HEPATITIS B AND C viruses (HBV and HCV) pose significant health risks. The World Health Organization (WHO) reports that HBV can resist extreme temperatures and humidity; it can live outside the body for at least 7 days and remain infectious to those who haven’t received an HBV vaccine. In their chronic form, years after initial infection, both viruses can result in severe health issues, including liver cirrhosis, liver cancer, and deaths related to viral hepatitis.

Nurses have an important role to play in helping to eliminate these viruses as well as in recognizing the signs and symptoms to ensure timely care. Through advocacy efforts that include patient education, screening, treatment, and vaccine promotion, nurses can actively contribute to reducing HBV and HCV incidence (new cases) within their healthcare organizations and communities.

About HBV

Most HBV infections acquired in adulthood will recover completely. These adults will clear themselves of the virus and develop protective HBV antibodies; however, about 5% to 10% of adults progress to chronic HBV infection, which can lead to cirrhosis and, in some cases, end-stage liver disease. The Centers for Disease Control and Prevention (CDC) estimates that 90% of infected infants and 30% of children between age 1 and 5 years infected with HBV will remain chronically infected. HBV acquired at infancy (vertical transmission) can occur during pregnancy, delivery, or breastfeeding. Horizontal transmission occurs through spreading from person to person in the same environment or community.

HBV primarily affects the liver and may cause liver diseases such as acute or chronic hepatitis, hepatic failure, liver cirrhosis, and hepatocellular carcinoma (HCC). In 2022, according to the WHO, an estimated 254 million people worldwide (about 3.3% of the global population) were living with chronic HBV infection (primarily adults). Although among the population of adults with acute HBV infection, only 1% to 2% progressed into fulminant hepatic failure, and 5% to 10% of adult cases became chronic.

Annually, according to Hu and colleagues, 0.5% to 1.4% of HBV infections exhibit no symptoms and progress to spontaneous clearance (a negative HBV RNA in at least two consecutive serum sample tests within 1 year after a seroconversion [positive HBV RNA] without treatment) in about 3 months; however, chronic HBV cases remain positive. According to Lee and Ho, acute HBV infection lasts for less than 6 months; chronic HBV lasts 6 months or longer. Factors related to spontaneous clearance, which remain controversial among researchers, include male sex, HBV genotype B, low initial HBV DNA levels, and ages younger than 30 years and older than 60.

HBV phases and symptoms

Because HBV symptoms may take years to develop, many patients remain unaware of the illness. According to the CDC, in the United States, about one-third of those with HBV are unaware of their hepatitis status.

According to Samji, HBV symptoms typically occur progressively depending on the disease phase: viral replication, prodromal, icteric, and convalescence.

Most patients remain asymptomatic in the viral replication phase. In the prodromal (pre-icteric) phase, 5% to 10% of patients may experience nonspecific symptoms, including anorexia, malaise, and fatigue. Some patients may experience fever, arthritis, myalgias, photophobia, arthralgias, or a urticarial rash. Nurse assessment should include close attention to vital signs. Symptomatic patients may show signs of dehydration, as evidenced by tachycardia and temperature changes, which may reflect disease severity. Samji also recommends evaluating patients for skin turgor, dry mucous membranes, and increased capillary refill. (See HBV symptoms.)

Symptoms associated with the icteric phase include jaundice, dark- or tea-colored urine, and clay stools. In this phase, which typically occurs 1 week to 2 months after symptom onset, nurses should assess skin, mucous and tympanic membranes, and sclera for icterus (yellowing); in patients with dark skin, icterus may prove challenging to detect, but is assessed in the sclera, gums, inner lips, and hard palate. As HBV progresses, skin assessment should include evaluation for rash.

In the final phase (convalescence), viral levels decrease and symptoms abate for most patients. Jaundice should decrease and urine and stool color return to normal.

