Hospitals crack down on workers refusing flu shots

CHICAGO (AP) — Patients can refuse a flu shot. Should doctors and nurses have that right, too? That is the thorny question surfacing as U.S. hospitals increasingly crack down on employees who won't get flu shots, with some workers losing their jobs over their refusal.

"Where does it say that I am no longer a patient if I'm a nurse," wondered Carrie Calhoun, a longtime critical care nurse in suburban Chicago who was fired last month after she refused a flu shot.

Hospitals' get-tougher measures coincide with an earlier-than-usual flu season hitting harder than in recent mild seasons. Flu is widespread in most states, and at least 20 children have died.

Most doctors and nurses do get flu shots. But in the past two months, at least 15 nurses and other hospital staffers in four states have been fired for refusing, and several others have resigned, according to affected workers, hospital authorities and published reports.

In Rhode Island, one of three states with tough penalties behind a mandatory vaccine policy for health care workers, more than 1,000 workers recently signed a petition opposing the policy, according to a labor union that has filed suit to end the regulation.

Why would people whose job is to protect sick patients refuse a flu shot? The reasons vary: allergies to flu vaccine, which are rare; religious objections; and skepticism about whether vaccinating health workers will prevent flu in patients.

Dr. Carolyn Bridges, associate director for adult immunization at the federal Centers for Disease Control and Prevention, says the strongest evidence is from studies in nursing homes, linking flu vaccination among health care workers with fewer patient deaths from all causes.

"We would all like to see stronger data," she said. But other evidence shows flu vaccination "significantly decreases" flu cases, she said. "It should work the same in a health care worker versus somebody out in the community."

Cancer nurse Joyce Gingerich is among the skeptics and says her decision to avoid the shot is mostly "a personal thing." She's among seven employees at IU Health Goshen Hospital in northern Indiana who were recently fired for refusing flu shots. Gingerich said she gets other vaccinations but thinks it should be a choice. She opposes "the injustice of being forced to put something in my body."

Medical ethicist Art Caplan says health care workers' ethical obligation to protect patients trumps their individual rights.

"If you don't want to do it, you shouldn't work in that environment," said Caplan, medical ethics chief at New York University's Langone Medical Center. "Patients should demand that their health care provider gets flu shots — and they should ask them."

For some people, flu causes only mild symptoms. But it can also lead to pneumonia, and there are thousands of hospitalizations and deaths each year. The number of deaths has varied in recent decades from about 3,000 to 49,000.

A survey by CDC researchers found that in 2011, more than 400 U.S. hospitals required flu vaccinations for their employees and 29 hospitals fired unvaccinated employees.

At Calhoun's hospital, Alexian Brothers Medical Center in Elk Grove Village, Ill., unvaccinated workers granted exemptions must wear masks and tell patients, "I'm wearing the mask for your safety," Calhoun says. She says that's discriminatory and may make patients want to avoid "the dirty nurse" with the mask.

The hospital justified its vaccination policy in an email, citing the CDC's warning that this year's flu outbreak was "expected to be among the worst in a decade" and noted that Illinois has already been hit especially hard. The mandatory vaccine policy "is consistent with our health system's mission to provide the safest environment possible."

The government recommends flu shots for nearly everyone, starting at age 6 months. Vaccination rates among the general public are generally lower than among health care workers.

According to the most recent federal data, about 63 percent of U.S. health care workers had flu shots as of November. That's up from previous years, but the government wants 90 percent coverage of health care workers by 2020.

The highest rate, about 88 percent, was among pharmacists, followed by doctors at 84 percent, and nurses, 82 percent. Fewer than half of nursing assistants and aides are vaccinated, Bridges said.

Some hospitals have achieved 90 percent but many fall short. A government health advisory panel has urged those below 90 percent to consider a mandatory program.

Also, the accreditation body over hospitals requires them to offer flu vaccines to workers, and those failing to do that and improve vaccination rates could lose accreditation.

Starting this year, the government's Centers for Medicare & Medicaid Services is requiring hospitals to report employees' flu vaccination rates as a means to boost the rates, the CDC's Bridges said. Eventually the data will be posted on the agency's "Hospital Compare" website.

Several leading doctor groups support mandatory flu shots for workers. And the American Medical Association in November endorsed mandatory shots for those with direct patient contact in nursing homes; elderly patients are particularly vulnerable to flu-related complications. The American Nurses Association supports mandates if they're adopted at the state level and affect all hospitals, but also says exceptions should be allowed for medical or religious reasons.

Mandates for vaccinating health care workers against other diseases, including measles, mumps and hepatitis, are widely accepted. But some workers have less faith that flu shots work — partly because there are several types of flu virus that often differ each season and manufacturers must reformulate vaccines to try and match the circulating strains.

While not 100 percent effective, this year's vaccine is a good match, the CDC's Bridges said.

