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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Armstrong Admits Doping in Tour, Sources Say

Lance Armstrong today admitted to Oprah Winfrey that he used performance enhancing drugs to win the Tour de France, sources told ABC News.

A government source tells ABC News that Armstrong is now talking with authorities about paying back some of the US Postal Service money from sponsoring his team. He is also talking to authorities about confessing and naming names, giving up others involved in illegal doping. This could result in a reduction of his lifetime ban, according to the source, if Armstrong provides substantial and meaningful information.

Armstrong made the admission in what sources describe as an emotional interview with Winfrey to air on "Oprah's Next Chapter" on Jan. 17.

The 90-minute interview at his home in Austin, Texas, was Armstrong's first since officials stripped him of his world cycling titles in response to doping allegations.

Word of Armstrong's admission comes after a Livestrong official said that Armstrong apologized today to the foundation's staff ahead of his interview.

The disgraced cyclist gathered with about 100 Livestrong Foundation staffers at their Austin 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.

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

Lance Armstrong Stripped of Tour de France Titles Watch Video

Lance Armstrong Doping Charges: Secret Tapes Watch Video

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.

Armstrong, 41, was stripped of his seven Tour de France titles and banned from the sport for life by the U.S. Anti-Doping Agency in October 2012, after allegations that he benefited from years of systematic doping, using banned substances and receiving illicit blood transfusions.

"Lance Armstrong has no place in cycling and he deserves to be forgotten in cycling," Pat McQuaid, the president of the International Cycling Union, said at a news conference in Switzerland announcing the decision. "This is a landmark day for cycling."

The U.S. Anti-Doping Agency issued a 200-page report Oct. 10 after a wide-scale investigation into Armstrong's alleged use of performance-enhancing substances.

Armstrong won the Tour de France from 1999 to 2005.

According to a source, speaking to ABC News, a representative of Armstrong's once offered to make a donation estimated around $250,000 to the agency, as "60 Minutes Sports" on Showtime first reported.

Lance Armstrong's attorney Tim Herman denied it. "No truth to that story," Herman said. "First Lance heard of it was today. He never made any such contribution or suggestion."

Armstrong, who himself recovered from testicular cancer, created the Lance Armstrong Foundation (now known as the LIVESTRONG Foundation) to help people with cancer cope, as well as foster a community for cancer awareness. Armstrong resigned late last year as chairman of the LIVESTRONG Foundation, which raised millions of dollars in the fight against cancer.

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Asian stocks up, Shanghai jumps on regulator comments

HONG KONG: Asian shares were mostly higher on Monday, led by a surge on the Shanghai index after the securities regulator raised hopes for increased foreign investment in China's stock market.

The euro made further gains after upbeat comments last week by the European Central Bank chief, and the yen slid again after reports that the Bank of Japan and government were poised to set a two-per cent inflation target.

Shanghai surged 3.06 per cent, or 68.74 points, to 2,311.74 after the head of China's securities regulator, Guo Shuqing, said the investment quota for foreigners in the domestic equity market could be increased 10-fold.

Hong Kong rose 0.64 per cent, or 149.19 points, to 23,413.26, Seoul added 0.52 per cent, or 10.37 points, to 2,007.04 and Sydney closed up 0.22 per cent, or 10.2 points, at 4,719.7.

But Singapore slipped 0.31 per cent, or 9.91 points, to 3,206.59, pulled down by property stocks after the government introduced new measures at the weekend to cool the local market.

Tokyo was closed for a public holiday.

At a Hong Kong conference on Monday, Guo said at present investment by foreign institutions -- individuals are barred -- accounts for "just 1.5 or 1.6 per cent" of China's A-share market, stock denominated in the domestic yuan currency.

He said the quota could be increased 10-fold in an effort to boost the stock market, without elaborating.

There was no clear lead from Wall Street, where stocks closed in mixed territory on Friday.

The Dow Jones Industrial Average was up 0.13 per cent, the broad-based S&P 500 was flat, while the tech-heavy Nasdaq Composite rose 0.12 per cent.

Investors were looking ahead to a speech by US Federal Reserve chief Ben Bernanke later on Monday.

Minutes from the December meeting of Fed policymakers showed they were divided over how long the central bank should continue asset purchases.

But dealers thought Bernanke was likely to put an end to speculation that US policymakers may end the quantitative-easing programme, with expectations about his comments pushing down the dollar.

"I'd be shocked if he said anything other than they're buying bonds for the long haul," said Davis Scutt, a currency trader at Arab Bank in Sydney.

