After early start, worst of flu season may be over

NEW YORK (AP) — The worst of the flu season appears to be over.

The number of states reporting intense or widespread illnesses dropped again last week, and in a few states there was very little flu going around, U.S. health officials said Friday.

The season started earlier than normal, first in the Southeast and then spreading. But now, by some measures, flu activity has been ebbing for at least four weeks in much of the country. Flu and pneumonia deaths also dropped the last two weeks, the Centers for Disease Control and Prevention reported.

"It's likely that the worst of the current flu season is over," CDC spokesman Tom Skinner said.

But flu is hard to predict, he and others stressed, and there have been spikes late in the season in the past.

For now, states like Georgia and New York — where doctor's offices were jammed a few weeks ago — are reporting low flu activity. The hot spots are now the West Coast and the Southwest.

Among the places that have seen a drop: Lehigh Valley Hospital-Cedar Crest in Allentown, Pa., which put up a tent outside its emergency room last month to help deal with the steady stream of patients. There were about 100 patients each day back then. Now it's down to 25 and the hospital may pack up its tent next week, said Terry Burger, director of infection control and prevention for the hospital.

"There's no question that we're seeing a decline," she said.

In early December, CDC officials announced flu season had arrived, a month earlier than usual. They were worried, saying it had been nine years since a winter flu season started like this one. That was 2003-04 — one of the deadliest seasons in the past 35 years, with more than 48,000 deaths.

Like this year, the major flu strain was one that tends to make people sicker, especially the elderly, who are most vulnerable to flu and its complications

But back then, that year's flu vaccine wasn't made to protect against that bug, and fewer people got flu shots. The vaccine is reformulated almost every year, and the CDC has said this year's vaccine is a good match to the types that are circulating. A preliminary CDC study showed it is about 60 percent effective, which is close to the average.

So far, the season has been labeled moderately severe.

Like others, Lehigh Valley's Burger was cautious about making predictions. "I'm not certain we're completely out of the woods," with more wintry weather ahead and people likely to be packed indoors where flu can spread around, she said.

The government does not keep a running tally of flu-related deaths in adults, but has received reports of 59 deaths in children. The most — nine — were in Texas, where flu activity was still high last week. Roughly 100 children die in an average flu season, the CDC says

On average, about 24,000 Americans die each flu season, according to the CDC.

According to the CDC report, the number of states with intense activity is down to 19, from 24 the previous week, and flu is widespread in 38 states, down from 42.

Flu is now minimal in Florida, Kentucky, Maine, Montana, New Hampshire and South Carolina.

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Online:

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

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Health officials: Worst of flu season may be over

NEW YORK (AP) — The worst of the flu season appears to be over.

The number of states reporting intense or widespread flu dropped again last week, U.S. health officials said Friday.

The season started earlier than normal, spiking first in the Southeast and then spreading. But now, by some measures, flu activity has been ebbing for at least four weeks in much of the country. Flu and pneumonia deaths have been dropping for two weeks, the Centers for Disease Control and Prevention reported.

"It's likely that the worst of the current flu season is over," CDC spokesman Tom Skinner said in an email.

It's been nine years since a conventional flu season started like this one. That was the winter of 2003-04 — one of the deadliest in the past 35 years, with more than 48,000 deaths. Like this year, that season had the same dominant flu strain, one that tends to make people sicker.

But back then, the flu vaccine didn't protect against that bug, and fewer people got flu shots. The vaccine is reformulated each year, and the CDC has said this year's vaccine is a good match to the types that are circulating. A preliminary CDC study showed this year's version is about 60 percent effective.

So far, the season has been labeled moderately severe.

The government does not keep a running tally of flu-related deaths in adults, but has received reports of 59 such deaths in children. The most — nine — were in Texas, where flu activity was still high last week.

On average, about 24,000 Americans die each flu season, according to the CDC.

Flu vaccinations are recommended for everyone 6 months or older.

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Southern diet, fried foods, may raise stroke risk

Deep-fried foods may be causing trouble in the Deep South. People whose diets are heavy on them and sugary drinks like sweet tea and soda were more likely to suffer a stroke, a new study finds.

It's the first big look at diet and strokes, and researchers say it might help explain why blacks in the Southeast — the nation's "stroke belt" — suffer more of them.

