Scientists identify new lethal virus in Africa

ATLANTA – Scientists have identified a lethal new virus in Africa that causes bleeding like the dreaded Ebola virus. The so-called "Lujo" virus infected five people in Zambia and South Africa last fall. Four of them died, but a fifth survived, perhaps helped by a medicine recommended by the scientists.

It's not clear how the first person became infected, but the bug comes from a family of viruses found in rodents, said Dr. Ian Lipkin, a Columbia University epidemiologist involved in the discovery.

"This one is really, really aggressive" he said of the virus.

A paper on the virus by Lipkin and his collaborators was published online Thursday on in PLoS Pathogens.

The outbreak started in September, when a female travel agent who lives on the outskirts of Lusaka, Zambia, became ill with a fever-like illness that quickly grew much worse.

She was airlifted to Johannesburg, South Africa, where she died.

A paramedic in Lusaka who treated her also became sick, was transported to Johannesburg and died. The three others infected were health care workers in Johannesburg.

Investigators believe the virus spread from person to person through contact with infected body fluids.

"It's not a kind of virus like the flu that can spread widely," said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, which helped fund the research.

The name given to the virus — "Lujo" — stems from Lusaka and Johannesburg, the cities where it was first identified.

Investigators in Africa thought the illness might be Ebola, because some of the patients had bleeding in the gums and around needle injection sites, said Stuart Nichol, chief of the molecular biology lab in the CDC's Special Pathogens Branch. Other symptoms include include fever, shock, coma and organ failure.

Genetic extracts of blood and liver from the victims were tested at Columbia University in New York, and additional testing was done at CDC in Atlanta. Tests determined it belonged to the arenavirus family, and that it is distantly related to Lassa fever, another disease found in Africa.

The drug ribavirin, which is given to Lassa victims, was given to the fifth Lujo virus patient — a Johannesburg nurse. It's not clear if the medicine made a difference or if she just had a milder case of the disease, but she fully recovered, Nichol said.

The research is a startling example of how quickly scientists can now identify new viruses, Fauci said. Using genetic sequencing techniques, the virus was identified in a matter of a few days — a process that used to take weeks or longer.

Along with Fauci's institute, the National Heart, Lung, and Blood Institute and Google also helped fund the research.

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On the Net:

PLoS Pathogens: http://www.plospathogens.org/home.action

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Stroke group expands time for clot-busting drugs

DALLAS – A change to stroke treatment guidelines is expanding the time that some patients can get clot-busting drugs. Current recommendations limit the use of the medicine to within three hours after the start of stroke symptoms. That treatment window is now being lengthened to 4 1/2 hours for some patients.

But the committee that made the change stressed that the earlier the treatment, the better for stroke victims.

"They should call the ambulance straight away and get moving," said Dr. Gregory del Zoppo, of the University of Washington School of Medicine in Seattle, who headed the committee for the American Heart Association Stroke Council.

The update, published online Thursday in the heart group's journal Stroke, comes after a European study last fall found stroke sufferers still benefited from getting the medicine an hour or so beyond the three-hour window.

The new guideline is expected to increase the number of people who get the treatment. Only about a third of stroke sufferers get help within three hours, and only about 5 percent get the drug now. Many people don't recognize the signs of a stroke: numbness or weakness in the face, arm or leg; trouble speaking, seeing or walking; a sudden, severe headache.

Stroke is the third leading cause of death in the U.S., with about 795,000 people suffering a new or recurrent stroke each year and more than 140,000 people dying. Strokes caused by blood clots are the most common; the clot blocks an artery supplying blood to the brain, which starves brain cells of oxygen. The drug TPA breaks up the clot and opens the artery.

Another member of the committee, Dr. Jeffrey Saver, of the University of California at Los Angeles, said some hospitals extended the time for using the clot dissolver after the European study, while many have been waiting for national guidelines.

He said the change could increase the number of people who get the drug by a third, to 7 or 8 percent of stroke victims.

Dr. Mark D. Johnson, a stroke specialist at the University of Texas Southwestern Medical Center in Dallas, said that the expanded time frame is good news but the emphasis is still on getting treatment sooner rather than later.

"If you were to arrive in 30 minutes, the chances of a better outcome are higher than if you arrive in four hours," said Johnson.

The new guideline notes that some patients should still be restricted to treatment within the three-hour period: people older than 80, those suffering from a severe stroke or with a history of stroke and diabetes or those taking anti-clotting drugs.

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On the Net:

American Stroke Association: http://www.strokeassociation.org

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CDC says October soonest for swine flu shots

ATLANTA – A U.S. health official said a swine flu vaccine could be available as early as October, but only if vaccine production and testing run smoothly this summer.

Dr. Anne Schuchat (Shook-it) of the U.S. Centers for Disease Control and Prevention said the agency began shipping virus samples to manufacturers in the past several days. The government will have to review the safety and effectiveness of what's produced, and decide if a vaccination campaign is warranted. October is about the time seasonal flu vaccine campaigns generally get rolling.

CDC officials reported more than 8,500 probable and confirmed cases in the U.S., including 12 deaths and more than 500 hospitalizations.

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Congress can learn from Mass., Tenn. health plans

Laid off from her job in Massachusetts, Danielle Marks thought immediately about losing her health insurance. How could she afford the medication and physical therapy she needed to heal after shoulder surgery?

Valerie Nash, laid off in Tennessee, thought about her diabetes. Could she stock up enough test strips and insulin before her coverage expired?

The two women, both briefly uninsured, got covered again thanks to their home states' 3-year-old experiments in expanding health insurance coverage. And while both are mostly pleased with the coverage and low cost of their new state-backed plans, their futures hold plenty of doubt.

Congressional lawmakers can look north to Massachusetts and south to Tennessee for guidance as they craft a national plan to restrain costs and cover the nation's estimated 50 million uninsured.

In Massachusetts, nearly every resident has health insurance, but doctors are turning away new patients, costs to the state are climbing and thousands have paid tax penalties for being uninsured. In Tennessee, that state's much smaller program hasn't cramped the budget, but few people are buying the new insurance even though premiums are as cheap as a monthly cell phone bill.

"The belief that we should all have health insurance coverage is broadly held," said Alan Weil of the nonpartisan National Academy for State Health Policy. "But there are tremendous differences around the country in beliefs on how to achieve that goal."

A Massachusetts-style requirement for individuals to obtain health insurance is likely to emerge as part of the health overhaul taking shape in Congress, although details remain unsettled. A variation of Tennessee's practice of charging higher premiums to smokers and those who are overweight also may emerge; some in Congress are discussing a lifestyle tax on alcohol and sugar-sweetened drinks to help finance the national plan.

In Plymouth, Mass., Marks and her husband, Tad, now pay just $78 a month for state-subsidized insurance that covers doctor visits, prescriptions and hospital stays. Because she's pregnant, Marks, who worked as an administrative assistant until her layoff, pays nothing for her checkups, medicine and vitamins.

But pared-down benefits may lie ahead in Massachusetts because throngs of the newly insured swelled costs of Commonwealth Care to $628 million last year.

And the demand for care is outstripping the number of doctors. One in five Massachusetts adults said a doctor's office or clinic told them they weren't taking new patients with their type of insurance, or they weren't accepting new patients at all, according to a new study published Thursday in the journal Health Affairs.

Massachusetts chose to cover virtually everyone. It set high standards for minimum health insurance and decided to deal with costs later. Soon a state commission expects to call for fundamental changes in the way doctors and hospitals are paid, a plan that amounts to putting them on a financial diet.

"Once you start down the moral path to universal coverage, you inevitably confront costs," said Jon Kingsdale, who directs the board that oversees the state's plan. He and others said Congress can learn the Massachusetts way: coverage first, then cost control.

"If you get everybody covered first, it's easier to deal with costs," Kingsdale said. "If you're going to hold the uninsured hostage to containing costs, you have more than doubled the height to get up this hill."

Tennessee, on the other hand, chose to get just a few more people bare-bones insurance at a budget price with limits on how much plans would pay for hospital stays.

In Chattanooga, Tenn., Nash, who had worked at a car dealership, and her husband, Larry, now pay $193 a month for their state-subsidized coverage, called CoverTN. Their doctor visits and generic drugs are covered, but the plan pays only $10,000 a year on hospital bills. A serious medical crisis could bankrupt them.

"My husband and I barely squeak by as it is now," Valerie Nash said. "It would be a devastating blow."

Compared to Massachusetts, Tennessee is similar in population size, but has more uninsured adults of working age and higher rates of diabetes, childhood obesity, low birth weight and smoking.

What set the stage for Tennessee's go-slow approach was the state's history with expanding health insurance during the 1990s, said Gov. Phil Bredesen.

A state program built around Medicaid, called TennCare, "got totally out of control. It was growing at 15 percent a year. Tennessee had the most expensive Medicaid program in the country," Bredesen said. "Our experience with trying to do universal coverage ended up being a disaster."

