Hepatitis B is a viral infection caused by the hepatitis B virus (HBV) that primarily targets hepatocytes and can lead to acute hepatitis, chronic infection, cirrhosis, liver failure, and hepatocellular carcinoma (HCC). HBV is highly infectious and is transmitted through blood and certain body fluids.
While many adults clear acute HBV infection spontaneously, chronic infection is more likely when exposure occurs in infancy or early childhood. Globally, hepatitis B remains a major cause of preventable morbidity and mortality, and it is a key focus of public health prevention through universal vaccination, screening of pregnant patients, and treatment of chronic infection when clinically indicated.
From a nursing perspective, hepatitis B care commonly spans multiple settings: emergency and urgent care (evaluation of jaundice or acute hepatitis, occupational exposures), primary care (screening and vaccination), obstetrics (prenatal screening and perinatal prevention), inpatient units (management of severe hepatitis, cirrhosis complications), and specialty clinics (long-term monitoring and antiviral therapy).
Nurses play a central role in prevention (vaccination and post-exposure prophylaxis), patient education (transmission reduction, medication adherence), monitoring for complications and medication adverse effects, and psychosocial support, including stigma reduction and linkage to specialty care.
HBV is a partially double-stranded DNA virus (Hepadnaviridae). It replicates through reverse transcription, which contributes to persistent infection and the development of resistance with some older antiviral regimens. Key viral antigens and antibodies used in diagnosis and monitoring include hepatitis B surface antigen (HBsAg), surface antibody (anti-HBs), core antibody (anti-HBc), and e antigen (HBeAg), alongside quantitative HBV DNA. Understanding these markers is essential for accurate interpretation of infection status, immunity, and infectivity.
Etiology and epidemiology
Etiology and transmission
HBV is transmitted via percutaneous or mucosal exposure to infected blood or body fluids. Common routes include:
- Perinatal transmission from an infected pregnant patient to the newborn, especially when maternal HBV DNA is high and HBeAg is positive.
- Sexual transmission, including unprotected vaginal or anal sex, particularly with multiple partners or in the setting of other sexually transmitted infections.
- Percutaneous exposure, such as injection substance use (sharing needles or equipment), unsafe medical injections, needle stick injuries, or sharing items contaminated with blood (razors, glucose-monitoring equipment).
- Household exposure can occur through contact with open cuts or shared personal items, although casual contact (hugging, sharing utensils) doesn’t transmit HBV.
HBV is more infectious than HIV and can survive on surfaces for prolonged periods, reinforcing the importance of standard precautions and safe sharps handling in healthcare environments.
Epidemiology and risk groups
Hepatitis B burden varies by region. Higher prevalence is seen in parts of sub-Saharan Africa, East and Southeast Asia, and the Pacific Islands, with significant contributions from perinatal and early childhood transmission in many endemic areas. In lower-prevalence regions, infections occur more commonly via sexual contact and injection drug use.
Key risk groups include:
- Infants born to HBsAg-positive pregnant patients
- People who inject substances
- Sexual partners of people with HBV, and individuals with multiple partners
- Men who have sex with men
- Healthcare and public safety workers with exposure risk
- People receiving hemodialysis
- Household contacts of people with chronic HBV
- People born in or who have lived in higher-prevalence regions
- Immunocompromised patients (risk of reactivation if previously infected)
Natural history
HBV infection can be:
- Acute, with a spectrum from asymptomatic to fulminant hepatic failure.
- Chronic, defined by persistence of HBsAg for at least six months.
Chronic HBV can progress through phases characterized by varying degrees of viral replication and liver inflammation. Progression risk is influenced by age at infection, sex, alcohol use, metabolic factors, coinfections (hepatitis C, hepatitis D, HIV), and viral factors (HBV DNA level, genotype, HBeAg status).
Long-term complications include cirrhosis, decompensated liver disease, and HCC. Importantly, HCC risk isn’t eliminated even when viral replication is controlled, particularly in patients with cirrhosis or longstanding infection.