Blacks were five times more likely than whites to have the Southern dietary pattern linked with the highest stroke risk. And blacks and whites who live in the South were more likely to eat this way than people in other parts of the country were. Diet might explain as much as two-thirds of the excess stroke risk seen in blacks versus whites, researchers concluded.

"We're talking about fried foods, french fries, hamburgers, processed meats, hot dogs," bacon, ham, liver, gizzards and sugary drinks, said the study's leader, Suzanne Judd of the University of Alabama in Birmingham.

People who ate about six meals a week featuring these sorts of foods had a 41 percent higher stroke risk than people who ate that way about once a month, researchers found.

In contrast, people whose diets were high in fruits, vegetables, whole grains and fish had a 29 percent lower stroke risk.

"It's a very big difference," Judd said. "The message for people in the middle is there's a graded risk" — the likelihood of suffering a stroke rises in proportion to each Southern meal in a week.

Results were reported Thursday at an American Stroke Association conference in Honolulu.

The federally funded study was launched in 2002 to explore regional variations in stroke risks and reasons for them. More than 20,000 people 45 or older — half of them black — from all 48 mainland states filled out food surveys and were sorted into one of five diet styles:

—Southern: Fried foods, processed meats (lunchmeat, jerky), red meat, eggs, sweet drinks and whole milk.

—Convenience: Mexican and Chinese food, pizza, pasta.

—Plant-based: Fruits, vegetables, juice, cereal, fish, poultry, yogurt, nuts and whole-grain bread.

—Sweets: Added fats, breads, chocolate, desserts, sweet breakfast foods.

—Alcohol: Beer, wine, liquor, green leafy vegetables, salad dressings, nuts and seeds, coffee.

"They're not mutually exclusive" — for example, hamburgers fall into both convenience and Southern diets, Judd said. Each person got a score for each diet, depending on how many meals leaned that way.

Over more than five years of follow-up, nearly 500 strokes occurred. Researchers saw clear patterns with the Southern and plant-based diets; the other three didn't seem to affect stroke risk.

There were 138 strokes among the 4,977 who ate the most Southern food, compared to 109 strokes among the 5,156 people eating the least of it.

There were 122 strokes among the 5,076 who ate the most plant-based meals, compared to 135 strokes among the 5,056 people who seldom ate that way.

The trends held up after researchers took into account other factors such as age, income, smoking, education, exercise and total calories consumed.

Fried foods tend to be eaten with lots of salt, which raises blood pressure — a known stroke risk factor, Judd said. And sweet drinks can contribute to diabetes, the disease that celebrity chef Paula Deen — the queen of Southern cuisine — revealed she had a year ago.

The National Institute of Neurological Disorders and Stroke, drugmaker Amgen Inc. and General Mills Inc. funded the study.

"This study does strongly suggest that food does have an influence and people should be trying to avoid these kinds of fatty foods and high sugar content," said an independent expert, Dr. Brian Silver, a Brown University neurologist and stroke center director at Rhode Island Hospital.

"I don't mean to sound like an ogre. I know when I'm in New Orleans I certainly enjoy the food there. But you don't have to make a regular habit of eating all this stuff."

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Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP

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Critics seek to delay NYC sugary drinks size limit

NEW YORK (AP) — Opponents are pressing to delay enforcement of the city's novel plan to crack down on supersized, sugary drinks, saying businesses shouldn't have to spend millions of dollars to comply until a court rules on whether the measure is legal.

With the rule set to take effect March 12, beverage industry, restaurant and other business groups have asked a judge to put it on hold at least until there's a ruling on their lawsuit seeking to block it altogether. The measure would bar many eateries from selling high-sugar drinks in cups or containers bigger than 16 ounces.

"It would be a tremendous waste of expense, time, and effort for our members to incur all of the harm and costs associated with the ban if this court decides that the ban is illegal," Chong Sik Le, president of the New York Korean-American Grocers Association, said in court papers filed Friday.

City lawyers are fighting the lawsuit and oppose postponing the restriction, which the city Board of Health approved in September. They said Tuesday they expect to prevail.

"The obesity epidemic kills nearly 6,000 New Yorkers each year. We see no reason to delay the Board of Health's reasonable and legal actions to combat this major, growing problem," Mark Muschenheim, a city attorney, said in a statement.

