Hepatitis B: What nurses need to know

Submitted by ADonahue on
Graphic of human abdominal skeletal system with liver highlighted

What is hepatitis B (HBV)?

Hepatitis B is a liver infection caused by the hepatitis B virus (HBV). Most people with HBV have an acute infection characterized by short-term symptoms lasting less than six months. Chronic HBV occurs when an infected person’s immune system cannot clear the virus from the body and symptoms last longer than six months. Chronic HBV is typically a lifelong infection and raises the risk of cirrhosis (scarring of the liver), liver cancer, liver failure, and even death. The World Health Organization estimates that 254 million people were living with chronic HBV in 2022, with 1.2 million new infections and 1.1 million deaths each year.

The risk of chronic HBV is greater in infants and children. While approximately 95 percent of adults with acute HBV will completely recover, 90 percent of infected infants and 30 percent of infected children aged one to five will become chronically infected with HBV. While there is no cure, HBV is a vaccine-preventable disease. Vaccines remain the safest and most effective way to prevent infection.

What are the symptoms of hepatitis B (HBV)?

Not all people with HBV have symptoms. HBV can range from asymptomatic or mild disease to rapid liver failure. Common symptoms of an acute infection include: 

  • Dark urine or clay-colored stools
  • Feeling tired
  • Fever
  • Joint pain
  • Loss of appetite
  • Nausea, stomach pain, or vomiting
  • Yellow skin or eyes (jaundice)

The incubation period from exposure to symptom onset is one to six months. Symptoms most commonly occur around three months after exposure and can last several weeks to six months. However, many people with HBV are asymptomatic. About half of all older children, adolescents, and adults will not experience symptoms of acute HBV. Additionally, most infants and children younger than five have no symptoms.

Symptoms of chronic HBV can take decades to develop and may be similar to those of an acute infection. Many people with chronic HBV don’t have symptoms or know they are infected. Chronic HBV can lead to serious complications, like cirrhosis, liver cancer, and liver failure.

How is hepatitis B (HBV) transmitted?

HBV is transmitted when infected bodily fluids like blood or semen enter the body of an uninfected individual. Common ways that HBV is transmitted include:

  • Childbirth – Pregnant people infected with HBV can pass the virus to their babies during childbirth, which is the most common cause of transmission. Infant vaccination can prevent infection of the baby during birth.
  • Sexual contact – HBV can spread during unprotected sex with an infected individual. The virus can pass via an infected person's blood, saliva, semen, or vaginal fluids.
  • Sharing of needles – Used needles and syringes contaminated with infected blood can transmit HBV. Sharing items like razors or toothbrushes can also transmit HBV, though this risk of transmission is lower than via needles.
  • Accidental needlestick – Exposure to infected blood from accidental needlestick or other sharp instrument injuries can spread HBV. This has significant implications for health care workers and other professions that often use needles. Sharp object injuries account for 75 percent of occupational exposures in health care settings, while the remaining 25 percent of exposures occur via the eyes, mouth, or skin.

Who needs the hepatitis B (HBV) vaccine?

Getting vaccinated is the best way to prevent HBV. The HBV vaccine is a series of two to four shots depending on the vaccine brand and is recommended for:

  • All infants – The first dose of the HBV vaccine is recommended at birth and another dose to complete the series is recommended around six to 18 months of age. The birth dose of the HBV vaccine is an important part of preventing severe illness, given that 90 percent of infected infants will progress to chronic illness.
  • Children and adults who have not been vaccinated – HBV vaccination is recommended for all children and adolescents younger than 19, as well as adults 19 to 59, who have not received the vaccine.
  • Adults 60 and older with risk factors for HBV – HBV vaccination is recommended for adults 60 years or older at increased risk of exposure to HBV who were not vaccinated previously. Adults 60 years or older who are not at increased risk and were not vaccinated may also be vaccinated.

Why is the hepatitis B (HBV) vaccine recommended for infants at birth?

HBV can survive outside the body for at least a week and is very infectious (50 to 100 times more infectious than HIV). That means dried bodily fluids of an infected individual run the risk of transmitting HBV. This can be on the playground, at school, or any surface that a child may encounter. Just because an individual is not participating in risky behavior, like using drugs or having unprotected sex, does not mean that they or their child cannot catch the disease. In fact, between 30 to 40 percent of HBV patients had no identifiable risk factors at all.

Since 1991, the CDC has recommended HBV vaccination for all infants with the first dose being administered at birth before hospital discharge. From 1990 to 2019, incidence of acute HBV among children, adolescents, and young adults less than 19 years of age decreased by 99 percent in the U.S. due to universal infant vaccination. Birth dose HBV vaccination is an essential public health strategy that has prevented lifelong infections in thousands of American children.

What protections do nurses and other health care workers need to prevent exposure to hepatitis B (HBV)?

Health care employers are responsible for providing a safe work and patient care environment. OSHA’s Bloodborne Pathogens Standard requires employers to implement exposure control plans to prevent exposure to HBV and other bloodborne pathogens in the workplace. This includes the use of universal/standard precautions, safe sharp devices, personal protective equipment (PPE), and other measures. 

Multilayered infection prevention measures based on scientific evidence and the precautionary principle should be implemented in all health care facilities, including:

  • Access to vaccines – Employers should provide access to vaccines at a reasonable time and place and at no cost for any nurse or other health care worker who is not already vaccinated.
  • Standard precautions – HBV requires standard precautions, not just bloodborne precautions, as HBV is also transmitted through semen, vaginal fluids, saliva, and amniotic fluid.
  • PPE – Use a face shield or goggles, mask, gown, and gloves when caring for infected patients or handling contaminated materials. Employers must provide PPE at no cost to employees.
  • Hand hygiene – Wash hands frequently using soap and warm water.
  • Proper use and disposal of sharps – Implementation of strategies that encourage the proper use and disposal of sharps are important to prevent percutaneous injuries. Components of such a program include:
    • Avoiding the re-sheathing of needles,
    • Avoiding unnecessary needle and sharp object use,
    • Using puncture-resistant needle and sharp object disposal containers located as close as possible to the point of use,
    • Using safer devices such as needles that sheath or retract after use,
    • Using needleless vascular access systems when practical to obtain blood such as ports, and
    • Avoiding unnecessary placement of intravenous catheters by using needleless or protected needle infusion systems.
  • Sharps injury log – Health care employers should maintain a sharps injury log to record percutaneous injuries from contaminated sharps.
  • Training – Healthcare workers should be trained on effective measures and practices to prevent HBV exposure, especially those reducing sharp object injuries listed above.
  • Environmental cleaning – Clean surfaces contaminated with blood or bodily fluids with a diluted bleach solution (mix 1 part bleach with 9 parts water) or other appropriate disinfectants.
  • Exposure notification and contact tracing – When an HBV case is identified, employers should conduct contact tracing and immediately notify staff who were potentially exposed. Post-exposure medical evaluation and prophylaxis, if any, must be made available at a reasonable time and place and provided at no cost to the employee.