Several states have laws or regulations requiring flu vaccination for health care workers but only three — Arkansas, Maine and Rhode Island — spell out penalties for those who refuse, according to Alexandra Stewart, a George Washington University expert in immunization policy and co-author of a study appearing this month in the journal Vaccine.

Rhode Island's regulation, enacted in December, may be the toughest and is being challenged in court by a health workers union. The rule allows exemptions for religious or medical reasons, but requires unvaccinated workers in contact with patients to wear face masks during flu season. Employees who refuse the masks can be fined $100 and may face a complaint or reprimand for unprofessional conduct that could result in losing their professional license.

Some Rhode Island hospitals post signs announcing that workers wearing masks have not received flu shots. Opponents say the masks violate their health privacy.

"We really strongly support the goal of increasing vaccination rates among health care workers and among the population as a whole," but it should be voluntary, said SEIU Healthcare Employees Union spokesman Chas Walker.

Supporters of health care worker mandates note that to protect public health, courts have endorsed forced vaccination laws affecting the general population during disease outbreaks, and have upheld vaccination requirements for schoolchildren.

Cases involving flu vaccine mandates for health workers have had less success. A 2009 New York state regulation mandating health care worker vaccinations for swine flu and seasonal flu was challenged in court but was later rescinded because of a vaccine shortage. And labor unions have challenged individual hospital mandates enacted without collective bargaining; an appeals court upheld that argument in 2007 in a widely cited case involving Virginia Mason Hospital in Seattle.

Calhoun, the Illinois nurse, says she is unsure of her options.

"Most of the hospitals in my area are all implementing these policies," she said. "This conflict could end the career I have dedicated myself to."

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Online:

R.I. union lawsuit against mandatory vaccines: http://www.seiu1199ne.org/files/2013/01/FluLawsuitRI.pdf

CDC: http://www.cdc.gov

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AP Medical Writer Lindsey Tanner can be reached at http://www.twitter.com/LindseyTanner

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Lance Armstrong Apologizes to Livestrong Staff

Lance Armstrong apologized today to the Livestrong staff ahead of his interview with Oprah Winfrey, a foundation official said.

The disgraced cyclist gathered with about 100 Livestrong Foundation staffers at their Austin, Texas, headquarters for a meeting that included social workers who deal directly with patients as part of the group's mission to support cancer victims.

Armstrong's "sincere and heartfelt apology" generated lots of tears, spokeswoman Katherine McLane said, adding that he "took responsibility" for the trouble he has caused the foundation.

McLane declined to say whether Armstrong's comments included an admission of doping, just that the cyclist wanted the staff to hear from him in person rather than rely on second-hand accounts.

Armstrong then took questions from the staff.

Armstrong's story has never changed. In front of cameras, microphones, fans, sponsors, cancer survivors -- even under oath -- Lance Armstrong hasn't just denied ever using performance enhancing drugs, he has done so in an indignant, even threatening way.

Riccardo S. Savi/Getty Images|Ray Tamarra/Getty Images

Lance Armstrong Doping Charges: Secret Tapes Watch Video

Lance Armstrong's Winfrey Interview: Expected to Admit to Doping Watch Video

Today, sources tell ABC News, will be different. Today Armstrong is expected to rewrite his own, now infamous story, to Winfrey. So what should she ask? There are enough questions to fill a book, but here's our shot at five, for starters, all based on the belief that his first words will be an admission. Feel free to comment and add your own.

1) Witnesses have told the U.S. Anti Doping Agency that after recovering from cancer, you increased your use of performance enhancing drugs, but swore off one of them—Human Growth Hormone—specifically noting your cancer as a reason to avoid it. Do you believe your cancer may have been caused by performance enhancing drug use?

2) Some people seem able to forgive or rationalize the use of performance enhancing drugs, but what troubles them is the vicious cover-up. Why did you feel it necessary to go beyond denials, to attack and even threaten and file legal claims against those who accused you of drug use, even to the point of causing serious harm to people's lives and reputations?

3) In 1996, while recovering from cancer, your former close friend Frankie Andreu and his wife Betsy say they were in the hospital room when you told doctors you'd used several different performance enhancing drugs during your career. They testified under oath about this, but you always denied it and vilified them. This caused the Andreus great harm. Did it happen?

4) What do you tell your kids?

5) Up until today, everything you've said and done—even that picture on twitter of you and your yellow jerseys—has said to the world that you're not sorry, and that you're the real winner of seven Tours. Aren't you just coming forward now to help yourself, rather than to come clean or set the record straight?

Whatever the answers, a small army of lawyers and even criminal investigators will be listening closely. Will Armstrong's interview be the start of his redemption or the beginning of even bigger problems?

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France bombs Islamist stronghold in north Mali

BAMAKO/PARIS (Reuters) - French fighter jets pounded an Islamist rebel stronghold deep in northern Mali on Sunday as Paris poured more troops into the capital Bamako, awaiting a West African force to dislodge al Qaeda-linked insurgents from the country's north.