After tumbling on Friday when the Japanese government unveiled a stimulus package, the yen slid further as reports said the Bank of Japan and the government would jointly set a two-per cent inflation target following pressure from new Prime Minister Shinzo Abe.

The two sides are to finalise a joint statement on monetary measures in time for the central bank's policy meeting on January 21-22, the Asahi Shimbun reported.

A weaker yen helps the country's many exporters, as it makes their products cheaper abroad.

The euro has been surging since Thursday when ECB chief Mario Draghi said there was "a significant improvement in financial market conditions" in the single currency bloc.

On foreign exchange markets in Asian afternoon trade, the euro was at $1.3387, compared to $1.3341 in the US late Friday. The dollar was at 89.61 yen from 89.18 yen, and the euro traded at 119.96 yen from 119.00 yen.

Oil was up. New York's main contract, light sweet crude for delivery in February, rose 69 cents to $94.25 a barrel in the afternoon, and Brent North Sea crude for February delivery gained 43 cents to $111.07.

Gold was at 1,669.90 at 0935 GMT compared with $1,669.80 late Friday.

In other markets:

-- Wellington rose 0.54 per cent, or 22.16 points to 4,153.92.

Fletcher Building added 1.61 per cent to NZ$8.86, Telecom Corp rose 1.08 per cent to NZ$2.335 and The Warehouse gained 0.66 per cent to NZ$3.07.

-- Taipei was flat, edging up 4.82 points to 7,823.97.

Taiwan Semiconductor Manufacturing Co gained 1.0 per cent at NT$102.0 while leading smartphone maker HTC climbed 5.1 per cent to NT$291.0.

-- Manila advanced 0.70 per cent, or 42.15 points, to 6,093.90.

Top-traded Bloomberry Resorts Corp. gained 1.54 per cent to 13.16 pesos while BDO Unibank rose 2.46 per cent to 77 pesos.

- AFP/xq

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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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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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MSF to focus on better organising its delivery of social services

SINGAPORE: Acting Minister for Social and Family Development Chan Chun Sing said his ministry will focus on how to better deliver social services to the people.

This comes after Finance Minister Tharman Shanmugaratnam announced that Budget Day this year will be on February 25.

Mr Chan spoke to reporters on the sidelines of a community event on Sunday morning.

He noted that beyond adjusting and tweaking some of the policies, it is important to assess how these policies can be systematically implemented across the ministry's entire span of social services.

He added that announcements will be made by his ministry in the lead-up to Budget Day.

Mr Chan said: "The focus is not just on the policies alone, of course that we will do, but the focus is also to make sure that we organise ourselves better so that we prepare the ground and set up the social service infrastructure for the many years to come so that in time to come when our social needs increase, when we have more social challenges, we have what we call the social service infrastructure in place to deliver the help to the people in need."

- CNA/fa

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People living near LoC demand grant for constructing bunkers

SRINAGAR: People living in areas close to Line of Control (LoC) in Kashmir are demanding special grant for construction of bunkers to escape shelling as India and Pakistan have resumed hostilities by heavy firing at each others' position.

Residents of villages close to the LoC in Uri sector of north Kashmir Baramulla district claim that the earthquake of 2005, which had flattened wide parts of Kashmir on either side of the ceasefire line, had destroyed their bunkers.

"We did not reconstruct those bunkers as we did not feel the need. The ceasefire between India and Pakistan along the LoC had held good for two years," Mohammad Aslam, a resident of Churunda village in Uri, said.

Churunda has been the worst affected areas in recent time as three civilians were killed in Pakistani shelling in October last year.

The village was again the target on January 6 but the cross LoC shelling resulted in damage to a residential house.

India and Pakistan agreed to a ceasefire along the Line of Control in Jammu and Kashmir in November 2003. Barring minor aberrations, the ceasefire had been successful, providing major relief to the residents of borders areas in the state who were living in constant fear.

However, the recent incidents of shelling along the LoC and transgression of the ceasefire line by Pakistani troops in Mendhar area of Poonch district is threatening the truce pact. Two Indian soldiers were killed in Mendhar incident while Pakistan has claimed that two of its soldiers died in shelling by Indian army since January 6.

A delegation of villagers living close to LoC told PTI that government should provide them special grant for reconstructing the bunkers in case the hostilities continue.

"The government should either construct or provide us money to construct these bunkers. If they fail to do so, we might have to migrate from the area," Bashir Ahmad, who was heading the delegation, said.

He said the areas of Uri likely to be affected by cross-LoC shelling include Hathlanga, Churunda, Tilwari, Silikote and Sura, where over 1,000 families reside.