Another city lawyer, Thomas Merrill, has said officials believe businesses have had enough time to get ready for the new rule. He has noted that the city doesn't plan to seek fines until June.

Mayor Michael Bloomberg and other city officials see the first-of-its-kind limit as a coup for public health. The city's obesity rate is rising, and studies have linked sugary drinks to weight gain, they note.

"This is the biggest step a city has taken to curb obesity," Bloomberg said when the measure passed.

Soda makers and other critics view the rule as an unwarranted intrusion into people's dietary choices and an unfair, uneven burden on business. The restriction won't apply at supermarkets and many convenience stores because the city doesn't regulate them.

While the dispute plays out in court, "the impacted businesses would like some more certainty on when and how they might need to adjust operations," American Beverage Industry spokesman Christopher Gindlesperger said Tuesday.

Those adjustments are expected to cost the association's members about $600,000 in labeling and other expenses for bottles, Vice President Mike Redman said in court papers. Reconfiguring "16-ounce" cups that are actually made slightly bigger, to leave room at the top, is expected to take cup manufacturers three months to a year and cost them anywhere from more than $100,000 to several millions of dollars, Foodservice Packaging Institute President Lynn Dyer said in court documents.

Movie theaters, meanwhile, are concerned because beverages account for more than 20 percent of their overall profits and about 98 percent of soda sales are in containers greater than 16 ounces, according to Robert Sunshine, executive director of the National Association of Theatre Owners of New York State.

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Critics seek to delay NYC sugary drinks size limit

NEW YORK (AP) — Opponents are pressing to delay enforcement of the city's novel plan to crack down on supersized, sugary drinks, saying businesses shouldn't have to spend millions of dollars to comply until a court rules on whether the measure is legal.

With the rule set to take effect March 12, beverage industry, restaurant and other business groups have asked a judge to put it on hold at least until there's a ruling on their lawsuit seeking to block it altogether. The measure would bar many eateries from selling high-sugar drinks in cups or containers bigger than 16 ounces.

"It would be a tremendous waste of expense, time, and effort for our members to incur all of the harm and costs associated with the ban if this court decides that the ban is illegal," Chong Sik Le, president of the New York Korean-American Grocers Association, said in court papers filed Friday.

City lawyers are fighting the lawsuit and oppose postponing the restriction, which the city Board of Health approved in September. They said Tuesday they expect to prevail.

"The obesity epidemic kills nearly 6,000 New Yorkers each year. We see no reason to delay the Board of Health's reasonable and legal actions to combat this major, growing problem," Mark Muschenheim, a city attorney, said in a statement.

Another city lawyer, Thomas Merrill, has said officials believe businesses have had enough time to get ready for the new rule. He has noted that the city doesn't plan to seek fines until June.

Mayor Michael Bloomberg and other city officials see the first-of-its-kind limit as a coup for public health. The city's obesity rate is rising, and studies have linked sugary drinks to weight gain, they note.

"This is the biggest step a city has taken to curb obesity," Bloomberg said when the measure passed.

Soda makers and other critics view the rule as an unwarranted intrusion into people's dietary choices and an unfair, uneven burden on business. The restriction won't apply at supermarkets and many convenience stores because the city doesn't regulate them.

While the dispute plays out in court, "the impacted businesses would like some more certainty on when and how they might need to adjust operations," American Beverage Industry spokesman Christopher Gindlesperger said Tuesday.

Those adjustments are expected to cost the association's members about $600,000 in labeling and other expenses for bottles, Vice President Mike Redman said in court papers. Reconfiguring "16-ounce" cups that are actually made slightly bigger, to leave room at the top, is expected to take cup manufacturers three months to a year and cost them anywhere from more than $100,000 to several millions of dollars, Foodservice Packaging Institute President Lynn Dyer said in court documents.

Movie theaters, meanwhile, are concerned because beverages account for more than 20 percent of their overall profits and about 98 percent of soda sales are in containers greater than 16 ounces, according to Robert Sunshine, executive director of the National Association of Theatre Owners of New York State.

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Follow Jennifer Peltz at http://twitter.com/jennpeltz

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Bullying study: It does get better for gay teens

CHICAGO (AP) — It really does get better for gay and bisexual teens when it comes to being bullied, although young gay men have it worse than their lesbian peers, according to the first long-term scientific evidence on how the problem changes over time.