The attack on Gao, the largest city in the desert region controlled by the Islamist alliance, marked a decisive intensification on the third day of French air raids, striking at the heart of the vast territory seized by rebels in April.

France is determined to end Islamist domination of north Mali, which many fear could act as a base for attacks on the West and for links with al Qaeda in Yemen, Somalia and North Africa.

France's Defense Minister Jean-Yves Le Drian said French intervention on Friday had prevented the advancing rebels from seizing Bamako. He vowed that air strikes would continue.

"The president is totally determined that we must eradicate these terrorists who threaten the security of Mali, our own country and Europe," he told French television.

In Gao, a dusty town on the banks of the Niger river where Islamists have imposed an extreme form of sharia law, residents said French jets pounded the airport and rebel positions. A huge cloud of black smoke rose from the militants' camp in the city's north, and pick-up trucks ferried dead and wounded to hospital.

"The planes are so fast you can only hear their sound in the sky," resident Soumaila Maiga said by telephone. "We are happy, even though it is frightening. Soon we will be delivered."

Paris said four state-of-the-art Rafale jets flew from France to strike rebel training camps, logistics depots and infrastructure in Gao with the aim of weakening the rebels and preventing them from returning southward.

A spokesman for Ansar Dine, one of the main Islamist factions, said the French had also bombed targets in the towns of Lere and Douentza. Residents said rebel fighters had fled from Douentza aboard pick-up trucks.

France has deployed about 550 soldiers to Mali under "Operation Serval" - named after an African wildcat - split between Bamako and the town of Mopti, 500 km (300 miles) north.

In Bamako, a Reuters cameraman saw more than 100 French troops disembark on Sunday from a military cargo plane at the international airport, on the outskirts of the capital.

The city itself was calm, with the sun streaking through the dust enveloping the city as the seasonal Harmattan wind blew from the Sahara. Some cars drove around with French flags draped from the windows to celebrate Paris's intervention.

AFRICAN TROOPS EXPECTED

More than two decades of peaceful elections had earned Mali a reputation as a bulwark of democracy, but that image unraveled in a matter of weeks after a military coup in March which left a power vacuum for the Islamist rebellion.

French President Francois Hollande's intervention in Mali has won plaudits from leaders in Europe, Africa and the United States but it is not without risks.

It raised the threat level for eight French hostages held by al Qaeda allies in the Sahara and for the 30,000 French expatriates living in neighboring, mostly Muslim states.

Concerned about reprisals, France has tightened security at public buildings and on public transport. It advised its 6,000 citizens to leave Mali as spokesmen for Ansar Dine and al Qaeda's north Africa wing AQIM promised to exact revenge.

In its first casualty of the campaign, Paris said a French pilot was killed on Friday when rebels shot down his helicopter.

Hours earlier, a French intelligence officer held hostage in Somalia by al Shabaab extremists linked to al Qaeda was killed in a failed commando raid to free him.

President Hollande says France's aim is simply to support a mission by West African bloc ECOWAS to retake the north, as mandated by a U.N. Security Council resolution in December.

With Paris pressing West African nations to send their troops quickly, Ivory Coast President Alassane Ouattara, who holds the rotating ECOWAS chairmanship, kick-started the operation to deploy 3,300 African soldiers.

Ouattara, installed in power with French military backing in 2011, convened a summit of the 15-nation bloc for Saturday in Ivory Coast to discuss the mission.

"The troops will start arriving in Bamako today and tomorrow," said Ali Coulibaly, Ivory Coast's African Integration Minister. "They will be convoyed to the front."

The United States is considering sending a small number of unarmed surveillance drones to Mali as well as providing logistics support, a U.S. official told Reuters. Britain and Canada have also promised logistical support.

Former French colonies Senegal, Niger and Burkina Faso have all pledged to deploy 500 troops within days. In contrast, regional powerhouse Nigeria, due to lead the ECOWAS force, has suggested it would take time to train and equip the troops.

HOUSE-TO-HOUSE SEARCHES

France, however, appeared to have assumed control of the operation on the ground. Its airstrikes allowed Malian troops to drive the Islamists out of the strategic town of Konna, which they had briefly seized this week in their southward advance.

Analysts expressed doubt, however, that African nations would be able to mount a swift operation to retake north Mali - a harsh, sparsely populated terrain the size of France - as neither the equipment nor ground troops were prepared.

"My first impression is that this is an emergency patch in a very dangerous situation," said Gregory Mann, associate professor of history at Columbia University, who specializes in francophone Africa and Mali in particular.

While France and its allies may be able to drive rebel fighters from large towns, they could struggle to prise them from mountain redoubts in the region of Kidal, 300 km (200 miles) northeast of Gao, where April's uprising began.

Calm returned to Konna on Sunday after three nights of combat as the Malian army mopped up any rebel fighters. A senior Malian army official said more than 100 rebels had been killed.