When Bredesen took office in 2003, he inherited soaring state health care spending. In 2005, he cut 170,000 adults from TennCare. He reduced benefits for thousands more.

His new initiative, CoverTN, takes "baby steps" toward covering more people. It targets workers at small businesses, the self-employed and the recently unemployed. The cost of monthly premiums is shared by the state, the individual and employers. No one is forced to participate.

Bredesen said the plan design reflects what uninsured Tennesseans want — primary care, not catastrophic care — in a trimmed-down package. Only eight people have exceeded the annual maximum for inpatient hospital costs since the program began.

"This is not the insurance for someone who's going to get into a motorcycle accident," Bredesen said.

The program costs less than anticipated and a fraction of Massachusetts' cost — $10.9 million last year, in part because only about 19,000 have signed up so far.

"I've dreamed about 100,000," Bredesen said. "I'm always amazed, however, when you actually charge someone for health insurance, how many fewer people are willing to sign up for it, than are willing to demand affordable health care."

Mostly it's the "young invincibles" who are staying away. Those are young adults who "don't feel like they're going to get sick," said Laurie Lee, who directs CoverTN and other state health benefits programs. "We've been surprised by that," she said. Older people with chronic conditions are signing up.

Massachusetts officials boast of adding 432,000 to the insured population; 187,000 of those got insurance through their employers or individual purchase. A state survey last year found fewer than 4 percent of working age adults remained uninsured.

Tennessee's uninsured rate for working-age adults probably is not much lower than it was before CoverTN, roughly 20 percent. New census data on the uninsured comes out later this year.

"We learn from Massachusetts that a bold objective matters. If it can be sustained, that's terrific," said Weil, who's lived in both states and said the plans reflect the states' different political cultures. "It would be nice if you had a southern state that had achieved universal coverage and did it in a different way, but we don't have that."

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Associated Press writers Bill Poovey in Chattanooga, Tenn., and Steve LeBlanc in Boston contributed to this report.

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US prescription drug use fell in 2008, study says

NEW YORK – Prescription drug use in the U.S. fell last year, although total spending on drugs increased as prices rose sharply on brand-name products, pharmacy benefits manager Medco Health Solutions said Wednesday.

Medco said the overall decline in prescriptions was the first in a decade. The company, which handles drug benefits covering about 60 million people, said total prescription use was down because few new drugs were launched last year, former blockbuster drugs like Zyrtec became available without a prescription, and some drugs faced safety issues that led to decreased use.

Those factors had a bigger impact on prescriptions than the recession, the company said.

Total spending grew 3.3 percent, Medco said, mainly due to greater use of "specialty" drugs, which often treat chronic or complex illnesses. The strongest growth came from diabetes drugs, and use of specialty treatments for cancer, along rheumatological disease, seizure disorders and antiviral drugs also increased. The average price of brand-name pharmaceuticals rose more than 8 percent in 2008, the fastest increase in five years.

Medco said specialty drug prices are rising more quickly than those for other drugs. Specialty drugs often require special handling that is not needed for other drugs, like refrigeration or protection from light, and many must be administered by a doctor or nurse instead of the patient.

Drugmakers tend to raise the price of a product as the date of its patent expiration approaches. After the key patents supporting a drug expire, generic versions usually reach the market and are available for a fraction of the price.

Several drugmakers cited higher prices in their first-quarter earnings reports. Bristol-Myers Squibb, which makes the anti-clotting drug Plavix, said higher prices were responsible for half its revenue growth in the first quarter of 2009.

Medco projects prescriptions will rise no more than 1 percent in 2009 and in 2010 as well. But it believes higher prices will lift total spending by 3 to 5 percent this year and 4 to 6 percent next year.

Franklin Lakes, N.J.-based Medco is the largest pharmacy benefits manager in the U.S. The company filled almost 800 million prescriptions last year.

Revenue from specialty drugs rose almost 16 percent for the year. Medco said growing use of low-cost generic drugs reduced the growth in total spending: 64 percent of all prescriptions were filled with generic drugs. Medco and other pharmacy benefits managers make a larger profit when generic drugs are substituted for brand-name ones. They encourage health plans to develop ways to increase use of generics and 90-day mail-order prescriptions.

Some drugs that were previously available only with a prescription became over-the-counter in 2008, reducing total prescriptions. The biggest names were Zyrtec, an allergy medication, and the laxative Miralax. Drug use was essentially flat with 2008 if Zyrtec and Miralax are excluded, Medco said.

Prescriptions for people 19 and under grew faster than for any other age group. Medco said that was due to rising rates of diabetes among the young, and more prescriptions for attention deficit disorder and similar problems.

Several billion dollar-selling drugs took hits due to potential safety issues last year. Sales of the diabetes treatment Avandia fell after the Food and Drug Administration added new warnings to its labeling, pointing out concerns about heart problems. Sales of the cholesterol drug Vytorin fell after a study released in January showed it was no better than an older drug, Zocor, at reducing plaque buildup in neck arteries. Zocor is available in generic form for about 80 percent less.

Sales of Amgen's Aranesp and other drugs used to treat chemotherapy-induced anemia have been sliding for two years, since studies connected the drugs to the faster growth of some tumors. Medco said safety issues also affected sales of osteoporosis drugs and hormone replacement therapies, and product recalls hurt sales of migraine and cough and cold therapies.

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Births to unwed moms rising, N. Europe beats US

ATLANTA – The percentage of births to unmarried women in the United States has been rising sharply, but it's way behind Northern European countries, a new U.S. report on births shows.

Iceland is the leader with 6 in 10 births occurring among unmarried women. About half of all births in Sweden and Norway are to unwed moms, while in the U.S., it's about 40 percent.

France, Denmark and the United Kingdom also have higher percentages than the United States, according to the report from the U.S. Centers for Disease Control and Prevention.

The U.S. and at least 13 other industrialized nations have seen significant jumps in the proportion of unmarried births since 1980, said Stephanie Ventura of the CDC's National Center for Health Statistics.

Rates have doubled and even tripled in these countries, according to the CDC report released Wednesday.

"Basically we're seeing the same patterns," Ventura said, noting the trend has accelerated in the last five years.

Experts are not certain what's causing the trend but say there seems to be greater social acceptance of having children outside of marriage.

"The values surrounding family formation are changing and women are more independent than they used to be. And young people don't feel they have to live under the same social rules that their parents once did," said Carl Haub, a demographer at the Population Reference Bureau in Washington, D.C.

But there are differences in how unmarried pregnancies are viewed in different countries.

In the United States, unmarried mothers are more likely to be on their own and — traditionally — they are more likely to be poor and uneducated, experts said.

In northern Europe, men and women more often live together in unmarried, long-term, stable relationships, Haub said. Because of declining birth rates in some European countries, people tend to be more focused on whether the baby is born healthy instead of whether the mother is married, Haub said.

He predicted that the total number of births internationally will decline — that's already happening in some European countries — because of faltering economies. But he expects trends in the percentage of mothers who are unmarried will persist.

The CDC previously has reported on the percentage of U.S. births to unmarried mothers. The new report gathers previously released information from other countries to make an international comparison.

The report shows trends from 1980 to the most recent years available — 2007 for the United States and most of the other countries, but 2006 for six nations.

Japan had the lowest percentage of unmarried births, with 2 percent in 2007, up from 1 percent in 1980.

Increases were much more dramatic in the other countries, with Italy rising from 4 percent to 21 percent, Ireland from 5 percent to 33 percent, Canada from 13 to 30 percent, and the United Kingdom from 12 percent to 44 percent.

The U.S. proportion of unmarried births rose from 18 percent to 40 percent during that period, according to the report.

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On the Net:

The CDC report: http://www.cdc.gov/nchs

(This version CORRECTS U.S. number to 40 percent in last graf.)

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Swine flu fears evident as world's cases top 6,000

MEXICO CITY – In China, mask-wearing police cordoned off more hotels Wednesday, quarantining anyone who came in contact with swine flu patients, no matter how mild their symptoms. Not so in Mexico, where the health secretary encouraged tourists to come relax in their favorite vacation spots despite a growing swine flu caseload.

The global outbreak appears mild, but skittishness is evident. Not long after Switzerland lifted its advisory against travel to Mexico and the United States, the Japanese national women's soccer team canceled a tour to North America, where most swine flu cases have been reported.

And in China, hundreds of people have been quarantined inside hotels, hospitals and homes after they came in contact with several infected plane or train travelers from Canada and U.S. The U.S. Embassy said Americans are among those quarantined.

There are now 33 countries reporting an estimated total of 6,080 confirmed swine flu cases, including 3,009 in 45 U.S. states, 2,446 in Mexico and 358 in Canada. But the death total is relatively low — 65, of which 60 were in Mexico, three in the U.S., one in Canada and one in Costa Rica.