ICD-10 code
Hepatitis B coding depends on whether the condition is acute, chronic, and whether there is associated hepatic coma or coinfection with hepatitis delta virus. Commonly used ICD-10-CM codes include:
Acute hepatitis B
- B16.0 Acute hepatitis B with delta-agent (coinfection) with hepatic coma
- B16.1 Acute hepatitis B with delta-agent without hepatic coma
- B16.2 Acute hepatitis B without delta-agent with hepatic coma
- B16.9 Acute hepatitis B without delta-agent and without hepatic coma
Chronic hepatitis B
- B18.0 Chronic viral hepatitis B with delta-agent
- B18.1 Chronic viral hepatitis B without delta-agent
Other related codes used in practice (when applicable)
- Z22.51 Carrier of viral hepatitis B (used when documenting carrier state when clinically appropriate in a given charting context)
Note: ICD-10 selection is typically finalized by coding professionals based on provider diagnosis, acuity, and documentation specificity. Nursing documentation supports accurate coding when it clearly reflects clinical status, complications (for example, encephalopathy, ascites), and care provided.
Diagnosis
Clinical presentation
Acute hepatitis B may be asymptomatic or present with:
- Malaise, fatigue, anorexia
- Nausea, vomiting
- Right upper quadrant discomfort
- Fever (sometimes)
- Dark urine, pale stools
- Jaundice and pruritus
- Arthralgias and rash (immune-complex phenomena)
Severe cases may develop:
- Coagulopathy (elevated INR)
- Encephalopathy
- Hypoglycemia
- Rapidly rising bilirubin
These features raise concern for acute liver failure and warrant urgent escalation.
Chronic hepatitis B is often asymptomatic until advanced disease. Symptoms of cirrhosis or decompensation can include ascites, variceal bleeding, hepatic encephalopathy, muscle wasting, and jaundice.
Initial nursing assessment priorities
- Symptom onset and progression; exposure history (sexual, household, percutaneous)
- Pregnancy status and gestational age when applicable
- Occupational exposure details (time, source status, depth, device type)
- Substance use history (injection drug use, alcohol use)
- Medication review, including hepatotoxic agents and supplements
- Signs of liver dysfunction (jaundice, asterixis, confusion, bruising, edema)
- Vaccination history and prior hepatitis testing
- Household and sexual contacts at risk
Laboratory evaluation
Liver function and synthetic function
- ALT and AST (often markedly elevated in acute infection)
- Alkaline phosphatase, GGT
- Total and direct bilirubin
- Albumin
- PT/INR (critical for severity assessment)
- CBC (evaluate thrombocytopenia, anemia)
- Basic metabolic panel (renal status, electrolytes)
- Serum glucose (acute liver failure risk)
HBV serologies and interpretation
Key markers:
- HBsAg: indicates current infection (acute or chronic).
- Anti-HBs: indicates immunity from vaccination or recovery.
- Total anti-HBc (IgG): indicates past or current infection (not produced by vaccination).
- IgM anti-HBc: suggests recent infection and supports acute infection diagnosis.
- HBeAg: suggests higher viral replication and increased infectivity (not absolute).
- Anti-HBe: often indicates lower replication, but interpretation depends on HBV DNA and phase.
Virologic testing
- HBV DNA quantitative: measures viral load and guides treatment decisions and monitoring.
- Consider HBV genotype in select cases (more relevant for interferon decisions and epidemiology).
Additional tests based on context
- Hepatitis D testing (anti-HDV and/or HDV RNA) in HBsAg-positive patients with risk factors or unexpectedly severe disease.
- HIV and hepatitis C screening due to shared transmission routes.
- Pregnancy: baseline HBV DNA and liver panel, and coordination for perinatal management.
Imaging and fibrosis assessment
For chronic infection, staging of liver disease informs prognosis and management:
- Ultrasound (evaluate liver morphology, steatosis, masses, signs of portal hypertension)
- Noninvasive fibrosis tests (transient elastography, serum fibrosis panels)
- Liver biopsy in select cases when noninvasive tests are inconclusive or to evaluate alternative etiologies
Hepatocellular carcinoma surveillance
Patients with chronic HBV at elevated risk require surveillance, typically with ultrasound at regular intervals, with or without AFP, depending on local protocols. Nurses often coordinate scheduling, reinforce adherence, track results, and follow up.
Management
Management depends on whether infection is acute or chronic, disease severity, and patient-specific factors such as pregnancy, comorbidities, and immune status.
Acute hepatitis B management
Most immunocompetent adults recover spontaneously with supportive care.
