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But for the most part, Alter says, no one knows for sure why the rate has gone down, and no one can say with any certainty that it won't rise again.
"You'd be surprised at how many groups only know about HIV -- they don't even know that hepatitis B is around," she says. "There's a lot of work to be done to educate individuals that the vaccine is available."
Much of the work is at least being attempted in California, which in 1990 was one of a handful of states nationwide to pass a law requiring hepatitis B screening for all pregnant women. If their mothers are carriers, babies need to be immunized within 12 hours of birth, and need a dose of hepatitis B immune globulin (HBIG), an added preventative; follow-up doses of HBIG and vaccine win children 70 percent protection, the CDC estimates. (The CDC also recommends that family members of carrier moms be vaccinated.)
In 1991, taking the lead in prevention efforts, the San Francisco Department of Public Health initiated a CDC-funded demonstration project that provided free hepatitis B vaccine to hospitals where babies are delivered. The goal was to immunize all 14,000 babies born each year with at least a first dose. "Starting vaccination at birth allows completion of the three-shot series before children are 6 months old," as Martinez explains, "which is when well-baby visits to the doctor tend to drop off." The result: About 64 percent of mothers signed consent forms and allowed their babies the shot. "We don't know why more mothers didn't agree," Martinez says.
The project's second component, managed by coordinator Linda Boyer-Chu, offered free vaccinations for seventh-graders at eight middle schools, with stronger success.
"If there had been an unlimited source of vaccine, then probably all seventh-graders could have been vaccinated," says Martinez. "About 90 percent of the students got consent from parents to receive the shots and, of those, 99 percent" -- about 3,300 -- "received the full three doses."
Adolescent vaccinations, meanwhile, are the wave of the future. The CDC this summer is expected to revise and expand its hep B vaccination recommendations to include not only all newborns, but all children between 11 and 12 years old. The aim is to reach kids before they become sexually active, winnowing out the disease so that by 1998, 90 percent of all children are inoculated.
And in California, a bill with broad support -- it sailed through the Assembly and is currently under consideration in the Senate -- would require all children to be hep B vaccinated before they can enter school. The prime lobbyist and "name sponsor" for the bill, interestingly, is vaccine manufacturer SmithKline Beecham.
"We'd be a beneficiary, but we think this is a case where we're doing well by doing good," says company spokesman Rick Koenig.
And so in the end, prompted at turns by local health officials, special projects, or profits, the goal of protecting the public proceeds two steps forward and one step back. The bottom line remains constant: In the absence of knowledge, love, or terror, humans tend to shun strong medicine. We cannot believe that our actions today might slay us tomorrow.
October 1991. Wendy Marx was happy and healthy. Life seemed backlit by the miraculous, so bright was the relief between a coma and the ability to tie her shoes, walk down the street -- do anything at all. When Marx began to feel tired, two years after her first liver transplant, she couldn't believe it. "But then my numbers started to go up," she says. She had elevated liver enzymes. Doctors did a biopsy. The hepatitis, still in her bloodstream, as it always will be, had attacked her new liver. She needed another transplant.
"I was terrified. I was frustrated. I thought I'd made it, I thought I was going to be OK," Marx says. By January, she was back in the hospital, this time fully conscious and painfully aware of all the possibilities. But she was strangely blessed, again, when news came of teen-age boy who'd died in New Mexico. She received her second new liver via an abdominal slice that surgeons call the "Mercedes cut," because it resembles the shape of the Mercedes-Benz logo. She suffered a few bouts of illness afterward, but for the past two years has been completely healthy.
"My feelings about it are something I can't even express. I am so overwhelmed at the thought that at their most bleak moments, someone will do something like this and let another person live," she says.
Marx works these days as an account director for the same company that first hired her when she came to San Francisco, Redgate Communications. She specializes in marketing via computer, CD-ROMs, and the Internet. She focuses on the future.
"I used to always be looking over my shoulder, worrying about the disease," she says. "When I was in the hospital the second time, I kept thinking, 'Why am I even trying this transplant when it's just going to come back and kill me?' " But Marx says she has faith, and years of health, to soothe her.
Some of her friends still ask what they can do to help, just as so many people did when she first got sick. Marx always says the same thing. She said it when people visited after the first transplant, she said it after the second transplant, she said it when she lay at home adjusting to a new life that two other humans had given her.