"Soldiers are patrolling the streets and have encircled the town," one resident, Madame Coulibaly, told Reuters by phone. "They are searching houses for arms or hidden Islamists."

Human Rights Watch said at least 11 civilians, including three children, had been killed in the fighting.

A spokesman for Doctors Without Borders in neighboring Mauritania said about 200 Malian refugees had fled across the border to a camp at Fassala and more were on their way.

In Bamako, civilians tried to contribute to the war effort.

"We are very proud and relieved that the army was able to drive the jihadists out of Konna. We hope it will not end there, that is why I'm helping in my own way," said civil servant Ibrahima Kalossi, 32, one of over 40 people who queued to donate blood for wounded soldiers.

(Additional reporting by Adama Diarra, Tiemoko Diallo and Rainer Schwenzfeier in Bamako, Joe Bavier in Abidjan, Leila Aboud in Paris and Phil Stewart in Washington; Writing by Daniel Flynn; Editing by Will Waterman)

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Urgent CO2 cuts may spare millions hardship: report

PARIS: Tens of millions of people may be spared droughts and floods by 2050 if Earth-warming carbon emissions peak in 2016 rather than 2030, scientists said on Sunday.

Climate researchers in Britain and Germany said emission cuts now would delay some crippling impacts by decades and prevent some altogether.

By 2050, an Earth heading for warming of 2-2.5 degrees Celsius by 2100 could have two very different faces, depending on the route taken to get there, said their study published in the journal Nature Climate Change

Policies that cap Earth-warming carbon emissions in 2016 and then reduce them by five per cent per year could see between 39 and 68 million people spared exposure to a higher risk of water shortages by 2050, Nigel Arnell of the University of Reading told AFP.

This is the best-case scenario, though.

In contrast, if emissions peak in 2030 and fall by five per cent annually, the number of people who escape this risk drops to between 17 and 48 million.

Similarly, about 100-161 million people would avoid a higher risk of river flooding on the 2016-peak scenario.

This compares to 52-120 million people if emissions peak 14 years later, said Arnell, director of the university's Walker Institute on climate change.

"Basically in 2050, the 2030-peaking policy has about half to two-thirds of the benefit than the best (2016) policy," even though both lead to a similar temperature peak of about 2-2.5 deg C by 2100, he said.

"You may hit the same (temperature) point at the end of the century but... the mayhem that's been caused on the way to that point is different under the different pathways."

Under a scenario without any emissions curbs, temperatures could rise as much as 4-5.5 deg C, said the new paper which claimed to be the broadest assessment yet of the benefits of avoiding climate change impacts.

Global average warming of 4 degrees Celsius would see almost a billion people have less water in 2100 than they have now, and 330 million will be at greater risk of river flooding, Arnell told a pre-release press conference.

A peak in 2016 seems unlikely, with the world's nations aiming to adopt a new global climate pact by 2015 for entry into force only five years later.

The latest round of UN climate talks that concluded in Doha, Qatar in December failed to set pre-2020 emissions cuts for countries that have not signed up to the Kyoto Protocol that seeks to curb warming, even as scientists warned the concentration of carbon in the atmosphere continues to rise.

Three of the world's four biggest polluters -- China, the United States and India -- are among those with no binding emission limits, which cover countries responsible for only about 15 per cent of the world's carbon pollution.

Many scientists believe that Earth is set for warming that will be far above the United Nations' 2 degrees Celsius target on pre-industrial levels.

"Reducing greenhouse gas emissions won't avoid the impacts of climate change altogether of course, but our research shows it will buy time to make things like buildings, transport systems and agriculture more resilient to climate change," said Arnell.

- AFP/jc

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Flu more widespread in US; eases off in some areas

NEW YORK (AP) — Flu is now widespread in all but three states as the nation grapples with an earlier-than-normal season. But there was one bit of good news Friday: The number of hard-hit areas declined.

The flu season in the U.S. got under way a month early, in December, driven by a strain that tends to make people sicker. That led to worries that it might be a bad season, following one of the mildest flu seasons in recent memory.

The latest numbers do show that the flu surpassed an "epidemic" threshold last week. That is based on deaths from pneumonia and influenza in 122 U.S. cities. However, it's not unusual — the epidemic level varies at different times of the year, and it was breached earlier this flu season, in October and November.

And there's a hint that the flu season may already have peaked in some spots, like in the South. Still, officials there and elsewhere are bracing for more sickness

In Ohio, administrators at Miami University are anxious that a bug that hit employees will spread to students when they return to the Oxford campus next week.

"Everybody's been sick. It's miserable," said Ritter Hoy, a spokeswoman for the 17,000-student school.

Despite the early start, health officials say it's not too late to get a flu shot. The vaccine is considered a good — though not perfect — protection against getting really sick from the flu.

Flu was widespread in 47 states last week, up from 41 the week before, the Centers for Disease Control and Prevention said on Friday. The only states without widespread flu were California, Mississippi and Hawaii.