Health Secretary Jose Angel Cordova said Wednesday that Mexico has tested about 9,000 sick people, working through a backlog of samples taken before and after the virus was identified as swine flu — and found that Mexico's dead represents 2.5 percent of confirmed cases, suggesting the virus is not as deadly as intitially feared.

Pneumonia, often brought on by regular seasonal flu, may be much more deadly, Cordova said — killing 9,500 people in Mexico last year. The last death from swine flu was on May 7, he said.

Cordova also addressed Mexico's hard-hit tourism industry, saying there are "very few" cases in tourist destinations — including 7 in Cancun.

"There is no risk for tourists — they can return to these relaxing vacation spots," he said.

There is a danger the virus will mutate into something more dangerous — perhaps by combining with the more deadly but less easily spread bird flu virus circulating in Asia and Africa, according to experts at the U.S. Centers for Disease Control and Prevention.

Another concern is that it will combine with the northern winter's seasonal H1N1 virus. While not unusually virulent, it was resistant to Tamiflu, and health officials worry it could make the new swine flu resistant to Tamiflu as well.

With swine flu still spreading around the globe, the World Health Organization is warning countries to limit the use of antiviral drugs to ensure adequate supplies.

European countries have been using antiviral drugs such as Tamiflu and Relenza much more aggressively than the U.S. and Mexico, administering them whenever possible in an attempt to contain the virus before it spreads more widely.

Officials from EU and Latin American nations, including Mexico, were meeting in Prague on Wednesday to discuss the threat.

A WHO medical expert, Dr. Nikki Shindo, said the U.N. agency thinks antivirals should be targeted mainly at people already suffering from other diseases or complications — such as pregnancy — that can lower a body's defenses against flu.

The CDC also said pregnant women should take the drugs if diagnosed with swine flu — even though the effects on the fetus are not completely known.

Pregnant women are more likely to suffer pneumonia when they catch flu, and flu infections have raised the risk of premature birth in past flu epidemics. A pregnant Texas woman with swine flu died last week, and at least 20 other pregnant women with swine flu have been hospitalized in the U.S., including some with severe complications.

For all these reasons, risks from the virus are greater than the unknown risks to the fetus from Tamiflu and Relenza, said Dr. Anne Schuchat of the CDC.

"We really want to get the word out about the likely benefits of prompt antiviral treatment" for pregnant women, she said.

Mexico now gives Tamiflu to anyone who has had direct contact with a person infected with swine flu, Cordova said. And now that schools are back in session, authorities plan to give it to any children who show symptoms and are suspected of being infected.

In Mexico's Baja California state, on the U.S. border, 5,689 children were turned away from schools when classes resumed because they had symptoms like runny noses, headaches or sore throats, the state education department reported Tuesday.

Swiss pharmaceuticals company Roche Holding AG announced it was donating enough Tamiflu for 5.65 million more people to WHO. A further 650,000 packets containing smaller doses of the drug will be used to create a new stockpile for children.

Mexican authorities had enough Tamiflu for 1 million people at the start of the outbreak and have received more, building reserves of 1.5 million courses.

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Medicare won't cover 'virtual colonoscopy'

WASHINGTON – Medicare won't pay for the so-called virtual colonoscopy procedure, concluding Tuesday that there's inadequate evidence to support the cheaper, less intrusive alternative to the dreaded colonoscopy.

Some experts had hoped that popularizing the X-ray procedure would boost screening for colon cancer, the country's second leading cancer killer. Screening to spot early cancer or precancerous growths has resulted in fewer deaths over the last two decades.

But in a decision posted on its Web site, the Centers for Medicare and Medicaid Services said that the test does not qualify for Medicare coverage. The memo noted that the procedure is performed on people without symptoms and cannot, in itself, rid a patient of precancerous growths, like a regular colonoscopy can.

Medicare does cover regular colonoscopies, in which a long, thin tube equipped with a small video camera is snaked through the large intestine to view the lining. Any growth can be removed during the procedure.

CT colonography, also known as virtual colonoscopy, is a super X-ray of the colon that is quicker, cheaper and easier on the patient, but involves radiation. Both procedures involve preparation to clean out the bowels.

The Medicare memo notes that the virtual colonoscopy has shown better precision in detecting larger polyps than smaller ones.

There's been some division of opinion in the medical community over the virtual colonoscopy. Some doctors question its utility since, if a polyp is found, a regular colonoscopy would typically have to follow, anyway.

Others support it, saying it can result in early cancer detection. The American Cancer Society recommends it as an alternative to a regular colonoscopy.

A concern for Medicare officials, according to their decision Tuesday, was the effectiveness of the procedure for the Medicare population — people 65 and older — as opposed to younger patients. More data is needed to answer that, Medicare said.

The U.S. Preventive Services Task Force opted last fall not to give its stamp of approval to the virtual colonoscopy, citing the risk of radiation among other factors. Medicare said it took that decision into account in reaching Tuesday's determination, which is final.

Some private insurers cover the virtual procedure but others don't. Colonoscopies cost up to $3,000 while the X-ray test costs $300 to $800.

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On the Net:

Centers for Medicare and Medicaid Services: http://www.cms.hhs.gov/

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Flu drug advised for pregnant women with swine flu

ATLANTA – Pregnant women should take prescription flu medicines if they are diagnosed with the new swine flu, health officials said Tuesday. So far, the swine flu has not proven to be much more dangerous than seasonal influenza, and it's not clear whether or not pregnant women catch swine flu more often than other people. But in general, flu poses added risks for pregnant women, said Dr. Anne Schuchat of the U.S. Centers for Disease Control and Prevention.

Pregnancy weakens a woman's immune system, so that she's more likely to suffer pneumonia when she catches the flu. In earlier flu pandemics, infection also raised the risk of a premature birth, said Schuchat.

Risks from the virus are greater than the unknown risks to the fetus from the drugs Tamiflu and Relenza, Schuchat said at a press conference Tuesday.

"We really want to get the word out about the likely benefits of prompt antiviral treatment" for pregnant women, she said.

Still, the flu medicines' effectiveness is somewhat limited, studies have shown. They can relieve symptoms and shorten the disease by about a day. They only work if started within 48 hours of first symptoms, and little is known about whether they cut the chances of serious flu complications. Most people recover from the flu with no medical treatment.

But a pregnant Texas woman who had swine flu died last week, and at least 20 other pregnant women have swine flu, including some with severe complications.

In total, about 3,000 U.S. cases of swine flu have been confirmed through lab testing so far, most of them ages 18 and under. Officials think the actual number of infections is much higher, and that infections are still occurring.

CDC officials said the swine flu may seem to be mild now, but they worry the virus will mutate into something more dangerous. One concern is that it will combine with the more deadly but less easily spread bird flu virus that has been circulating in Asia and other parts of the world.

Another concern is that it will combine with the seasonal H1N1 virus that went around over the winter. That virus was not unusually virulent, but it was resistant to Tamiflu — the current first-line defense against the new swine flu. If the two virus strains combine, it's possible the swine flu will become resistant to Tamiflu as well, health officials worry.

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On the Net:

CDC swine flu web site: http://www.cdc.gov/h1n1flu/

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As swine flu spreads, who should get Tamiflu?

MEXICO CITY – The swine flu epidemic may seem mild now, with relatively few deaths even as the virus infects thousands in at least 33 countries. But experts worry it could mutate into something more dangerous — making the question of who should get antiviral therapy ever more important.

The World Health Organization said Tuesday that countries should save antiviral drugs for those patients most at risk, and the U.S. Centers for Disease Control and Prevention added that pregnant women in particular should take the drugs if they are diagnosed with swine flu — even though the effects on the fetus are not completely known.

European countries have been using antiviral drugs such as Tamiflu and Relenza much more aggressively than the United States and Mexico — administering it whenever possible in an attempt to contain the virus before it spreads more widely.

Instead, the WHO recommends that antivirals be targeted mainly at people already suffering from other diseases or complications — such as pregnancy — that can lower a body's defenses against flu, WHO medical expert Dr. Nikki Shindo said.

Pregnant women are more likely to suffer pneumonia when they catch flu, and flu infections raised the risk of premature birth in past epidemics. A pregnant Texas woman who had swine flu died last week, and at least 20 other pregnant women have swine flu, including some with severe complications.

For all these reasons, risks from the virus are greater than the unknown risks to the fetus from Tamiflu and Relenza, said Dr. Anne Schuchat of the U.S. Centers for Disease Control and Prevention.

"We really want to get the word out about the likely benefits of prompt antiviral treatment" for pregnant women, she said.

Mexico is now giving Tamiflu to anyone who has had direct contact with a person infected with swine flu, Health Secretary Jose Angel Cordova said. And now that schools are back in session, authorities plan to give Tamiflu to any children who show symptoms and are suspected of being infected.