Supportive care includes:
- Hydration and nutrition support
- Antiemetics as ordered
- Pruritus management (skin care, topical measures, cholestyramine if ordered)
- Avoid alcohol and avoid unnecessary hepatotoxic medications
- Monitor labs (ALT/AST, bilirubin, INR) based on severity
- Patient education on transmission prevention and follow-up testing
When to escalate urgently:
- INR elevation, altered mental status, hypoglycemia, severe jaundice, rapidly worsening labs, or signs of acute liver failure
- These patients need urgent provider evaluation, potential transfer to a transplant-capable center, and intensive monitoring.
Antiviral therapy in acute infection:
Antivirals may be considered in severe acute hepatitis or acute liver failure based on specialist guidance. Be prepared to monitor renal function and medication adherence if treatment is initiated.
Chronic hepatitis B management
Goals:
- Suppress HBV replication (reducing HBV DNA).
- Reduce hepatic inflammation and prevent progression to cirrhosis.
- Reduce risk of HCC.
- Prevent transmission.
Indications for antiviral treatment
Treatment decisions are guided by a combination of:
- HBV DNA level
- ALT elevation (and persistence)
- Degree of fibrosis or cirrhosis
- HBeAg status and age
- Comorbidities, pregnancy, and immunosuppression plans
Patients with cirrhosis and detectable HBV DNA typically warrant treatment, even if ALT is normal, due to high risk of decompensation and HCC.
First-line antiviral options (commonly used)
Preferred long-term oral agents generally include:
- Tenofovir disoproxil fumarate (TDF)
- Tenofovir alafenamide (TAF)
- Entecavir
These agents have a high barrier to resistance compared with older therapies. Choice depends on kidney function, bone health, pregnancy considerations, prior antiviral exposure, and insurance or formulary access.
Nursing monitoring considerations
- Tenofovir (especially TDF): monitor renal function and consider bone health risk assessment.
- Entecavir: generally well-tolerated; ensure correct dosing in renal impairment.
- All agents: monitor adherence closely, because missed doses can lead to viral rebound and hepatic flares.
Pegylated interferon
Pegylated interferon may be considered for selected patients due to a finite treatment duration and potential for durable responses. It has significant adverse effects and contraindications (for example, decompensated cirrhosis, uncontrolled psychiatric disease). Nursing roles include screening for depression, monitoring CBC and thyroid function, and coaching symptom management.
Monitoring during chronic HBV care
Monitoring plans vary by phase and treatment status, but often include:
- ALT/AST and liver synthetic function periodically
- HBV DNA at defined intervals
- HBeAg and anti-HBe in HBeAg-positive patients, as relevant
- Renal function for tenofovir-based regimens
- Surveillance for HCC in at-risk patients
- Assessment for cirrhosis complications: ascites, varices, encephalopathy
Management in pregnancy and perinatal prevention
Key elements:
- Universal prenatal screening for HBsAg.
- For pregnant patients with high HBV DNA, antiviral therapy in late pregnancy may be recommended by specialists to reduce perinatal transmission risk.
- Newborn prophylaxis: hepatitis B vaccine series beginning at birth, and hepatitis B immune globulin (HBIG) for infants born to HBsAg-positive patients, per protocols.
- Post-vaccination serologic testing in infants is performed at appropriate timing to confirm immunity and rule out infection.
Nursing coordination is critical across prenatal care, labor and delivery, postpartum, and pediatrics to ensure prophylaxis is administered correctly and follow-up testing occurs.
Post-exposure prophylaxis
For occupational or nonoccupational exposure, the response depends on:
- Source HBsAg status (positive, negative, unknown)
- Exposed person’s vaccination status and anti-HBs level
- Timing since exposure
Care typically involves rapid evaluation, baseline labs, consideration of HBIG, initiation or completion of vaccination, and follow-up serologies per protocol. Nurses frequently lead immediate triage, documentation, and follow-up coordination.
HBV reactivation prevention
HBV reactivation can occur in patients with current or past infection who undergo immunosuppressive therapy (for example, certain chemotherapy, anti-CD20 agents, high-dose steroids). Prevention includes:
- Screening before immunosuppression (HBsAg, anti-HBc, anti-HBs)
- Prophylactic antivirals in high-risk situations as directed by specialists
Nurses support timely screening, patient education, and monitoring.