District development commissioner Baramulla Khwaja Ghulam Ahmad said the authorities have not received any representation for construction of bunkers so far.

"However, we will forward a proposal to Government if any such application is received," Ahmad said.

He said all the families living along the LoC in Uri were given Rs 15,000 in mid-1990s for construction of the underground bunkers.

"These bunkers do not get affected by earthquake," he added.

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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.

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

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Poisoned Lottery Winner's Kin Were Suspicious

Urooj Khan had just brought home his $425,000 lottery check when he unexpectedly died the following day. Now, certain members of Khan's family are speaking publicly about the mystery -- and his nephew told ABC News they knew something was not right.

"He was a healthy guy, you know?" said the nephew, Minhaj Khan. "He worked so hard. He was always going about his business and, the thing is: After he won the lottery and the next day later he passes away -- it's awkward. It raises some eyebrows."

The medical examiner initially ruled Urooj Khan, 46, an immigrant from India who owned dry-cleaning businesses in Chicago, died July 20, 2012, of natural causes. But after a family member demanded more tests, authorities in November found a lethal amount of cyanide in his blood, turning the case into a homicide investigation.

"When we found out there was cyanide in his blood after the extensive toxicology reports, we had to believe that ... somebody had to kill him," Minhaj Khan said. "It had to happen, because where can you get cyanide?"

In Photos: Biggest Lotto Jackpot Winners

Authorities could be one step closer to learning what happened to Urooj Khan. A judge Friday approved an order to exhume his body at Rosehill Cemetery in Chicago as early as Thursday to perform further tests.

Lottery Winner Murdered: Widow Questioned By Police Watch Video

Moments after the court hearing, Urooj Khan's sister, Meraj Khan, remembered her brother as the kind of person who would've shared his jackpot with anyone. Speaking at the Cook County Courthouse, she hoped the exhumation would help the investigation.

"It's very hard because I wanted my brother to rest in peace, but then we have to have justice served," she said, according to ABC News station WLS in Chicago. "So if that's what it takes for him to bring justice and peace, then that's what needs to be done."

Khan reportedly did not have a will. With the investigation moving forward, his family is waging a legal fight against his widow, Shabana Ansari, 32, over more than $1 million, including Urooj Khan's lottery winnings, as well as his business and real estate holdings.

Khan's brother filed a petition Wednesday to a judge asking Citibank to release information about Khan's assets to "ultimately ensure" that [Khan's] minor daughter from a prior marriage "receives her proper share."

Ansari may have tried to cash the jackpot check after Khan's death, according to court documents, which also showed Urooj Khan's family is questioning if the couple was ever even legally married.

Ansari, Urooj Khan's second wife, who still works at the couple's dry cleaning business, has insisted they were married legally.

She has told reporters the night before her husband died, she cooked a traditional Indian meal for him and their family, including Khan's daughter and Ansari's father. Not feeling well, Khan retired early, Ansari told the Chicago Sun-Times, falling asleep in a chair, waking up in agony, then collapsing in the middle of the night. She said she called 911.

"It has been an incredibly hard time," she told ABC News earlier this week. "We went from being the happiest the day we got the check. It was the best sleep I've had. And then the next day, everything was gone.

"I am cooperating with the investigation," Ansari told ABC News. "I want the truth to come out."

Ansari has not been named a suspect, but her attorney, Steven Kozicki, said investigators did question her for more than four hours.

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Obama, Karzai accelerate end of U.S. combat role in Afghanistan

WASHINGTON (Reuters) - President Barack Obama and Afghan President Hamid Karzai agreed on Friday to speed up the handover of combat operations in Afghanistan to Afghan forces, raising the prospect of an accelerated U.S. withdrawal from the country and underscoring Obama's determination to wind down a long, unpopular war.

Signaling a narrowing of differences, Karzai appeared to give ground in talks at the White House on U.S. demands for immunity from prosecution for any American troops who stay in Afghanistan beyond 2014, a concession that could allow Obama to keep at least a small residual force there.

Both leaders also threw their support behind tentative Afghan reconciliation efforts with Taliban insurgents, endorsing the establishment of a Taliban political office in Qatar in hopes of bringing insurgents to inter-Afghan talks.

Outwardly, at least, the meeting appeared to be something of a success for both men, who need to show their vastly different publics they are making progress in their goals for Afghanistan. There were no signs of the friction that has frequently marked Obama's relations with Karzai.