The number of hard-hit states fell to 24 from 29, where larger numbers of people were treated for flu-like illness. Now off that list: Florida, Arkansas and South Carolina in the South, the first region hit this flu season.

Recent flu reports included holiday weeks when some doctor's offices were closed, so it will probably take a couple more weeks to get a better picture, CDC officials said Friday. Experts say so far say the season looks moderate.

"Only time will tell how moderate or severe this flu season will be," CDC Director Dr. Thomas Frieden said Friday in a teleconference with reporters.

The government doesn't keep a running tally of adult deaths from the flu, but estimates that it kills about 24,000 people in an average year. Nationally, 20 children have died from the flu this season.

Flu vaccinations are recommended for everyone 6 months or older. Since the swine flu epidemic in 2009, vaccination rates have increased in the U.S., but more than half of Americans haven't gotten this year's vaccine.

Nearly 130 million doses of flu vaccine were distributed this year, and at least 112 million have been used. Vaccine is still available, but supplies may have run low in some locations, officials said.

To find a shot, "you may have to call a couple places," said Dr. Patricia Quinlisk, who tracks the flu in Iowa.

In midtown Manhattan, Hyrmete Sciuto got a flu shot Friday at a drugstore. She skipped it in recent years, but news reports about the flu this week worried her.

During her commute from Edgewater, N.J., by ferry and bus, "I have people coughing in my face," she said. "I didn't want to risk it this year."

The vaccine is no guarantee, though, that you won't get sick. On Friday, CDC officials said a recent study of more than 1,100 people has concluded the current flu vaccine is 62 percent effective. That means the average vaccinated person is 62 percent less likely to get a case of flu that sends them to the doctor, compared to people who don't get the vaccine. That's in line with other years.

The vaccine is reformulated annually, and this year's is a good match to the viruses going around.

The flu's early arrival coincided with spikes in flu-like illnesses caused by other bugs, including a new norovirus that causes vomiting and diarrhea, or what is commonly known as "stomach flu." Those illnesses likely are part of the heavy traffic in hospital and clinic waiting rooms, CDC officials said.

Europeans also are suffering an early flu season, though a milder strain predominates there. China, Japan, the West Bank, the Gaza Strip, Algeria and the Republic of Congo have also reported increasing flu.

Flu usually peaks in midwinter. Symptoms can include fever, cough, runny nose, head and body aches and fatigue. Some people also suffer vomiting and diarrhea, and some develop pneumonia or other severe complications.

Most people with flu have a mild illness. But people with severe symptoms should see a doctor. They may be given antiviral drugs or other medications to ease symptoms.

Some shortages have been reported for children's liquid Tamiflu, a prescription medicine used to treat flu. But health officials say adult Tamiflu pills are available, and pharmacists can convert those to doses for children.

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Associated Press writers Dan Sewell in Cincinnati, Catherine Lucey in Des Moines, and Malcolm Ritter in New York contributed to this report.

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Online:

CDC flu: http://www.cdc.gov/flu/index.htm

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Thousands Protest in Moscow Against Adoption Ban

Jan 13, 2013 10:37am

KIRILL KUDRYAVTSEV/AFP/Getty Images

MOSCOW — Thousands of Russians took to the streets on Sunday to protest Russia’s new ban on adoptions to the United States.

In what organizers called the “March Against Scoundrels” they paraded down a tree-lined boulevard in central Moscow chanting “Hands off our children” and “Russia will be free.” They also carried signs with the faces of Russian politicians who approved the ban and the word “Shame” written on them.

“I am not an apologist for the U.S. I am a patriot of this country. But this monstrous law must be canceled,” leftist protest leader Sergei Udaltsov told the crowd before the march began, according to the Interfax news agency.

As usual, organizers and police disagreed on the size of the crowd. Organizers estimated between 20,000 and 50,000 people turned out. Police put the figure much lower at about 7,000, but overhead photos of the protest appear to show a crowd larger than that.

Significantly smaller protests, some consisting of just a few dozen people, took place in other cities around the country, according to Interfax. A nationwide poll taken in December by the Public Opinion Foundation found 56 percent support for the ban.

But participants in Sunday’s protests accused the ban’s proponents of playing politics with the lives of children.

The adoption ban was a late amendment to a bill retaliating for a set of human rights sanctions that President Obama signed into law in December. It cut off adoptions to the United States, one of the most popular destinations for international adoptions from Russia, starting Jan. 1.

More than 60,000 Russian orphans have been adopted by Americans since the end of the Soviet Union, according to the State Department. Many of them are sick or suffer from disabilities.

READ: Unclear Russian Adoption Ban Frustrates US Families

But Russian officials have pointed to the cases of 19 children who died after being adopted by Americans. They also noted cases in which American parents accused of abusing their adopted children received, in their view, lenient sentences.