CDC officials said the swine flu may seem to be mild now, but they worry the virus will mutate into something more dangerous — perhaps by combining with the more deadly but less easily spread bird flu virus circulating in Asia and Africa.

Another concern is that it will combine with the northern winter's seasonal H1N1 virus. While not unusually virulent, it was resistant to Tamiflu, and health officials worry that it could make the new swine flu resistant to Tamiflu as well.

The nearly 6,000 confirmed cases worldwide so far have included 63 deaths, and Mexico's death toll rose by two on Tuesday to 58, with 2,282 confirmed infections. But Cordova said the worst appears over — and the more cases the country confirms, the less deadly the virus appears. The increasing toll reflects a testing backlog, Cordova said, with the last confirmed case on May 8.

The U.S. has the world's highest caseload, at more than 3,000 infections in 45 U.S. states, but many countries have focused their energy on containing the spread from Mexico, rather than the U.S. Cuba, Thailand and Finland reported their first cases Tuesday, all in people who had returned from Mexico, and criticism of Mexico's handling of the crisis continues.

Cuba's first case — a Mexican student attending a Cuban medical school — came despite strict restrictions on flights and travelers, prompting former president Fidel Castro to accuse Mexico of hiding the epidemic until after President Barack Obama visited last month.

Mexico has denied hiding anything — and the timeline supports this: Obama's April 16 visit came a week before Canadian and U.S. scientists identified swine flu in Mexican patients, at which point Mexico quickly imposed an unprecedented shutdown of most aspects of public life for days.

"The response by Mexico's health care system and the country's transparency in the way it conducted itself has allowed all nations ... to be able to take preventive measures in a timely manner so they could combat this illness," President Felipe Calderon said Tuesday.

China said it has tracked down and quarantined most passengers who shared flights with the mainland's first known swine flu sufferer — a Chinese graduate student from the U.S. who is said to be improving.

"We must attach great importance to the fact that the flu epidemic is still spreading in some countries and regions, and that China has discovered one case," said President Hu Jintao.

About 260 people were quarantined in Beijing, including 70 foreigners, the China Daily reported. In Sichuan province, the government said another 95 people were being isolated.

With the virus now spreading worldwide, Swiss pharmaceuticals company Roche Holding AG announced it is donating enough Tamiflu for 5.65 million more people to WHO. A further 650,000 packets containing smaller doses of the drug will be used to create a new stockpile for children.

At the start of the outbreak, Mexico had enough Tamiflu for 1 million people, and has since received more, building reserves of 1.5 million courses.

Each country's health experts must decide if infected people should immediately be treated with antivirals, Shindo said — a decision that also must take into account how many antivirals are available.

"As part of pandemic preparedness plans, we urge countries to plan for prioritization," Shindo said.

Mexico's overburdened health system has been strained. Dozens of government doctors and nurses marched and blocked streets in the Gulf coast city of Jalapa to demand higher pay and better working conditions.

Mexico also is trying to revive its economy after the epidemic pummeled tourism, the country's third-largest source of legal foreign income. Cordova said there have been no swine flu cases in five top Mexican vacation spots, including Los Cabos, Puerto Vallarta, Cozumel, Mazatlan and Zihuatanejo.

But with incoming flights virtually empty of tourists, Tourism Secretary Rodolfo Elizondo said a $90 million publicity campaign would focus on encouraing Mexicans to vacation at home.

Promoting trips by foreigners now, he said, "would be like throwing money away."

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Associated Press writers Michael Stobbe in Atlanta; Maria Cheng in London; and Gillian Wong in Beijing contributed to this report.

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Senators weigh tax hikes to pay for health care

WASHINGTON – Senators are considering limiting — but not eliminating — the tax-free status of employer-provided health benefits to help pay for President Barack Obama's plan to provide coverage to 50 million uninsured Americans.

Finance Committee Chairman Max Baucus, D-Mont., said Tuesday that there are no easy options. Senators began grappling with how to finance guaranteed coverage, a cornerstone of Obama's plan to overhaul the health care system. Independent experts put the costs at about $1.5 trillion over 10 years.

Obama sees a world in which doctors and hospitals compete to offer quality service at lower costs, and the savings help cover the uninsured. Turning that vision into reality remains the biggest challenge for the president and his backers, because hard cash — not just ideas — is required to cover upfront costs of expanding coverage.

The president put health care industry leaders on notice Tuesday that he expects them to fulfill their dramatic offer of $2 trillion in savings over 10 years. "I will hold you to your pledge to get this done," Obama said in a letter released by the White House that went to groups representing insurers, hospitals, doctors, drug makers and others.

But those savings — even if the industry delivers every penny — won't all accrue to the government. So the financing package for Obama's plan is likely to include a mix of tax increases and spending cuts in federal health programs.

Among the possibilities: tax increases on alcoholic beverages, tobacco products and sugary soft drinks, and restrictions on other health care-related tax breaks, such as flexible spending accounts.

But some taxes don't seem to be on the table, such as a federal sales levy to pay for health care or a new payroll tax.

Congressional leaders say they want to pass legislation in the Senate and House this summer.

On the controversial question of taxing health benefits, Baucus is staking out a position that could put him at odds with Obama.

The president adamantly opposed such taxes during the campaign, arguing they would undermine job-based coverage. Obama's aides now say he's open to suggestions from Congress, even if he criticized Republican presidential rival John McCain for proposing a sweeping version of the same basic idea.

Baucus said he wants to modify the tax break, not abolish it.

"We are not going to repeal it," he said.

Baucus suggested that the benefit could be limited by taxing health insurance provided to high-income individuals, although he did not specify at what income levels. He also said that plans offering rich benefits — for example, no co-payments or deductibles — might be taxed once their value exceeded a yet-to-be-determined threshold.

White House press secretary Robert Gibbs resisted being drawn into the congressional debate. "We're not going to get into a daily scorekeeping of each idea and proposal," he said.

Employer-provided health insurance is considered part of workers' compensation, but unlike wages, it is not taxed. The forgone revenue to the federal government amounts to about $250 billion a year.

Proponents of repealing the benefit say it encourages lavish health insurance plans that only add to waste in the health care system. And they argue that the benefit is unfair, since self-employed people don't get as big a tax break for health care.

Many experts say that Congress won't be able to come up with the kind of money needed to provide coverage for all unless limitations on the health care tax break are part of the mix.

"I don't see how you're going to put a package together ... unless you touch the exclusion," said Robert Greenstein, director of the Center on Budget and Policy Priorities, which advocates for low-income people. In government jargon, the tax-free status of health insurance is called the "tax exclusion."

Obama has proposed to pay for the plan with a 50-50 mix of tax increases and spending cuts. On the tax side, the president would limit income tax deductions for families making more than $250,000 a year, raising $267 billion over 10 years. Baucus said Tuesday that idea deserves consideration.

The ranking Republican on the Finance Committee, Sen. Charles Grassley of Iowa, said lawmakers should try to squeeze wasteful spending out of the system before imposing new taxes. But Grassley ridiculed the health care industry's pledge of $2 trillion in savings through voluntary efforts to hold down costs.

"I'm sure we will be waiting for some time before this fairy dust becomes real gold," he said.

One option for lawmakers would be to codify the industry's cost reduction offer in federal law, giving it some teeth by applying it to federal health insurance programs.

Protesters who back government-run health care disrupted the Finance Committee hearing. Police ejected five doctors and nurses after they interrupted Baucus and Grassley at the start of the session.

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Associated Press writer Erica Werner contributed to this report.

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Miami VA: Steps taken to prevent contamination

MIAMI – The top Veterans Affairs official in Miami said Tuesday she has taken steps locally to prevent the kind of problems that exposed patients to contaminated medical equipment at VA hospitals in three states.

Mary D. Berrocal, director of the Miami VA Healthcare System, told The Associated Press she has hired someone in Miami to supervise training, make sure biomedical equipment works properly there and ensure the problems aren't repeated.

"We have truly scrutinized our systems to ensure that doesn't happen," she said. "We truly, truly are on it ... We've really, really, really expended every effort possible to make sure that this is an isolated situation."

But she declined to discuss specifics about the contamination problems or say how they went undetected for so long.

Five patients have tested positive for HIV — three of them in Miami — and 33 have tested positive for hepatitis since February, when the VA started notifying more than 11,000 people treated at three VA medical centers to get follow-up blood checks because they could have been exposed to infectious body fluids. The equipment is used for colonoscopies and ear, nose and throat procedures.

The hospitals are in Miami, Murfreesboro, Tenn., and Augusta, Ga.

Berrocal, who has been praised by some Miami veterans in the aftermath of the scandal, said that when she first heard about the situation: "I was heartbroken, you know."

The problems with cleaning equipment — and possibly co-mingling infectious body fluids — went on for five years at the Miami and Murfreesboro hospitals and about a year in Augusta.

Berrocal said she couldn't discuss the specifics because of a continuing investigation by the VA and its inspector general.

