%n+ C e$ %l. Ou$*+&e +1 *("+n!* (e,%$!$!s B !n *%u*%s!%n *(!l#"en #u"!n % :8 /e%" +se"%$!+n ,e"!+#. J He,%$+l 77< :7 <78. 9. J%"% P5 B+"$$+l+$$! F. Al,(% !n$e"1e"+n $"e%$&en$ +1 *("+n!* (e,%$!$!s B !n *(!l#(++# % *+nsensus %#!*e %se# +n e-,e"!en*e !n Eu"+,e%n *(!l#"en. J Pe#!%$" G%s$"+en$e"+l Nu$" 777 :7 >98. . L%! CL5 C(!en RN5 Leun N e$ %l. A +ne/e%" $"!%l +1 l%&!u#!ne 1+" *("+n!* (e,%$!$!s B. As!% He,%$!$!s L%&!u#!ne S$u#/ G"+u,. N Enl J Me# 77< 997>><. 3. L!% YF5 Leun N5 C(%n 5 Gu%n R5 Lee CM5 N Y5 u PC e$ %l. E11e*$s +1 e-$en#e# l%&!u#!ne $(e"%,/ !n As!%n ,%$!en$s !$( *("+n!* (e,%$!$!s B. As!% He,%$!$!s L%&!u#!ne S$u#/ G"+u,. G%s$"+en$e"+l+/ :888 7: <8.