Since the law went into effect, Russian officials have struggled to explain whether the ban would cancel 52 adoption cases that had already received court approval and were within weeks of completion. Kremlin spokesman Dmitri Peskov said Thursday that at least some of those adoptions which had cleared the courts would be allowed to proceed, but did to say how many.

The ban was controversial even before it became law. Even though it received nearly unanimous approval from Russia’s rubber stamp parliament, prominent cabinet officials, including Russia’s Foreign Minister Sergei Lavrov, came out against the ban. Even President Vladimir Putin himself evaded questions about it when asked during an end of year press conference.

READ: Russians Rally to Help US Adoption Mom Fighting for Child

Since the ban was approved, top Russian officials have pledged to devote more resources to reforming the country’s dilapidated orphanages and to encourage more Russians to adopt.

Sunday’s protest was organized by some of the same opposition leaders who organized last year’s anti-Putin rallies. The last such protest, held without city approval and under heavy police presence, drew relatively few people in December, suggesting the protest movement had fizzled. Protest leader and anti-corruption blogger Alexy Navalny, however, told Interfax today that he hopes the adoption ban could rally more Russians to continue protesting.

SHOWS: World News

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Russia rejects Assad exit as precondition for Syria deal

MOSCOW/BEIRUT (Reuters) - Russia voiced support on Saturday for international peace envoy Lakhdar Brahimi but insisted Syrian President Bashar al-Assad's exit cannot be a precondition for a deal to end the country's conflict.

Some 60,000 Syrians have been killed during the 21-month-old revolt and world powers are divided over how to stop the escalating bloodshed. Government aircraft bombed outer districts of Damascus on Saturday after being grounded for a week by stormy weather, opposition activists in the capital said.

A Russian Foreign Ministry statement following talks on Friday in Geneva with the United States and Brahimi reiterated calls for an end to violence in Syria, but there was no sign of a breakthrough.

Brahimi said the issue of Assad, who the United States, European powers and Gulf-led Arab states insist must step down to end the civil war, appeared to be a sticking point.

Russia's Foreign Ministry said: "As before, we firmly uphold the thesis that questions about Syria's future must be decided by the Syrians themselves, without interference from outside or the imposition of prepared recipes for development."

Russia has been Assad's most powerful international backer, joining with China to block three Western- and Arab-backed U.N. Security Council resolutions aimed to pressure him or push him from power. Assad can also rely on regional powerhouse Iran.

Russia called for "a political transition process" based on an agreement by foreign powers last June.

Brahimi, who is trying to build on that agreement, has met three times with senior Russian and U.S. diplomats since early December and met Assad in Damascus.

Russia and the United States disagreed over what the June agreement meant for Assad, with Washington saying it sent a clear signal he must go and Russia contending it did not.

Qatar on Saturday made a fresh call for an Arab force to end bloodshed in Syria if Brahimi's efforts fail, according to the Doha-based al Jazeera television.

"It is not a question of intervention in Syria in favor of one party against the other, but rather a force to preserve security," Qatar's Prime Minister and Foreign Minister, Sheikh Hamad bin Jassim al-Thani, said in an al Jazeera broadcast.

CONFLICT INTENSIFIES

Moscow has been reluctant to endorse the "Arab Spring" popular revolts of the last two years, saying they have increased instability in the Middle East and created a risk of radical Islamists seizing power.

Although Russia sells arms to Syria and rents one of its naval bases, the economic benefit of its support for Assad is minimal. Analysts say President Vladimir Putin wants to prevent the United States from using military force or support from the U.N. Security Council to bring down governments it opposes.

However, as rebels gain ground in the war, Russia has given indications it is preparing for Assad's possible exit, while continuing to insist he must not be forced out by foreign powers.

Opposition activists say a military escalation and the hardship of winter have accelerated the death toll.

Rebel forces have acquired more powerful anti-tank and anti-aircraft weapons during attacks on Assad's military bases.

Assad's forces have employed increasing amounts of military hardware including Scud-type ballistic missiles in the past two months. New York-based Human Rights Watch said they had also used incendiary cluster bombs that are banned by most nations.

STALEMATE IN CITIES

The weeklong respite from aerial strikes has been marred by snow and thunderstorms that affected millions displaced by the conflict, which has now reached every region of Syria.

On Saturday, the skies were clear and jets and helicopters fired missiles and dropped bombs on a line of towns to the east of Damascus, where rebels have pushed out Assad's ground forces, the Syrian Observatory for Human Rights said.

The British-based group, which is linked to the opposition, said it had no immediate information on casualties from the strikes on districts including Maleiha and farmland areas.

Rebels control large swathes of rural land around Syria but are stuck in a stalemate with Assad's forces in cities, where the army has reinforced positions.

State TV said government forces had repelled an attack by terrorists - a term it uses for the armed opposition - on Aleppo's international airport, now used as a helicopter base.

Reuters cannot independently confirm reports due to severe reporting restrictions imposed by the Syrian authorities and security constraints.