Nursing implications

Individualized nursing care for patients with HBV involves a thorough approach to managing symptoms, preventing transmission, and promoting liver health. Patients with cirrhosis should receive antiviral treatment, as should anyone with concurrent HIV infection and evidence of chronic liver disease. Patients who test positive for HBV surface antigen but have no symptoms will require careful attention to blood and body fluid (including semen, vaginal secretions, urine, cerebrospinal, synovial, pleural, and amniotic) precautions to protect nursing staff and others during patient care.

Infant care. To help prevent the transmission of HBV from the mother to the newborn, nurses should prioritize routine newborn care and early administration of preventive immunization. Within 24 hours of delivery, administer the initial HBV vaccine and a dose of hepatitis B immune globulin (HBIG) to reduce the risk of HBV transmission from mother to newborn. Avoiding HBV transmission at birth can help reduce the risk that the newborn will develop chronic HBV with cirrhosis, progressing to HCC. According to the American Gastroenterological Association, a pregnant person with chronic HBV and an HBV DNA level ≥200,000 IU/mL (≥5.3 log10 IU/mL) should receive prophylaxis tenofovir starting at the 28th week of pregnancy (third semester) and continue until at least birth to reduce the risk of mother-to-child transmission.

Kothari and colleagues note that the contraindications for tenofovir include a history of severe hypersensitivity to tenofovir or significant renal impairment. If HBV DNA is below 200,000 IU/mL, tenofovir isn’t prescribed due to a lower risk of vertical transmission and the sufficiency of standard neonatal prophylaxis.

Management. Patients with GI symptoms (nausea and vomiting) require attention to hydration and nutrition. Providers may order medications (antiemetics, H2 blockers, and proton pump inhibitors). Management may include supportive care and correction of reversible factors, such as discontinuing medications that may contribute to nausea, correcting electrolyte imbalances, and avoiding triggering smells and tastes. In the in-patient setting, invasive procedures, such as GI tube placement, should be avoided unless specifically indicated, such as in patients with bowel obstruction.

Encourage patients with HBV to eat a balanced diet that includes adequate protein (which aids liver repair, as does sufficient rest), carbohydrates, fats, vitamins, and minerals. Consider referral to a nutritionist for recommendations on incorporating high-protein foods.

To prevent nausea, vomiting, and flatus, advise patients to eat small meals and consider some of the strategies that cancer patients use to increase calorie intake and prevent nausea triggers. For example, recommend sweet flavors and chocolate, cold foods rather than warm, and avoiding foods with strong odors. Adding nutritional supplements, such as protein shakes, to foods can help add extra calories.

Medications for pain will promote client comfort. However, avoid acetaminophen to prevent liver toxicity.

Patient education. Advise patients with HBV to limit or avoid consuming alcohol, which can exacerbate liver damage and accelerate the progression of liver disease. Also explain the importance of practicing safe sex to avoid infecting their partners, and to avoid sharing household items, such as razors and utensils.

Refer individuals with a substance use disorder for rehabilitation services and therapies aimed at addressing addiction. Reinforce the need to stop I.V. drug use to promote community health, prevent transmission, and reduce the risk of complications associated with liver disease. For those who continue to use I.V. drugs, advise them against sharing needles.

Learn about new treatment modalities, clinical guidelines, and trials so you can share that information with patients.

Prevention. Focus prevention efforts on targeted interventions based on individual health risk factors. Vaccination remains vital to the national strategic plan aimed at eliminating viral hepatitis. Clinicians should be aware of HBV prevention and ensure that patients at increased risk for infection are offered vaccination unless documentation of prior vaccination or immunity exists. (Learn more about HBV vaccines and immunization schedules at cdc.gov/hepatitis-b/vaccination/index.html)

Infants should receive an HBV vaccination within 24 hours of birth; older children and adolescents not previously vaccinated should receive education about the importance of vaccination. In addition, all individuals at risk of HBV infection—including healthcare workers, men who have sex with men, incarcerated people, patients receiving hemodialysis, those who use I.V. drugs, and those with sexually transmitted infections—should receive HBV vaccination.