U.S. Rep. Kendrick Meek, D-Fla., was informed Monday that the VA inspector general's report will be issued within weeks or days to the House Veterans' Affairs Committee, Meek's spokesman Adam Sharon said.

Meek called for congressional hearings when the scandal broke out. Sharon said those hearings are expected to take place shortly after the report is issued.

North Carolina Sen. Richard Burr, the top Republican on the Senate Veterans' Affairs Committee, has also called for hearings on the subject.

The endoscopic equipment is made by Center Valley, Pa.-based Olympus American Inc., and the company has said its recommended cleaning procedures are clear. Berrocal said it's "very complicated equipment."

She said a series of experts have reviewed the processes and the systems and improved them.

She added, "I think our quest has to be about doing everything possible, everything that we can to minimize the potential for error and to take care of our patients. We have to constantly be vigilant"

The VA has stressed that the positive tests are "not necessarily linked" to medical treatment at its hospitals, and infections don't always cause symptoms and can go undetected for years.

No matter where the patients contracted the illnesses, Berrocal said the VA will treat them.

"Miami has a very high percentage of those illnesses anyway. It is very hard to tell whether they contracted it from this or not," she said. "To me, it just doesn't matter how they got it. If we found it, we are going to treat it."

Berrocal said the discovery of the problems at the VA may have helped improve health care nationwide.

"It's really unfortunate that this happened, however, I believe that it has increased awareness across the country about this piece of equipment. It's not only used in VA," she said.

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FDA takes issue with Cheerios health claims

WASHINGTON – Federal regulators are scolding the maker of Cheerios, saying it made inappropriate claims about the popular cereal's ability to lower cholesterol and treat heart disease.

The Food and Drug Administration says in a warning letter to General Mills that language on the Cheerios box suggests the cereal is designed to prevent or treat heart disease. Regulators say that only FDA-approved drugs are allowed to make such claims.

Among other claims, the labeling states: "you can lower your cholesterol 4 percent in six weeks."

General Mills said the health claims on Cheerios have been approved for 12 years and the FDA's complaints deal with how the language appears on the box. The company said in a statement that the science was not in question.

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Obama praises health industry's vow to cut costs

WASHINGTON – Barack Obama praised the health care industry's promise to cut $2 trillion in costs over 10 years Monday, taking a sharply different course than President Bill Clinton did 16 years ago in an opening bid to overhaul the U.S. health system.

Drawing skepticism from lawmakers, Obama summoned representatives of the insurance industry, doctors, hospitals, pharmaceutical companies and labor groups to the White House for what he called "a watershed event in the long and elusive quest for health care reform."

It was a gathering of strange bedfellows. More than a decade ago, then-President Bill Clinton and his wife, now-Secretary of State Hillary Rodham Clinton, designed a health care plan in secret, fought industry leaders over it and lost — setting back the Democratic Party's cause for years.

If Obama succeeds in lowering costs and increasing access to health care, the meeting will be remembered as pivotal. If not, it will be just another Washington photo-op.

Indeed, the industry's proposal was short on specifics. And it appeared to do little to change minds in Congress as lawmakers attempt to write legislation to implement Obama's goal of extending health care to some 50 million uninsured Americans.

Within moments of Obama's appearance with the industry leaders, lawmakers praised the effort but suggested it didn't go to the heart of the health care debate.

Several lawmakers made clear that the industry proposal would do nothing to stave off the outcome that health insurers and others are trying to avoid — a new government insurance plan that would be available to middle-income Americans. Health insurers say such a plan would drive them out of business.

Sen. Ron Wyden, D-Ore., cautiously welcomed the industry's offer while saying, "I am not about to take the fox's word that the hen house is safe." He said the industry's promises need to be given the weight of law.

The industry groups said they would slow the growth of health care costs by 1.5 percent a year by coordinating care, reducing administrative costs and focusing on quality, efficiency and standardization. Health care costs would still grow faster than the economy as a whole, but not as fast as they otherwise would.

The specifics, industry officials said, would come later.

Obama has spoken often of the exorbitant costs in the nation's health care system, but slowing the rate price increases doesn't translate directly to paying the estimated $1.5 trillion cost of covering the uninsured. Money saved by the private sector doesn't flow directly to the federal treasury.

The top Republican on the Senate Finance Committee, Chuck Grassley of Iowa, called the announcement a "move in the right direction," but said it would be more significant if the Congressional Budget Office, Washington's arbiter of what costs or saves money for the government, determined it saved money.

"When the White House and the industry put concrete proposals on paper and get a score from the Congressional Budget Office, then we'll know if the suggestions really achieve that kind of savings, and it'll be big news," Grassley said. "For health care budgeting purposes, CBO's word is the only one that counts."

Karen Ignagni, president of America's Health Insurance Plans, contended that the voluntary cost-containment effort would help lawmakers who are aiming to craft health overhaul legislation by August.

"They need help from the stakeholder community on cost containment and what you're hearing from all of us is we intend to help and that I think is the story today," Ignagni said.

The groups who signed onto Monday's effort were the American Medical Association, America's Health Insurance Plans, the Pharmaceutical Research and Manufacturers of America, the Service Employees International Union, the American Hospital Association and the Advanced Medical Technology Association.

Officials said they could bring costs down even while continuing to stay profitable — noting that if health care legislation passes they'd be able to tap into a huge pool of currently uninsured people.

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Associated Press writers Henry C. Jackson and Ricardo Alonso-Zaldivar contributed to this report.

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Worry over weight: Poll finds health disconnect

WASHINGTON – Scan the breathless headlines at any magazine rack — Fight Flab in Minutes! Get Beach Ready! Add the skinny yet buxom model, and it should be no surprise that the average woman feels insecure if not downright unhappy with her real-world figure. Hang on: Are we worried just about appearance, or about whether our size signals a health problem?

There's a big disconnect between body image and true physical condition, an Associated Press-iVillage poll suggests. A lot of women say they're dieting despite somehow avoiding healthy fruits and veggies. Many others think they're fat when they're not.

"The priorities are flipped," says Dr. Molly Poag, chief of psychiatry at New York's Lennox Hill Hospital.

She points to women athletes as much better role models than supermodels: "There's an undervaluing of physical fitness and an overvaluing of absolute weight and appearance for women in our culture."

About 60 percent of Americans are overweight or obese. The AP-iVillage poll of 1,000 adult women mirrors the government's count on that. More surprising, perhaps, are women's attitudes and actions.

Half don't like their weight, even 26 percent of those whose body mass index or BMI — a measure of weight for height — is in the normal range. But just a third don't like their physical condition, even though being overweight and sedentary are big risk factors for Type 2 diabetes, heart disease and other ailments.

The poll found women putting in a median of 80 minutes of exercise a week, meaning half do even less. The average adult is supposed to get 2 1/2 hours of exercise a week for good health.

And just 8 percent of women ate the minimum recommended servings of fruits and vegetables — five a day. A staggering 28 percent admit they get that recommended serving once a week or less.

Time is a big barrier.

"I was a fanatic about exercise when I was younger, and I quit focusing on that when I had kids," says Laura Comer, 45, of Sugar Land, Texas, a mother of two.

But she just her lost her job as a hospital system vice president and is using the new free time to ease in more activity. First up: walking 10,000 steps a day.

Vesna Stemwell, 51, of Delano, Minn., has a sedentary job — she's a computer programmer — with lots of overtime and a 45-minute commute.

Temporarily giving up meat and dairy products for a religious observance helped her drop five pounds, so she's considering becoming vegetarian to drop more. But her husband isn't keen about a menu change.

"Changing the diet," Stemwell said, "affects everybody in the house and it's hard to have something different."

About a quarter of the women surveyed said they'd consider plastic surgery to feel more beautiful. Their overwhelming choice: a tummy tuck.

"There isn't any quick fix," says Dr. Nieca Goldberg, who directs the women's heart program at the New York University Langone Medical Center.

A tummy tuck is cosmetic, removing just some surface fat, and a far cry from more radical surgeries like stomach stapling that are reserved to help the health of the very obese.

"People can't see the damage that's being done inside their body," says Goldberg. "If you increase your fitness but don't lose as much weight, you still have a lower heart disease risk than someone who is obese and sedentary."

At the other end of the spectrum, the poll found 16 percent of normal-weight women who nonetheless are dieting to drop pounds. Most extreme are eating disorders like the anorexia that has tormented Daleen Johnson of Oceanside, Calif., for years.

Her two children spurred the 5-foot-9 Johnson to put on 20 pounds in the past year, getting up to 125.

"My 8-year-old came up to me and was like, 'Mom, why don't my hip bones stick out like yours?'" said Johnson, 28. "I could put my selfishness aside so that she didn't think being skinny is what matters."

Still, Johnson says, "Summer's coming and I'm panicking because I don't think that I'm good enough. I don't look like the supermodel on TV."