Nursing care plan
Below is a structured nursing care plan framework that can be adapted to acute hepatitis B, chronic hepatitis B, and cirrhosis-related complications.
Nursing considerations
- Use standard precautions consistently. Reinforce sharps safety and proper cleaning of blood spills.
- Maintain confidentiality and use stigma-sensitive language.
- Coordinate multidisciplinary care: primary care, hepatology, infectious disease, obstetrics, social work, and substance use treatment services when needed.
- Recognize red flags of liver failure: confusion, easy bleeding, worsening jaundice, hypotension, hypoglycemia.
- Anticipate psychosocial needs: anxiety after diagnosis, fear of disclosure, immigration and insurance barriers, and family screening concerns.
Assessment
Subjective data
- Fatigue, malaise, nausea, anorexia
- RUQ pain or fullness
- Pruritus, sleep disturbance
- Dark urine, light stools
- Alcohol intake, acetaminophen use, supplements
- Sexual and household exposure history (use a respectful, nonjudgmental approach)
- Injection substance use history and harm reduction needs
- Pregnancy status and prenatal care engagement
- Medication adherence and barriers (cost, side effects, stigma, health literacy)
Objective data
- Vital signs, hydration status
- Jaundice, scleral icterus, excoriations from scratching
- Hepatomegaly, RUQ tenderness
- Symptoms of chronic liver disease: spider angiomas, palmar erythema, ascites, edema
- Neurologic status: orientation, asterixis
- Laboratory trends: ALT/AST, bilirubin, INR, albumin, platelets
- Virologic data: HBV DNA, HBeAg status, serology patterns
- Renal function if on tenofovir-based therapy
Nursing diagnosis/risk for
Common nursing diagnoses that may apply include:
- Deficient knowledge related to new diagnosis, transmission risk, and long-term monitoring requirements.
- Risk for infection transmission related to blood and body fluid exposure and limited understanding of prevention measures.
- Imbalanced nutrition: less than body requirements related to anorexia, nausea, and altered metabolism.
- Fatigue related to systemic illness and altered hepatic metabolism.
- Risk for bleeding related to impaired hepatic synthesis of clotting factors and thrombocytopenia in advanced disease.
- Risk for impaired skin integrity related to pruritus and excoriation.
- Risk for acute confusion related to hepatic encephalopathy in severe hepatitis or decompensated cirrhosis.
- Ineffective health management related to complex treatment regimens, substance use disorders, or limited access to care.
- Anxiety related to diagnosis, stigma, and fear about cancer or chronic disease.
Interventions
Education and counseling
- Explain HBV basics: what it is, how it spreads, and what it does not spread through.
- Review safer sex practices and the importance of barrier protection until partners are vaccinated and immune.
- Teach patients not to share razors, toothbrushes, nail clippers, glucose-monitoring devices, or injection equipment.
- Encourage disclosure to household and sexual contacts in a supportive manner, and offer scripts or resources.
- Promote vaccination for susceptible household and sexual contacts per local protocol.
Symptom management
- Nausea: small, frequent meals, antiemetics as ordered, hydration monitoring.
- Pruritus: cool baths, fragrance-free emollients, nail care to reduce excoriation, medications as prescribed.
- Fatigue: prioritize rest, energy conservation strategies, gradual activity as tolerated.
Medication administration and adherence support
- Reinforce dosing schedule for antivirals, including what to do if a dose is missed.
- Assess barriers: cost, pharmacy access, side effects, mental health, housing instability.
- Monitor for adverse effects:
- Tenofovir: renal labs, potential bone health concerns.
- Interferon: mood changes, flu-like symptoms, cytopenias, thyroid dysfunction.
- Coordinate lab monitoring appointments and ensure results are reviewed and communicated.
Monitoring and escalation
- Track trends in INR, bilirubin, mental status, and glucose in acute illness.
- Observe for decompensation signs: increasing abdominal girth, GI bleeding, worsening edema, confusion.
- Ensure timely referral to hepatology for chronic HBV with elevated HBV DNA, elevated ALT, evidence of fibrosis, pregnancy with high viral load, or immunosuppression planning.
Infection prevention in healthcare settings
- Standard precautions for all patients.
- Safe injection practices and proper sharps disposal.
- Post-exposure protocols: immediate wound cleansing, reporting, baseline labs, and timely prophylaxis as indicated.