The seven-year study involved more than 4,000 teens in England who were questioned yearly through 2010, until they were 19 and 20 years old. At the start, just over half of the 187 gay, lesbian and bisexual teens said they had been bullied; by 2010 that dropped to 9 percent of gay and bisexual boys and 6 percent of lesbian and bisexual girls.

The researchers said the same results likely would be found in the United States.

In both countries, a "sea change" in cultural acceptance of gays and growing intolerance for bullying occurred during the study years, which partly explains the results, said study co-author Ian Rivers, a psychologist and professor of human development at Brunel University in London.

That includes a government mandate in England that schools work to prevent bullying, and changes in the United States permitting same-sex marriage in several states.

In 2010, syndicated columnist Dan Savage launched the "It Gets Better" video project to encourage bullied gay teens. It was prompted by widely publicized suicides of young gays, and includes videos from politicians and celebrities.

"Bullying tends to decline with age regardless of sexual orientation and gender," and the study confirms that, said co-author Joseph Robinson, a researcher and assistant professor of educational psychology at the University of Illinois in Urbana-Champaign. "In absolute terms, this would suggest that yes, it gets better."

The study appears online Monday in the journal Pediatrics.

Eliza Byard, executive director of the Gay, Lesbian & Straight Education Network, said the results mirror surveys by her anti-bullying advocacy group that show bullying is more common in U.S. middle schools than in high schools.

But the researchers said their results show the situation is more nuanced for young gay men.

In the first years of the study, gay boys and girls were almost twice as likely to be bullied as their straight peers. By the last year, bullying dropped overall and was at about the same level for lesbians and straight girls. But the difference between men got worse by ages 19 and 20, with gay young men almost four times more likely than their straight peers to be bullied.

The mixed results for young gay men may reflect the fact that masculine tendencies in girls and women are more culturally acceptable than femininity in boys and men, Robinson said.

Savage, who was not involved in the study, agreed.

"A lot of the disgust that people feel when you bring up homosexuality ... centers around gay male sexuality," Savage said. "There's more of a comfort level" around gay women, he said.

Kendall Johnson, 21, a junior theater major at the University of Illinois, said he was bullied for being gay in high school, mostly when he brought boyfriends to school dances or football games.

"One year at prom, I had a guy tell us that we were disgusting and he didn't want to see us dancing anymore," Johnson said. A football player and the president of the drama club intervened on his behalf, he recalled.

Johnson hasn't been bullied in college, but he said that's partly because he hangs out with the theater crowd and avoids the fraternity scene. Still, he agreed, that it generally gets better for gays as they mature.

"As you grow older, you become more accepting of yourself," Johnson said.

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Online:

Pediatrics: http://www.pediatrics.org

It Gets Better: http://www.itgetsbetter.org

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

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New rules aim to get rid of junk foods in schools

WASHINGTON (AP) — Most candy, high-calorie drinks and greasy meals could soon be on a food blacklist in the nation's schools.

For the first time, the government is proposing broad new standards to make sure all foods sold in schools are more healthful.

Under the new rules the Agriculture Department proposed Friday, foods like fatty chips, snack cakes, nachos and mozzarella sticks would be taken out of lunch lines and vending machines. In their place would be foods like baked chips, trail mix, diet sodas, lower-calorie sports drinks and low-fat hamburgers.

The rules, required under a child nutrition law passed by Congress in 2010, are part of the government's effort to combat childhood obesity. While many schools already have improved their lunch menus and vending machine choices, others still are selling high-fat, high-calorie foods.

Under the proposal, the Agriculture Department would set fat, calorie, sugar and sodium limits on almost all foods sold in schools. Current standards already regulate the nutritional content of school breakfasts and lunches that are subsidized by the federal government, but most lunchrooms also have "a la carte" lines that sell other foods. Food sold through vending machines and in other ways outside the lunchroom has never before been federally regulated.

"Parents and teachers work hard to instill healthy eating habits in our kids, and these efforts should be supported when kids walk through the schoolhouse door," Agriculture Secretary Tom Vilsack said.

Most snacks sold in school would have to have less than 200 calories. Elementary and middle schools could sell only water, low-fat milk or 100 percent fruit or vegetable juice. High schools could sell some sports drinks, diet sodas and iced teas, but the calories would be limited. Drinks would be limited to 12-ounce portions in middle schools and to 8-ounce portions in elementary schools.