Eating disorders aside, normal-skinny doesn't automatically mean healthy, stresses University of Houston sociologist Samantha Kwan, who studies gender and body image.

"Someone who is fat or even overweight can be healthy if they have a balanced diet and are physically active," Kwan says. "Our culture really does put a lot of pressure on women to look a certain way," taking precedence over health measures.

Olive James, 60, of Cincinnati gets that message. She calls herself about 10 pounds over her target weight, but exercises 30 minutes a day and takes her cholesterol and blood pressure medicine.

"I do get a lot of compliments for the way I carry myself," she says. "I feel great."

The AP-iVillage poll was conducted April 20-30 by Knowledge Networks, which contacted survey participants using traditional telephone and mail polling methods but then intensively questioned them online, providing Internet access for those who needed it. The poll has a margin of error of plus or minus 3.7 percentage points.

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EDITOR'S NOTE — Lauran Neergaard covers health and medical issues for The Associated Press in Washington.

AP Polling Director Trevor Tompson and Associated Press Writer Christine Simmons contributed to this report.

On the Net:

iVillage sites: http://healthvideo.com/ap_poll and http://yourtotalhealth.ivillage.com/healthier-habits-tummy-tuck.html

AP survey results: http://surveys.ap.org/

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Swine flu spreads in world; Mexico opens schools

MEXICO CITY – Mexico welcomed millions of children back to school Monday with masks, thermometers and globs of hand sanitizer, as scientists estimated the new strain of swine flu could have sickened 23,000 people before anyone realized it was an epidemic.

At least 61 people have been killed by swine flu around the world, and the World Health Organization has confirmed 4,800 cases, including the first in mainland China. China scrambled Monday to find and quarantine more than 200 people on the infected man's flight from the U.S., though the University of Missouri campus where he had been studying planned no special precautions.

A study published Monday in the journal Science estimated Mexico alone may have had 23,000 cases by April 23, the day it announced the epidemic. The study estimates swine flu kills between 0.4 percent and 1.4 percent of its victims, but lead author Neil Ferguson of Imperial College, London, said the data remain incomplete.

"It's very difficult to quantify the human health impact at this stage," he said.

The reopening of kindergartens and primary and middle schools shut since April 24 was the latest step in Mexico's efforts to restore a sense of normality. Businesses, government services, high schools and universities reopened last week.

But six of Mexico's 31 states put off reopening schools for a week because of local rises in the number of cases, and a seventh ordered a one-day delay.

In Mexico City, children lined up outside the Ignacio L. Vallarta public elementary school so teachers could check students for flu symptoms. Some parents worried schools were opening too soon, but many were also relieved after spending two weeks trying to entertain bored children. Officials said any students with symptoms would be sent home.

"It's good that schools are reopening. Our children were getting lazy," said Eugenia Martinez as her 8-year-old son, Edgar, ran around in a white mask and Power Rangers T-shirt. "I think everything is under control."

The federal Education Department said Monday that all 250,000 schools — except some 30,000 in states that did not reopen Monday — had been cleaned and disinfected as 25 million children prepared to return to class.

"It's very important for families to know that the disease is curable; we have enough medicine to treat any cases that arise," Education Secretary Alonso Lujambio Irazabal said. "As soon as we suspect we have a case we are going to offer antivirals to that person, that teacher, that student."

Mexico also is trying to revive its economy after the epidemic pummeled tourism, the country's third-largest source of legal foreign income. Mexico provided details Monday of a 14 billion peso ($1.1 billion) package to help restaurants, hotels and other businesses.

At least 10 commercial banks are involved in the plan, promising three-month reprieves for small businesses with outstanding loans in Mexico City and two hard-hit states. Small businesses in beach resorts and other tourist destinations were promised a six-month grace period.

"We are not looking for magical or spectacular solutions — which would be illusory — only that businesses have the liquidity need to recover from this emergency," Finance Secretary Agustin Carstens said. "Mexico is facing a very complicated year that combines a flu outbreak with one of the most severe global recessions in the last 60 years."

Later in the day, Tourism Secretary Rodolfo Elizondo said the government would launch a 1.2 billion peso ($90 million) publicity campaign this week urging Mexicans to take vacations in their own country.

Noting several nations have issued travel warnings or restricted airline flights to Mexico, Elizondo said that for now trying to promote trips to Mexico by foreigners "would be like throwing money away." He said occupancy rates at Mexico's top beach resorts are averaging between 15 percent and 23 percent.

The number of countries reporting confirmed swine flu cases grew to 31, with Cuba saying a Mexican who came to the island to study was sick with the virus. Cuba said the student was among a group from several Mexican states that began arriving April 25 — four days before Cuban authorities halted airline flights from Mexico in hopes of keeping out the illness.

The United States now has the most confirmed cases — 2,618 — according to the U.S. Centers for Disease Control and Prevention. Mexico has confirmed 2,059 cases. Swine flu has killed 56 people in Mexico, three in the U.S., one in Canada and one in Costa Rica.

The analysis in Science suggests there are many more cases than those confirmed by laboratories — anywhere from 6,000 to 32,000 cases in Mexico as of April 23. The flu has since spread around the world, and the study said it appears to be substantially more contagious than normal, seasonal flu.

Researchers also compared the DNA of the viruses in 23 confirmed cases, and came up with an estimate of Jan. 12 for their earliest common ancestor — presumably when person-to-person transmission began. But with everything that isn't known, they said it could have been anywhere from Nov. 3 to March 2.

The researchers said the 2009 H1N1 flu appears to be about equal in severity to the flu of 1957 and less severe than the deadly 1918 version.

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Associated Press writers Maria Cheng in London, Randolph E. Schmid in Washington and Gillian Wong in Beijing contributed to this report.

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Critics: WHO slow on generics for swine flu

LONDON – As poor countries face a possible swine flu pandemic with only enough Tamiflu to treat a tiny fraction of their populations, some experts are calling for a simple but contentious solution: massive production of generics.

Antivirals such as Tamiflu are believed to be effective against swine flu if administered early.

Tamiflu, made by the Swiss drugmaker Roche, sells for as much as $100 per treatment in countries such as the U.S., but since 2005 the company has offered a discounted price of $16 per treatment to poor nations. Cheap generics also can easily be manufactured by other companies, if the drug producers allow it.

Many rich nations sit on stockpiles of expensive Tamiflu, which was created in 1996 and is patent protected in most countries. However, Roche granted two companies in China and one in India permission to produce generic versions of Tamiflu in 2006. It also announced a transfer of the technology needed to make the drug to a company in South Africa.

Roche could not say how many developing countries have ordered Tamiflu at the cheaper price.

"We remain ready to discuss options with any manufacturers who can make Tamiflu," David Reddy, who works on Roche's global pandemic task force in Basel, Switzerland, said Monday.

Despite this availability, the World Health Organization — which maintains its own stockpiles of Tamiflu for poor nations — has not ordered up new batches of generic Tamiflu, even though WHO raised its pandemic alert level to phase 5, signaling it believes a global flu outbreak to be "imminent."

Critics say Roche should allow even more companies to produce generic Tamiflu, and that money from donor countries would go further in the Third World, if WHO was buying generic flu medicines itself or advising poorer countries to do so.

Meanwhile, in India, which does not recognize Roche's patent, the pharmaceutical giant Cipla has said it will charge about $12 per course of a generic Tamiflu.

Some critics suspect WHO is reluctant to anger drug companies, which supply it with free stockpiles of drugs, by encouraging the use of generics. Given all they spend on research and development to produce new drugs, Western pharmaceuticals have long fought to keep generics out of the market in all circumstances.

"There needs to be a better system in place so that WHO does not have to rely on the goodwill and charity of drug makers to get medicines for poor countries," said Sangeeta Shashikant of Third World Network, a nonprofit development organization.

WHO insists it's doing its best to secure antivirals for poor countries.

"WHO will work on behalf of its member states to secure further antivirals as needed, either through donations or purchase at the lowest possible price, to support developing countries in need," said Elil Renganathan, a WHO official working on antivirals.

Tamiflu and a similar medicine, Relenza, are mainly used to treat flu, but they only work if started within 48 hours of first symptoms. Studies show they cut the duration of illness by about one day, compared with no treatment. Little is known about whether these medicines cut the chances of serious flu complications, like pneumonia, and few studies have tested them in children.

Experts say vaccines would offer the best protection against a swine flu pandemic, but they won't be available for months.

And even when they are, rich countries are first in line: Britain, Canada, Denmark, France, the United States and others have all signed deals with vaccine makers to ensure they get the first batches of pandemic vaccine off the production line.

WHO is appealing to vaccine makers to save some of their vaccines for poor countries, but it's doubtful they will get enough to treat a significant portion of the population.

Last week, Cipla said it could produce 1.5 million treatments of a generic version of Tamiflu in the next few weeks. But Yusuf Hamied, the company's chairman, said it is ready to make millions more courses as soon as poor countries and agencies like WHO place orders.