On Friday, rebels seized control of one of Syria's largest helicopter bases, Taftanaz in Idlib province, their first capture of a military airfield.

Eight-six people were killed on Friday, including 30 civilians, the Syrian Observatory said.

(Writing by Oliver Holmes; Editing by Tom Pfeiffer and Doina Chiacu)

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Vowing revenge, 15,000 rally in Paris over Kurd killings

PARIS: At least 15,000 Kurds from all over Europe vowed revenge as they rallied Saturday in Paris over the killing of three top Kurdish activists from a separatist group banned in Turkey.

The march, which began at the city's Gare de l'Est railway station, was emotionally charged, with demonstrators saying France would be an accomplice in the brazen murders if it did not identify and punish the killers.

Organisers disputed the police estimate saying more than 50,000 people joined the demonstration.

"This crime is a crime against the Kurdish people and against peace," said a woman demonstrator, calling for an end to the listing of the Kurdistan Workers' Party (PKK) as a terrorist organisation.

"The French state bears a responsibility. If the perpetrators of these crimes are not found, France will be indisputably considered as an accomplice," said a leaflet published and distributed by France's main Kurdish association, Feyka.

"It's the first time something like this has happened in Europe," said Celine Yildirim, a waitress in Paris who gained political asylum in France after being jailed in Turkey.

"We want to know who did this."

The demonstrators, marching under grey skies and an intermittent drizzle, held banners saying "Intikam! PKK," using the Turkish word for revenge, and "The Martyrs of the Revolution Are Eternal."

The three activists -- Sakine Cansiz, Fidan Dogan and Leyla Soylemez -- were found dead on Thursday at the Kurdistan Information Centre in the grimy 10th district of Paris, after last being seen alive at the centre at midday on Wednesday.

They were all shot in the head, at least three times each.

Cansiz was a founding member of the PKK, which took up arms in 1984 for Kurdish self-rule in southeastern Turkey and is branded a terrorist organisation by Ankara and much of the international community.

Police put the number of marchers at 15,000. They came from Belgium, the Netherlands, Britain, Switzerland and especially Germany, which is home to 800,000 Kurds, of whom 13,000 are believed to be PKK members.

Fikriye Cinar, who drove to Paris with eight members of her family from the German city of Dortmund, said she had "not really slept for three days as these murders have shaken me."

The killings came days after Turkish media reported that Turkey and the PKK leadership had agreed a roadmap to end the three-decade Kurdish insurgency, which has claimed more than 45,000 lives.

The deal was reportedly reached during a new round of talks between the Turkish government and jailed PKK leader Abdullah Ocalan which the government acknowledges have been taking place with the aim of disarming the rebels.

"This attack comes at a time when talks are on to find a solution to the Kurdish problem in Turkey," said Kurdish association Feyka.

French President Francois Hollande had said the murder was "terrible", adding that he knew one of the Kurdish women and that she "regularly met us" -- a comment seized upon by Turkish Prime Minister Recep Tayyip Erdogan, who on Saturday sought an explanation from Paris.

"How can he regularly meet with these people who are members of a group listed as a terrorist organisation by the European Union and who are wanted under red bulletin (issued by Interpol)?" Erdogan asked.

Erdogan said Hollande "must explain immediately to the French, Turkish and world public why... he is in communication with these terrorists."

The Turkish leader repeatedly accused some European states, including France and Germany, of obstructing Ankara's fight against the PKK, saying that they were letting PKK members freely circulate on their territory.

Experts have suggested a number of potential motives for the killings, including an attack by Turkish extremists and internal feuding within the PKK.

There are around 150,000 Kurds in France, the vast majority of them of Turkish origin.

-AFP/ac

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Reformed women alcoholics from Australia on taboo-breaking trip to India

NEW DELHI: She began drinking when she was 15 and couldn't stop thereafter. From then on, Janet, a 50-year-old Perth resident, would get drunk every time she touched any spirit. "It got so bad that I suffered three seizures. I was admitted to a detox unit and later taken to my first Alcoholics Anonymous (AA) meeting. That changed my life." Not only has Janet now written a book about her recovery and learned to fly a plane, she has also built a successful business.

Like Janet, women in India, too, are increasingly taking to drinking. In fact, binge drinking is on the rise not only in metros but smaller towns with cases of women in Punjab, for instance, calling up AA for help. But there are hardly any de-addiction centres for them here. Also, it doesn't help that alcoholism in India is seen by society as a moral problem, unlike abroad where it's perceived as an affliction.

It is to break these taboos that 91 foreign women, all recovering alcoholics, will come to India in the first-ever such delegation to tour the country. Starting January 13, they will go to colleges, hospitals, rehab facilities - holding meetings all the while - in Delhi, Kolkata, Surat, Mumbai, Chennai and Bangalore. Team members say they will "try to articulate" how societal acceptance can go a long way in recovery. Women form about 30% of AA abroad, in India it's barely 1%.