The standards will cover vending machines, the "a la carte" lunch lines, snack bars and any other foods regularly sold around school. They would not apply to in-school fundraisers or bake sales, though states have the power to regulate them. The new guidelines also would not apply to after-school concessions at school games or theater events, goodies brought from home for classroom celebrations, or anything students bring for their own personal consumption.

The new rules are the latest in a long list of changes designed to make foods served in schools more healthful and accessible. Nutritional guidelines for the subsidized lunches were revised last year and put in place last fall. The 2010 child nutrition law also provided more money for schools to serve free and reduced-cost lunches and required more meals to be served to hungry kids.

Sen. Tom Harkin, D-Iowa, has been working for two decades to take junk foods out of schools. He calls the availability of unhealthful foods around campus a "loophole" that undermines the taxpayer money that helps pay for the healthier subsidized lunches.

"USDA's proposed nutrition standards are a critical step in closing that loophole and in ensuring that our schools are places that nurture not just the minds of American children but their bodies as well," Harkin said.

Last year's rules faced criticism from some conservatives, including some Republicans in Congress, who said the government shouldn't be telling kids what to eat. Mindful of that backlash, the Agriculture Department exempted in-school fundraisers from federal regulation and proposed different options for some parts of the rule, including the calorie limits for drinks in high schools, which would be limited to either 60 calories or 75 calories in a 12-ounce portion.

The department also has shown a willingness to work with schools to resolve complaints that some new requirements are hard to meet. Last year, for example, the government relaxed some limits on meats and grains in subsidized lunches after school nutritionists said they weren't working.

Schools, the food industry, interest groups and other critics or supporters of the new proposal will have 60 days to comment and suggest changes. A final rule could be in place as soon as the 2014 school year.

Margo Wootan, a nutrition lobbyist for the Center for Science in the Public Interest, said surveys by her organization show that most parents want changes in the lunchroom.

"Parents aren't going to have to worry that kids are using their lunch money to buy candy bars and a Gatorade instead of a healthy school lunch," she said.

The food industry has been onboard with many of the changes, and several companies worked with Congress on the child nutrition law two years ago. Major beverage companies have already agreed to take the most caloric sodas out of schools. But those same companies, including Coca-Cola and PepsiCo, also sell many of the non-soda options, like sports drinks, and have lobbied to keep them in vending machines.

A spokeswoman for the American Beverage Association, which represents the soda companies, says they already have greatly reduced the number of calories that kids are consuming at school by pulling out the high-calorie sodas.

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Follow Mary Clare Jalonick on Twitter at http://twitter.com/mcjalonick

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New rules aim to get rid of junk foods in schools

WASHINGTON (AP) — Most candy, high-calorie drinks and greasy meals could soon be on a food blacklist in the nation's schools.

For the first time, the government is proposing broad new standards to make sure all foods sold in schools are more healthful.

Under the new rules the Agriculture Department proposed Friday, foods like fatty chips, snack cakes, nachos and mozzarella sticks would be taken out of lunch lines and vending machines. In their place would be foods like baked chips, trail mix, diet sodas, lower-calorie sports drinks and low-fat hamburgers.

The rules, required under a child nutrition law passed by Congress in 2010, are part of the government's effort to combat childhood obesity. While many schools already have improved their lunch menus and vending machine choices, others still are selling high-fat, high-calorie foods.

Under the proposal, the Agriculture Department would set fat, calorie, sugar and sodium limits on almost all foods sold in schools. Current standards already regulate the nutritional content of school breakfasts and lunches that are subsidized by the federal government, but most lunchrooms also have "a la carte" lines that sell other foods. Food sold through vending machines and in other ways outside the lunchroom has never before been federally regulated.

"Parents and teachers work hard to instill healthy eating habits in our kids, and these efforts should be supported when kids walk through the schoolhouse door," Agriculture Secretary Tom Vilsack said.

Most snacks sold in school would have to have less than 200 calories. Elementary and middle schools could sell only water, low-fat milk or 100 percent fruit or vegetable juice. High schools could sell some sports drinks, diet sodas and iced teas, but the calories would be limited. Drinks would be limited to 12-ounce portions in middle schools and to 8-ounce portions in elementary schools.