Nursing interventions also should include recommended screening and adherence to clinical prevention of HBV guidelines. Current CDC recommendations on HBV screening and testing include at least one viral hepatitis test for all persons over 18 years and for all pregnant individuals regardless of age using a triple panel test, which includes HBV surface antigen antibody to hepatitis B surface antigen and total antibody to hepatitis B core antigen. All infants born to those with HBV infection should receive testing between the ages of 9 and 12 months or, if the vaccine series is delayed, within 1 to 2 months of the end of the series. (See HBV risk.)

Within the clinical setting, proper sterilization of surgical equipment aids in the prevention of HBV infections.

Treatment. Although no treatment for acute HBV infection exists, antiviral medications can help suppress the patient’s viral load and immune modulators can boost their immune status. Patients with chronic HBV receive maintenance treatment, which also includes antiviral medications and immune modulators, to maintain optimal health. (See HBV medications.)

Follow-up and monitoring. In addition to thorough patient assessments and patient education, nurses should build a trusting nurse–patient relationship that allows for the encouragement of patient adherence with the prescribed treatment regimen, and maintain proper communication with the patient care team (especially with case management) to ensure appropriate coordination of care to achieve desired health outcomes. The American Association for the Study of Liver Diseases (AASLD) guidelines recommend follow-up every 6 months. Patients may undergo an ultrasound, fibroscan, or computed tomography scan to detect disease progression.

About HCV

From 2017 to 2020, according to the CDC, an estimated 2.4 to 4 million people in the United States were living with HCV. In 2022, the CDC reported 4,848 new cases of acute HCV and 93,805 new chronic cases. As new infections continue to be identified, the public health challenge involves increasing access to direct-acting antiviral medications.

Asymptomatic HCV can cause harm or the patient can spontaneously clear the infection (a negative HCV RNA in at least two consecutive serum sample tests in 1 year after a seroconversion [positive HCV RNA] without treatment). The contributing factors of spontaneous clearance remain controversial, but many researchers, including Ferrufino, have attributed sexual transmission of HCV as a factor due to a lower dose of the virus received during intercourse compared to a higher dose via I.V. drug use.

Transmission

Although the mode of HCV transmission is the same as HBV, HCV is more fragile. According to the National Institutes of Health, in its early phase, HCV can be completely eliminated. Most people acquire HCV from direct contact with infected blood, which can occur from sharing needles and drug-related paraphernalia, using intranasal drug delivery systems, and getting tattoos or body piercings with nonsterile tools. Inadequate sterilization of medical equipment also can result in transmission of the virus.

Risk factors

Different factors determine the infectivity of HCV. Risk factors include a history of I.V. drug use, HIV infection, hemodialysis, and certain medical conditions or treatments. These conditions and treatments include receiving clotting factor concentrates produced before 1987, a history of blood or blood component transfusions before July 1992, and receiving blood from a donor who later tested positive for HCV. Healthcare workers who’ve experienced needlestick injury or mucosal exposure to HCV-positive blood also are at risk of acquiring the infection. Individuals who received tattoos or body piercings with poorly sterilized or unsterilized equipment, incarcerated individuals, and those being born to HCV-positive mothers also are at risk.

Treatment

Early treatment, which can help reduce transmission and prevent liver damage, increases the likelihood of achieving a cure. The viral replication of HCV, which involves evading the host immune system through multiple mechanisms, facilitates viral persistence and chronic infection. However, current diagnostic tests, including serology and molecular assays for HCV antibody and RNA, are highly sensitive and specific.

Barriers to care, according to Stuart and colleagues, include a lack of awareness due to asymptomatic infections, limited access to care, and treatment cost. According to the CDC, individuals receiving Medicaid have lower rates of care than those otherwise insured. Watson reported that in 2021 antiviral treatment, which lasts from 8 to 12 weeks, costs between $54,600 and $95,500. According to Florko, in 2022, some prison systems were working directly with drug manufacturers to reduce the cost of treatment to $24,000.