Care coordination
- Arrange vaccinations, follow-up serologies, and HCC surveillance imaging when indicated.
- Connect patients to social work for insurance, transportation, and medication assistance programs.
- Offer harm reduction resources: syringe services programs where available, naloxone, and substance use treatment referrals.
Expected outcomes
- Patient verbalizes accurate understanding of transmission prevention and follow-up plan.
- Household and sexual contacts are referred for screening and vaccination as appropriate.
- Symptoms (nausea, pruritus) are reduced to a manageable level.
- Laboratory values stabilize or improve as expected for clinical phase, and the patient attends scheduled monitoring.
- Patient demonstrates adherence to antiviral therapy when prescribed, with minimized adverse effects.
- No occupational or household secondary transmission occurs related to modifiable risk factors.
- For patients with cirrhosis risk, surveillance is completed on schedule and abnormal results are acted on promptly.
Nursing considerations
Communication and stigma reduction
Hepatitis B can carry significant stigma. Use neutral, person-first language, such as “person living with hepatitis B.” Emphasize that HBV is a medical condition and that many people live long, healthy lives with appropriate monitoring and treatment.
Cultural humility and health literacy
HBV is more prevalent in certain regions and communities. Provide culturally sensitive counseling and use professional interpreters when needed. Confirm understanding using teach-back, and offer written materials in the patient’s preferred language.
Occupational health
Nurses should be familiar with facility-specific exposure protocols, including documentation, immediate first aid measures, and follow-up schedules. Confirm your own vaccination status and immunity per workplace policy.
Special patient populations
- Pregnant patients: coordinate timely referral and ensure neonatal prophylaxis planning.
- Hemodialysis patients: ensure vaccine schedules align with dialysis protocols; monitor titers if required by local policy.
- Immunocompromised patients: advocate for HBV screening prior to immunosuppressive therapy and coordinate prophylaxis when ordered.
- Children and adolescents: ensure completion of immunization series and follow-up testing as applicable.
Individual/caregiver education
Key teaching points
- How HBV spreads: blood, sex, perinatal. Not spread by casual contact, sharing food, or hugging.
- Preventing transmission: condoms until partners are immune; do not share personal items that may have blood; cover open wounds; safe disposal of sharps.
- Vaccination: highly effective; encourage vaccination of close contacts and completion of the full series.
- Alcohol and liver health: advise avoiding alcohol due to increased risk of liver injury. Discuss medication safety, especially acetaminophen limits per provider guidance.
- Follow-up matters: chronic HBV often has no symptoms; monitoring prevents late complications.
- Medication adherence: antivirals work best when taken consistently; stopping abruptly can cause hepatitis flares.
- When to seek urgent care: confusion, severe vomiting, fainting, bleeding, black stools, severe abdominal swelling, or rapidly worsening jaundice.
Caregiver guidance
- Household members should be screened and vaccinated if not immune.
- Caregivers can provide normal daily care with standard hygiene.
- Clean blood spills using appropriate disinfectants and gloves, per local guidance.
FAQs
Understanding Hepatitis
This course provides administrative and nursing professionals with an overview of viral hepatitis.
Additional Information
Resources
Patient and clinician resources that are commonly helpful:
- American Association for the Study of Liver Diseases (guideline resources and updates): https://www.aasld.org/
- European Association for the Study of the Liver (clinical practice guidelines): https://easl.eu/
- Hepatitis B Foundation (patient education and support): https://www.hepb.org/
- World Health Organization Hepatitis B resources: https://www.who.int/health-topics/hepatitis
References
- American Association for the Study of Liver Diseases (AASLD). (n.d.). Hepatitis B guidance and educational resources. https://www.aasld.org/
- Centers for Medicare and Medicaid Services (CMS). (Updated March 2026). ICD-10-CM code set and official resources. https://www.cms.gov/medicare/coding-billing/icd-10-codes
- ICD10Data. (2026). ICD-10-CM diagnosis code lookup (hepatitis B code groupings). https://www.icd10data.com/ICD10CM/Codes
- European Association for the Study of the Liver (EASL). (n.d.). Clinical practice guidelines and updates. https://easl.eu/
- World Health Organization (WHO). (n.d.). Hepatitis B fact sheets and guidance. https://www.who.int/health-topics/hepatitis