Karzai's visit came amid stepped-up deliberations in Washington over the size and scope of the U.S. military role in Afghanistan once the NATO-led combat mission concludes at the end of 2014.

"By the end of next year, 2014, the transition will be complete," Obama said at a news conference with Karzai standing at his side. "Afghans will have full responsibility for their security, and this war will come to a responsible end."

The Obama administration has been considering a residual force of between 3,000 and 9,000 troops - far fewer than some U.S. commanders propose - to conduct counterterrorism operations and to train and assist Afghan forces.

A top Obama aide said this week that the administration does not rule out a complete withdrawal after 2014, a move that some experts say would be disastrous for the weak Afghan central government and its fledgling security apparatus.

Obama on Friday left open the possibility of that so-called "zero option" when he several times used the word "if" to suggest that a post-2014 U.S. presence was far from guaranteed.

Insisting that Afghan forces were "stepping up" faster than expected, Obama said Afghan troops would take over the lead in combat missions across the country this spring, rather than waiting until the summer as originally planned. NATO troops will then assume a "support role," he said.

"It will be a historic moment and another step toward full Afghan sovereignty," Obama said.

Obama said final decisions on this year's troop cuts and the post-2014 U.S. military role were still months away, but his comments suggested he favors a stepped-up withdrawal timetable.

There are some 66,000 U.S. troops currently in Afghanistan. Washington's NATO allies have been steadily reducing their troop numbers as well despite doubts about the ability of Afghan forces to shoulder full responsibility for security.

'WAR OF NECESSITY'

Karzai voiced satisfaction over Obama's agreement to turn over control of detention centers to Afghan authorities, a source of dispute between their countries, although the White House released no details of the accord on that subject.

Obama once called Afghanistan a "war of necessity." But he is heading into a second term looking for an orderly way out of the conflict, which was sparked by the September 11, 2001, attacks on the United States by an al Qaeda network harbored by Afghanistan's Taliban rulers.

He faces the challenge of pressing ahead with his re-election pledge to continue winding down the war while preparing the Afghan government to prevent a slide into chaos and a Taliban resurgence once most NATO forces are gone.

Former Senator Chuck Hagel, Obama's nominee to become defense secretary, is likely to favor a sizable troop reduction.

Karzai, meanwhile, is eager to show he is working to ensure Afghans regain full control of their territory after a foreign military presence of more than 11 years.

Asked whether the cost of the war in lives and money was worth it, Obama said: "We achieved our central goal ... or have come very close to achieving our central goal, which is to de-capacitate al Qaeda, to dismantle them, to make sure that they can't attack us again."

He added: "Have we achieved everything that some might have imagined us achieving in the best of scenarios? Probably not. This is a human enterprise, and you fall short of the ideal."

Obama made clear that unless the Afghan government agrees to legal immunity for U.S. troops, he would withdraw them all after 2014 - as happened in Iraq at the end of 2011.

Karzai, who criticized NATO over civilian deaths, said that with Obama's agreement to transfer detention centers and the planned withdrawal of U.S. forces from Afghan villages, "I can go to the Afghan people and argue for immunity" in a bilateral security pact being negotiated.

Addressing students at Georgetown University later in the day, the Afghan leader predicted with certainty that the United States would keep a limited number of troops in Afghanistan after 2014, in part to battle al Qaeda and its affiliates.

"One of the reasons the United States will continue a limited presence in Afghanistan after 2014 in certain facilities in Afghanistan is because we have decided together to continue to fight against al Qaeda," Karzai said. "So there will be no respite in that."

Many of Obama's Republican opponents have criticized him for setting a withdrawal timetable and accuse him of undercutting the U.S. mission by reducing troop numbers too quickly.

Karzai and his U.S. partners have not always seen eye to eye, even though the American military has been crucial to preventing insurgent attempts to oust him.

In October, Karzai accused Washington of playing a double game by fighting the war in Afghan villages instead of going after insurgents who cross the border from neighboring Pakistan.

In Friday's news conference, Karzai did not back down from his previous comments that foreigners were responsible for some of the official corruption critics say is rampant in Afghanistan. But he acknowledged: "There is corruption in the Afghan government that we are fighting against."

Adding to tensions has been a rash of deadly "insider" attacks by Afghan soldiers and police against NATO-led troops training or working with them. U.S. forces have also been involved in a series of incidents that enraged Afghans, including burning Korans, which touched off days of rioting.

(Additional reporting by Roberta Rampton, Mark Felsenthal, Jeff Mason, Phil Stewart, Tabassum Zakaria, David Alexander; Editing by Warren Strobel and Will Dunham)

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