Nursing implications

Although the symptoms of HCV are similar to HBV, about 75% of patients with chronic HCV remain asymptomatic. However, about 20% to 30% of cases can progress to liver cirrhosis, a condition that may take years to develop. This knowledge is essential for effective patient care.

Screening. The U.S. Preventive Services Task Force recommends that all adults age 18 to 79 years receive screening for HCV at least once in their lifetime. Early detection can significantly slow liver damage; if discovered too late, liver cirrhosis can’t be stopped.

Screening for HCV typically involves measuring anti-HCV antibodies. However, although these antibodies indicate exposure to the virus, they don’t necessarily indicate active infection or the need for treatment. For this reason, individuals with a positive HCV RNA test result require further evaluation and consideration for antiviral therapy to manage and potentially cure their infection.

Nurses should encourage patients with alcoholic liver disease to get screened for HCV because some patients with this condition also have HCV, which may worsen liver inflammation and fibrosis. Dialysis nurses should have knowledge of the screening protocol (which involves screening all patients for HCV infection upon initiation of hemodialysis and every 6 months thereafter, regardless of their prior infection status) and remind providers to perform regular checks.

Prevention and patient education. Nurses can support prevention efforts by explaining to patients the need to avoid high-risk behaviors (needle sharing, drug injection, tattooing, piercing, and unprotected sex). The risk of HCV transmission via sharps injuries requires all healthcare workers to maintain standard precautions and to perform proper handwashing when caring for patients with the infection.

Transmission of HCV through blood transfusion has become rare in high-income countries due to interventions such as screening protocols for both the donor and the laboratory. Recommended preventive measures include stricter donor selection, universal laboratory screening, and serologic testing of all donated blood units for anti-HCV antibodies.

Patients with HCV should avoid alcohol consumption, which can accelerate cirrhosis and end-stage liver disease. They should maintain a well-balanced and nonfat diet, stay active, and attempt to lose mid-abdominal fat. Patient-centered exercise should focus on individual tolerability.

Management and treatment. Unlike HBV, no vaccines for HCV currently exist, which places the emphasis on prevention and early detection. Direct-acting antiviral medications approved by the CDC to treat HCV in adults and children (except those younger than 3 years) include protease inhibitors, nucleoside analog polymerase inhibitors, and nonstructural protein 5A (NS5A) inhibitors. The HCV infection genotype determines individual patient treatment. According to the CDC, these medications can cure HCV in 95% of patients within 8 to 12 weeks. (See HCV medications.)

Side effects of treatment depend on the specific medication used. They may include headache, fatigue, anemia, diarrhea, nausea, vomiting, and slow heartbeat.

Follow-up and monitoring. The AASLD and the Infectious Diseases Society of America guideline for testing, managing, and treating HCV recommends that patients follow up with their primary care provider for a viral detection test 12 weeks after treatment to determine whether they’re cured. Nurses should work to establish a good nurse/patient relationship, provide health education, and communicate clearly with the healthcare team to ensure appropriate coordination of care.

Enhance your knowledge

The key to combatting HBV and HCV includes proper screening and identifying at-risk populations. The death toll remains relatively high in patients receiving hemodialysis with HBV or HCV infection, even with prompt antiviral therapy. Raising awareness about transmission methods will lead to targeted interventions aimed at protecting those in high-risk populations.

HBV and HCV remain significant public health concerns that require interprofessional collaboration. By enhancing knowledge and awareness of these conditions, transmission modes, and preventive measures, nurses and other healthcare providers can aid effective management.

Juliana C. Agubokwu is an assistant professor of nursing at Bowie State University in Bowie, Maryland. Chizoba Anako is an advanced practice provider and assistant professor of nursing at Bowie State University. Nadege Djeukui is a nurse practitioner in neurology at the Washington DC VA Medical Center. Obinna Odoemena is an area manager at CareAccess Research in Boston, Massachusetts.

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Key words: acute hepatitis, viral hepatitis, liver disease, chronic hepatitis, hepatitis B, hepatitis C