Brenda, 57, a resident of Auckland, began drinking at 13. To compound matters, she ended up marrying an alcoholic with violent moods. "I became emotionally and spiritually bankrupt, and divorced my husband," she says. Fortunately, her ex-husband joined AA and got her along too. Today, this grandmother has remarried the same man and hasn't touched a drink in 28 years. "This kind of support is lacking in India," she says. And she wants to talk about it.

"Husbands abroad even come with their alcoholic wives to AA meetings," says Rahul, a member. In India, most women are brought in by desperate families. He hopes this trip by the foreign women will recognize and address what many parents see in India as a growing and deeply troubling issue. A counselor at a girls' school in Chandigarh says many of the kids, most of them in their early teens, who come to her for help fear they might be getting addicted to alcohol. "Their weekends pass by in a blur," she says.

Aruna, who is in her 40s, says accepting alcoholism as a problem that's getting more acute by the day especially in India's burgeoning cities with their freedom and independence, is the first step. "There was a time I could finish a bottle of vodka," she says. "When I joined AA, I was the only woman member then. It wasn't easy and I used to be so embarrassed. But being accepted with love helped. Just like men can have a problem, women can too. We need to see that. And it's really important that society stops seeing women with a drinking problem as being easily available and morally ambiguous."

(AA's helpline for women is 9971255335)

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Q&A: Scramble for vaccine as flu season heats up

WASHINGTON (AP) — Missed flu-shot day at the office last fall? And all those "get vaccinated" ads? A scramble for shots is under way as late-comers seek protection from a miserable flu strain already spreading through much of the country.

Federal health officials said Friday that there is still some flu vaccine available and it's not too late to benefit from it. But people may have to call around to find a clinic with shots still on the shelf, or wait a few days for a new shipment.

"We're hearing of spot shortages," said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention.

Colorado offers an example. Kaiser Permanente, which has 535,000 members in the state, stopped giving flu shots this week. But it expected to resume vaccinations when new shipments arrive, expected this weekend.

Some questions and answers about flu vaccines:

Q: Are we running out of vaccine?

A: It's January — we shouldn't have a lot left. The traditional time to get vaccinated is in the fall, so that people are protected before influenza starts spreading.

Indeed, manufacturers already have shipped nearly 130 million doses to doctors' offices, drugstores and wholesalers, out of the 135 million doses they had planned to make for this year's flu season. At least 112 million have been used so far.

The nation's largest manufacturer, Sanofi Pasteur, said Friday that it still has supplies of two specialty vaccines, a high-dose shot for seniors, and an under-the-skin shot for certain adults, available for immediate shipment. But it also is working to eke out a limited supply of its traditional shots — some doses that it initially hadn't packaged into syringes, said spokesman Michael Szumera. They should be available late this month.

And MedImmune, the maker of the nasal spray vaccine FluMist, said it has 620,000 extra doses available.

Q: Can't they just make more?

A: No. Flu vaccine is complicated to brew, with supplies for each winter made months in advance and at the numbers expected to sell. Although health officials recommend a yearly flu vaccination for nearly everybody, last year 52 percent of children and just 39 percent of adults were immunized. Most years, leftover doses have to be thrown out.

Q: Should I still hunt for a vaccine?

A: It does take two weeks for full protection to kick in. Still, health officials say it's a good idea to be vaccinated even this late, especially for older people, young children and anyone with medical conditions such as heart or lung diseases that put them at high risk of dangerous flu complications. Flu season does tend to be worst in January and February, but it can run through March.

Q: I heard that a new flu strain is spreading. Does the vaccine really work?

A: Flu strains constantly evolve, the reason that people need an updated vaccine every year. But the CDC says this year's is a good match to the types that are circulating, including a new kind of the tough H3N2 strain. That family tends to be harsher than other flu types — and health officials warned last fall that it was coming, and meant this winter would likely be tougher than last year's flu season, the mildest on record.

Q: But don't some people get vaccinated and still get sick?

A: Flu vaccine never is 100 percent effective, and unfortunately it tends to protect younger people better than older ones. But the CDC released a study Friday showing that so far this year, the vaccine appears 62 percent effective, meaning it's working about as well as it has in past flu seasons.

While that may strike some people as low, Frieden said it's the best protection available. "It's a glass 62 percent full," he said. "It's well worth the effort."

Q: What else can I do?

A: Wash your hands often, and avoid touching your eyes, nose and mouth. Viruses can spread by hand, not just through the air. Also, cough in your elbow, not your hand. When you're sick, protect others by staying home.

And people who are in those high-risk groups should call a doctor if they develop symptoms, added CDC spokesman Tom Skinner. They might be prescribed antiviral medication, which works best if given within the first 48 hours of symptoms.

___

AP Medical Writers Lindsey Tanner and Mike Stobbe contributed to this report.

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