Preventive measures includes (1) education of the public (especially food handlers and prepara- tion personnel) concerning personal hygiene and good   sanitation,   e.g.,   good   handwashing   and sanitary disposal of human feces; and (2) stressing handwashing  among  the  staff  after  each  diaper change in child care centers. If one or more cases occur,  consider  giving  immune  globulin  to  the staff,  to  other  children  who  attend,  and  to  the families  of  children  attending. Also,  travelers  to  highly  endemic  areas  who plan to remain for up to 3 months may be given human  immune  globulin  in  a  dose  of  0.2  to  0,4 ml/kg  of  body  weight  (or  2  ml  total  for  adults). For  continued  long-term  exposure,  0.6  ml/kg  of body weight (5 ml total for adults) may be given; it should be given every 4 to 6 months while in the area. At this time a vaccine specifically against hepatitis  A  is  not  available  for  general  use. Management  of  patients,  contacts,  and  nearby environment  includes  (1)  isolation  of  patients  with enteric  precautions  for  the  first  2  weeks  of  illness; (2)  passive  immunization  with  human  immune globulin  for  usually  only  household  and  sexual contacts (intimate contacts); and (3) investigation of contacts to include a search for missed cases, a search for a common source, and a surveillance of  household  or  close  contacts.  There  are  no  re- quirements  for  quarantine. When   necessary   during   epidemics,   several measures  are  required.  An  investigation  should be conducted to determine the method of trans- mission and to identify the population at risk of infection.  If  viral  hepatitis  A  is  diagnosed  in  a food  handler,  give  human  immune  globulin  to other  food  handlers  in  the  facility.  However,  it is recommended that patrons not be immunized unless  an  infected  food  handler  prepared  foods that were not cooked, his or her personal hygiene was  deficient,  and  human  immune  globulin  can be given within 2 weeks of exposure to the index case. If necessary, sanitary practices should be im- proved  to  prevent  fecal  contamination  of  food and  water.  Mass  administration  of  human  im- mune  globulin  should  be  considered  to  control outbreaks in institutions. Epidemics of hepatitis A  may  be  expected  during  disaster  situations where  large  numbers  of  people  are  crowded together  with  poor  sanitation  and  inadequate water supplies. If cases occur, it is recommended that  efforts  be  made  to  improve  sanitation  and water  supplies.  Administration  of  human  immune globulin cannot be recommended as a substitute for  proper  environmental  health  measures.  There is  no  requirement  for  international  measures. VIRAL   HEPATITIS   B.—   The  onset  pro- gresses gradually. There is loss of appetite, slight abdominal   discomfort,   nausea,   vomiting,   joint pain,  rash,  and  jaundice.  Fever,  if  present,  is usually mild. The severity of this disease ranges from  inapparent  cases  to  death  due  to  severe hepatic  injury. The  diagnosis  can  be  confirmed  by  demonstra- tion  of  a  specific  blood  virus  particle,  the  hepatitis B  surface  antigen  (HBsAg),  or  the  recent  develop- ment of antibody to core and/or surface antigens (anti-HBc, anti-HBs, respectively). HBsAg can be found in the serum for several weeks before the appearance  of  symptoms  and  for  weeks  to  months after  the  onset  and  remains  present  in  chronic  in- fections.  The  infectious  agent  is  the  hepatitis  B virus.  Man  is  the  only  recognized  reservoir. Although HBsAg is found in numerous body secretions/excretions,  only  blood,  saliva,  semen, and vaginal fluids have proven to be infectious. Transmission occurs by percutaneous inoculation (such as a needle stick) with infective body fluids or  by  sexual  exposure.  Human  blood,  plasma, serum,  and  other  blood  products  may  transmit the hepatitis B virus. Thus all blood products are screened  in  the  laboratory  for  HBsAg.  Con- taminated needles, syringes, and other intravenous equipment  are  frequently  involved  in  transmis- sion,  especially  among  drug  abusers.  The  infection is  also  rarely  spread  through  open  wound  con- tamination  by  blood  or  sera  from  another  infected individual. The agent may also be transmitted by heterosexual  and  homosexual  contact.  The  shared use  of  personal  items,  e.g.,  razors,  and  tooth- brushes, has been implicated as a rare cause. The average incubation period is from 60 to 90 days. Blood is infective several weeks before the   first   symptoms   appear,   during   the   acute clinical disease, and, in those cases that develop into the chronic carrier state, it may be infectious for years. The is no specific treatment except for supportive measures. There are several preventive measures. Inac- tivated vaccines are now commercially available against  viral  hepatitis  B.  The  vaccine  is  recom- mended  for  those  persons  who  may  come  into contact with blood, persons who receive repeated blood transfusions or blood fractions, household contacts  of  carriers,  the  sexually  promiscuous, staff  in  institutions  for  the  retarded,  hemodialysis patients,  and  illicit  injectable  drug  users.  Preg- nancy  is  not  necessarily  a  contraindication  for immunization. Pregnant women in high risk groups should be tested for the presence of HBsAg and, if positive, 11-12