"We could make a lot more, but there needs to be firm commitment from countries and international agencies like WHO," he said. "The ball is in their court."

So far, WHO has not recommended that countries with production capacity start making their own generic supplies of antivirals.

WHO has a stockpile of about 5 million Tamiflu treatment courses donated by Roche, and last week the agency began sending 2.4 million treatments to 72 poor countries. But such numbers pale in comparison to hundreds of millions of people in the developing world who would be vulnerable in a flu pandemic.

WHO says it is exploring generic production, but no decisions have been made. WHO says it is unsure how much massive generic production could increase the global supply and would not estimate a cost.

Renganathan said WHO wants to ensure any generic medicines meet drug safety standards. He said they are investigating the possibility of generic production with companies wherever they are located.

Still, critics say WHO has been slowfooted on generics.

"I don't know why WHO hasn't pursued generics," said Tido von Schoen-Angerer, director of Medecins Sans Frontieres' Access to Essential Medicines Campaign.

"A big role for WHO is to increase the world's generics supply of antivirals and make sure all countries have access," von Schoen-Angerer said. "It's not clear why WHO hasn't prioritized this."

With a large supply of generics, developing countries that could afford them, like Thailand and Brazil, could reinforce their own supplies. For poorer nations, agencies like UNICEF might buy the antivirals and distribute them to countries in need.

High rates of HIV, malaria, tuberculosis, malnutrition and other health problems greatly deepen the vulnerability of the world's poorest countries to a flu pandemic.

So far, critics say there's no indication from WHO that generic options will be prioritized for poor countries that can't afford Roche's Tamiflu.

"Countries are going to scramble to get as many medicines as they can in this situation," said Martin Khor, executive director of the South Centre, a think tank focused on developing countries.

"WHO should be helping countries to get stockpiles of antivirals as cheaply as possible."

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With swine flu, we're all in this together

MEXICO CITY – On the western edge of Mexico's capital, 10 new luxury apartment towers promise an antiseptically modern lifestyle with spas, private playgrounds and an exclusive shopping center. Blocks away, a world-class private hospital has opened.

But there's no escaping the view from these $1.5 million apartments: Just across a ravine is a slum where maids and construction workers make do in crowded, humid homes of raw concrete and spotty drinking water. For them, getting sick means medicating themselves at a discount pharmacy, or waiting for hours in an overcrowded public hospital.

Wealthy Mexicans aren't alone in trying — and failing — to distance themselves from deprivation and disease. People all over the world want to protect their families from the problems of the less fortunate.

But if there's anything we've learned from the swine flu epidemic, it is this: the virus doesn't discriminate.

"We're all in this together," President Barack Obama said as he urged public health agencies to reach all corners of America. "When one person gets sick, it has the potential of making us all sick."

The outbreak might not have become an epidemic if Mexico's first swine flu victims had been identified and treated quickly. We now know that for most, the virus causes only mild symptoms, and that nearly all of those who become quite sick can recover if they get proper treatment within 48 hours.

We also know that most of Mexico's dead didn't get that treatment in time.

But it feels awfully late to be pointing fingers over initial delays. And by ordering a nationwide shutdown last week of public gathering places where flu can spread, Mexico saved many more lives, experts say.

Now the world must face what Mexicans learned as they stayed home from schools and restaurants, venturing outside fearfully in face masks only to replenish their refrigerators: Rich and poor breathe the same air. The 53 people killed around the world so far range from poor day laborers to the grandson of one of the richest men in Mexico.

It's a moral challenge, as clear now as the view from those luxury living room windows: When vast numbers of poor people lack decent health care, no one is immune from disease.

A rural bricklayer with a bad cough, a kindergartner in a remote mountain village, a maintenance worker in a vast urban slum — these swine flu cases might have seemed a world away from the United States and Europe.

But it takes just four hours by bus for workers to reach the capital from the pig-farming community of La Gloria, where hundreds of villagers were suffering from acute respiratory infections for weeks before one of their kindergartners became Mexico's earliest confirmed swine flu case.

It takes even less time to fly from Mexico City to the U.S., where this strange new strain of swine flu was first identified in a 10-year-old San Diego boy.

No one knows yet where this outbreak began. Despite calls to close the U.S. border, scientists say the deadly chimera — a blend of bird, human and pig flu genes for which humans have limited natural immunity — may have jumped from pigs to humans in North Carolina, about 10 years and 10,000 generations of virus ago.

Millions of dollars have been spent on pandemic preparedness since scientists realized flu could jump between species. Top flu experts even developed a detailed containment plan — with an extremely limited window of opportunity.

World Health Organization experts determined that a virus with pandemic potential would have to be identified, the epicenter quarantined and 80 percent of the initially affected population blanketed with antiviral drugs within three weeks of the first symptoms.

Oh, and the outbreak would have to be limited to a small geographic area — like a remote village of about 1,000 people.

This H1N1 virus was likely spreading all over Mexico and parts of the United States long before anyone got sick enough to be tested. By the time the wheezing, sneezing villagers of La Gloria complained enough for their samples to be taken, dozens had been commuting to Mexico City for weeks.

Before anyone knew this flu's name, cases were popping up all over the megalopolis of 20 million.

A Canadian lab quickly confirmed that swine flu had reached Mexico, and a global alarm was raised. But only hours later, the WHO said it was useless to close borders and ban flights. Travelers had already carried the virus from Mexico to New York and New Zealand. It has since spread to at least 29 countries around the world.

So now Mexico's challenge has become a truly global problem. Experts say even normal seasonal flu infects millions and kills about 500,000 people worldwide every year. With the WHO warning that a possible swine flu pandemic could infect 2 billion people, how on earth can we protect the whole world?

The drug makers say they can "most likely" produce 917 million doses in 10 months, a number considered overly ambitious by some experts.

Even the first vaccines won't be ready for months — too late for the Southern Hemisphere, where flu season is about to start. And if the virus evolves into something more contagious or deadly — possibly by mixing with regular flu or even H5N1 bird flu, which is endemic in parts of Asia and Africa — these vaccines may not provide much protection in the end.

Antiviral drugs will be critical if it comes to that, but they are expensive, and there aren't enough to go around. The largest stockpiles are kept by the wealthiest nations, for their own citizens' protection.

But hoarding antivirals could backfire. A 2007 study modeled what would happen in a flu pandemic if wealthy nations hoard or share these drugs.

They concluded that the hardest-hit populations should be blanketed with antivirals, even if they are too poor to pay for them, and even if it means people with reliable health care in wealthier nations would go untreated.

Doing so would save many millions of lives, they found — including in the wealthy countries that share.

Nobody knows where this current outbreak is headed as the swine flu virus evolves. It may lose its potency.

Or it may become a real killer. And if that happens, there will be some hard decisions to make.

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US, Costa Rica swine flu deaths reported

SEATTLE – The number of swine flu-related deaths outside Mexico has inched up to five with the U.S. reporting its third fatality and Costa Rica its first, both involving men who also had underlying illnesses.

The number of confirmed cases of the infection in the U.S. has risen to 2,532 in 44 states, the Centers for Disease Control and Prevention reported Sunday.

Washington state health officials said the victim there was a man in his 30s who had underlying heart conditions and viral pneumonia when he died Thursday from what appeared to be complications from swine flu. The state Department of Health said in a statement Saturday that swine flu was considered a factor in his death.

"We're working with local and federal partners to track this outbreak," said Washington State Secretary of Health Mary Selecky.

The man was not further identified. He began showing symptoms on April 30, and was treated with anti-viral medication. Dr. Gary Goldbaum, Snohomish Health District medical director, said medical officials hadn't been able to isolate any "risk factors" for the man to identify where he might have been exposed.

The death of a 53-year-old man in Costa Rica on Saturday was the first involving swine flu outside North America. He also suffered from diabetes and chronic lung disease, the Health Ministry said.

Most of the victims in Mexico, the center of the outbreak where 48 people with swine flu have died, have been adults aged 20 to 49, and many had no reported complicating factors.

Previously, U.S. authorities reported swine flu deaths of a toddler with a heart defect and a woman with rheumatoid arthritis, and Canadian officials said the woman who died there also had other health problems but gave no details.

Mexico, which raised its count of confirmed cases to 1,626 based on tests of earlier patients, has been gradually lifting a nationwide shutdown of schools, businesses, churches and soccer stadiums.

But an upswing in suspected — though not confirmed — cases in parts of Mexico prompted authorities in at least six of the country's 31 states to delay plans to let primary school students return to class Monday after a two-week break.

"It has been very stable ... except for those states," Health Department spokesman Carlos Olmos said, referring to states in central and southern Mexico.

Mexican health authorities released a breakdown of the first 45 of the country's 48 flu deaths that showed that 84 percent of the victims were between the ages of 20 and 54. Only 2.2 percent were immune-depressed, and none had a history of respiratory disease.

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Marshall reported from Seattle; Jimenez reported from San Jose, Costa Rica.

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Health overhaul draws groups' competing demands

WASHINGTON – Patients and doctors. Small businesses and multinationals. Retirees, workers and insurance companies.

Some have more money and clout. All have something in common when it comes to overhauling health care: a huge stake in the outcome.

Their competing demands will help determine what happens as Congress writes legislation to reshape the nation's $2.5 trillion health care system to bring down costs and cover 50 million uninsured people. If the whole undertaking starts to fall apart, look to opposition from one or more of these groups as the reason why.

All say their goal is for everyone to have access to quality and affordable care. Beyond that, consensus breaks down.

A look at 10 groups with the most influence, or most at stake, in the health debate, and what they want and are trying to avoid:

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Workers:

Some 60 percent of people under age 65 get health care through an employer. But employers don't have to offer health insurance, and as the economy frays, some are dropping it. Labor unions want to require employers to help pay for coverage for their employees.

Unions also believe the path to affordable care runs through a new public insurance plan that would compete with private plans. Middle-class workers, for the first time, would have the option of government insurance. Proponents of this approach, already embraced by President Barack Obama and many Democrats, believe it would drive down costs for all.

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People with health conditions:

A common complaint about insurers is that they won't cover people with existing health conditions or that they charge them too much. Patients' advocacy groups want to require insurers to cover all comers, not just the healthy, and limit what they can charge the sick. They contend that would spread risk and costs throughout the population.

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Older people:

Among the top goals for AARP is ensuring health coverage for people age 50-64 (at 65 they can get Medicare). That could be done by allowing middle-aged people to buy into Medicare. AARP also is eager for Congress to fix the coverage gap in the Medicare drug benefit that patients fall into once their prescription expenses exceed about $2,700.

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Uninsured people:

The estimated 50 million uninsured people in the U.S. don't have lobbyists, but various advocacy groups aim to speak on their behalf. The liberal group Health Care for America Now says any health overhaul should mean coverage for everyone by including a public plan, basing out-of-pocket costs on ability to pay and providing a standard benefit with preventive care and treatment for serious and chronic diseases.

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Insurance companies:

For private insurers, the bogeyman is competition from the government. They contend a public plan would drive them out of business. To stave that off, the industry is offering to curb its practice of charging higher premiums to people with a history of medical problems, as long as Congress requires all Americans to get insurance.

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Small businesses:

Opposition from small business helped kill a health care overhaul during the Clinton years. Their top goal remains the same: to avoid any kind of requirement for employers to provide health care. The National Federation of Independent Business says that is unacceptable and favors subsidies to help people buy insurance. Small businesses want to make the same tax breaks for health insurance available to all, not just those who get coverage through an employer.

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Big businesses:

Even though most big businesses offer health care to their employees, they strongly oppose an employer mandate, fearing the government would start dictating what kind of policies they could offer. Businesses want to avoid taxes on the health insurance benefits.

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Hospitals:

Hospitals worry that a new government insurance plan would reduce the fees they can collect. They support requirements for individuals and employers to purchase insurance so "everyone plays a role in making sure that there's coverage," says Tom Nickels, a senior vice president at the American Hospital Association.

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Doctors: Doctors have similar concerns as hospitals about a public plan. They also want to prevent insurers from raising rates on patients with health problems. They would cap or eliminate tax breaks for employer-provided benefits, using the revenue to subsidize care for low-income people. Doctors want curbs on medical malpractice awards so they don't face the threat of huge jury awards. They contend that leads to "defensive medicine" — performing unnecessary procedures to avoid getting sued.

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Drug companies:

The drug lobby opposes a government insurance plan and has joined the advocacy group Families USA in proposing to cover more of the uninsured by expanding Medicaid, the federal-state insurance program for the poor. Pharmaceutical companies support federal subsidies to help middle-class people unable to afford insurance. Drug companies oppose efforts to squeeze bigger discounts from them under Medicaid.

"We don't want bureaucrats making the decisions about what medicines can be used by the patients of our country and that's the end result of a pure public plan," says Billy Tauzin, head of the Pharmaceutical Research and Manufacturers of America.

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On the Net:

Pharmaceutical Research and Manufacturers of America: http://www.phrma.org/

American Hospital Association: http://www.aha.org/

National Federation of Independent Business: http://www.nfib.com/

AFL-CIO: http://www.aflcio.org/

AARP: http://www.aarp.org/

America's Health Insurance Plans: http://www.ahip.org

American Medical Association: http://www.ama-assn.org/

Families USA: http://www.familiesusa.org/

Health Care for America Now: http://www.healthcareforamericanow.org/

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Flu exposes flaws in Mexico's health care system

MEXICO CITY – Mexicans will do almost anything to avoid a public hospital emergency room, where ailing patients may languish for hours slumped on cracked linoleum floors that smell of sweat, sickness and pine-scented disinfectant.

Many don't see doctors at all, heading instead to the clerk at the corner pharmacy for advice on coping with a cold or a flu.

So it's no surprise that when a dangerous new swine flu virus began to sweep across Mexico, many waited too long to seek medical help — more than a week on average, according to federal Health Secretary Jose Angel Cordova.

These initial delays complicated treatment, possibly explaining why 48 of the world's 52 confirmed swine flu-linked deaths occurred in Mexico.

It also made it more difficult for Mexico to recognize the outbreak for what it was. By the time Cordova announced a swine flu epidemic on April 23, the virus had already spread across the country and beyond.

Mexico's big cities have fancy private hospitals stocked with modern equipment and staffed with U.S. board-certified specialists. Americans increasingly come to Mexico for good care at low prices. The best of the public system is world-class too, with top doctors at elite centers for specialized diseases.

But Mexico's everyday public hospital system is in crisis.

Some patients suspected of having swine flu told The Associated Press that public hospitals turned them away or forced them to wait for hours for treatment even after the government declared a national emergency.

Those who sought help before the alert — often arriving with headaches, high fevers and difficulty breathing — encountered baffled doctors who had not been warned to watch for a new virus.

Mexicans navigate a patchwork of public and private hospital systems. There are hospitals for government employees and hospitals for workers enrolled in government health plans through private employers. Most patients have to go to a hospital tied to a specific agency.

"If someone is sick, he can't simply say, 'I'm going to the doctor' or 'I'm going to the hospital,' because it depends on whether he has Social Security or if he has to go to another institution," said Dr. Malaquias Lopez Cervantes, a leading epidemiologist at Mexico's National Autonomous University.

"And if he comes (to the wrong hospital), somebody is going to tell him that he doesn't have the right to be treated."

While access to health care is a right enshrined in the Mexican constitution, millions of Mexicans have no health insurance at all.

Mexico spends only 6.6 percent of its gross domestic product on health care — less than half the U.S. figure. No country in the 30-nation Organization for Economic Cooperation and Development puts a smaller share of public money into its health care system.

That means the hospitals serving most of Mexico's 44 million poor are often crowded, ill-equipped and staffed with harried, underpaid staff working for a dizzying array of bureaucracies.

It's so crowded, confusing and bureaucratic that the poor are more likely to head for a pharmacy, hoping to find a cheap remedy for "gripe" (pronounced GREE-pay) — a word that can cover anything from a mild cold to a deadly flu.

Most pharmacies dole out antibiotics and a host of other powerful drugs without a prescription. That encourages Mexicans to self-medicate, relying on a counter clerk's suggestion, dosing themselves with whatever worked the last time they had a fever and waiting a day or two to see what happens.

Some pharmacies even drum up business by tacking a doctor's office onto the side — offering basic checkups for as little as 25 pesos ($2) — still roughly half a day's pay for a minimum-wage worker.

In Mexico City's working-class Padierna neighborhood, Dr. Oscar Aguilera sees patients in a small office at the back of a discount pharmacy, with an open-air waiting room behind a row of graffiti-tagged taco stands.

Even in normal times, most of his patients come in with a cold or a flu. Most now show no signs of swine flu, he said, but "20 percent show some symptoms and we send them to the hospital."

Following the public alert on April 23, fear has driven patients to his office even at the slightest symptom.

Mexicans with flu symptoms might have sought better care far earlier if the public health care system had done the same kind of flu surveillance common in the U.S. and other developed nations.

Mexico keeps close watch on dangerous tropical diseases such as dengue, but epidemiologists pay less attention to flu, just one class of viruses contributing to Mexico's 23 million annual cases of respiratory illness.

Mexican doctors "really were not trained thinking of the existence of influenza" as a specific threat, Lopez Cervantes said.

In all of 2008, Mexico's official epidemiological bulletin reported only 151 confirmed cases of flu. By comparison, U.S. officials ran tests that confirmed nearly 40,000 flu cases last season. Mexico has about a third the population of the United States.

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