The standards will cover vending machines, the "a la carte" lunch lines, snack bars and any other foods regularly sold around school. They would not apply to in-school fundraisers or bake sales, though states have the power to regulate them. The new guidelines also would not apply to after-school concessions at school games or theater events, goodies brought from home for classroom celebrations, or anything students bring for their own personal consumption.

The new rules are the latest in a long list of changes designed to make foods served in schools more healthful and accessible. Nutritional guidelines for the subsidized lunches were revised last year and put in place last fall. The 2010 child nutrition law also provided more money for schools to serve free and reduced-cost lunches and required more meals to be served to hungry kids.

Sen. Tom Harkin, D-Iowa, has been working for two decades to take junk foods out of schools. He calls the availability of unhealthful foods around campus a "loophole" that undermines the taxpayer money that helps pay for the healthier subsidized lunches.

"USDA's proposed nutrition standards are a critical step in closing that loophole and in ensuring that our schools are places that nurture not just the minds of American children but their bodies as well," Harkin said.

Last year's rules faced criticism from some conservatives, including some Republicans in Congress, who said the government shouldn't be telling kids what to eat. Mindful of that backlash, the Agriculture Department exempted in-school fundraisers from federal regulation and proposed different options for some parts of the rule, including the calorie limits for drinks in high schools, which would be limited to either 60 calories or 75 calories in a 12-ounce portion.

The department also has shown a willingness to work with schools to resolve complaints that some new requirements are hard to meet. Last year, for example, the government relaxed some limits on meats and grains in subsidized lunches after school nutritionists said they weren't working.

Schools, the food industry, interest groups and other critics or supporters of the new proposal will have 60 days to comment and suggest changes. A final rule could be in place as soon as the 2014 school year.

Margo Wootan, a nutrition lobbyist for the Center for Science in the Public Interest, said surveys by her organization show that most parents want changes in the lunchroom.

"Parents aren't going to have to worry that kids are using their lunch money to buy candy bars and a Gatorade instead of a healthy school lunch," she said.

The food industry has been onboard with many of the changes, and several companies worked with Congress on the child nutrition law two years ago. Major beverage companies have already agreed to take the most caloric sodas out of schools. But those same companies, including Coca-Cola and PepsiCo, also sell many of the non-soda options, like sports drinks, and have lobbied to keep them in vending machines.

A spokeswoman for the American Beverage Association, which represents the soda companies, says they already have greatly reduced the number of calories that kids are consuming at school by pulling out the high-calorie sodas.

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Follow Mary Clare Jalonick on Twitter at http://twitter.com/mcjalonick

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Obama offers faith groups new birth control rule

WASHINGTON (AP) — Facing a wave of lawsuits over what government can tell religious groups to do, the Obama administration on Friday proposed a compromise for faith-based nonprofits that object to covering birth control in their employee health plans.

Some of the lawsuits appear headed for the Supreme Court, threatening another divisive legal battle over President Barack Obama's health care overhaul law, which requires most employers to cover birth control free of charge to female workers as a preventive service. The law exempted churches and other houses of worship, but religious charities, universities, hospitals and even some for-profit businesses have objected.

The government's new offer, in a proposed regulation, has two parts.

Administration officials said it would more simply define the religious organizations that are exempt from the requirement altogether. For example, a mosque whose food pantry serves the whole community would not have to comply.

For other religious employers, the proposal attempts to create a buffer between them and contraception coverage. Female employees would still have free access through insurers or a third party, but the employer would not have to arrange for the coverage or pay for it. Insurers would be reimbursed for any costs by a credit against fees owed the government.

It wasn't immediately clear whether the plan would satisfy the objections of Roman Catholic charities and other faith-affiliated nonprofits nationwide challenging the requirement.

Kyle Duncan, general counsel for the Becket Fund for Religious Liberty, which is representing religious nonprofits and businesses in lawsuits, said many of his clients will still have serious concerns.

"This is a moral decision for them," Duncan said. "Why doesn't the government just exempt them?"

Neither the Catholic Health Association, a trade group for hospitals, nor the U.S. Conference of Catholic Bishops had an immediate reaction, saying the regulations were still being studied.

Some women's advocates were pleased.

"The important thing for us is that women employees can count on getting insurance that meets their needs, even if they're working for a religiously affiliated employer," said Cindy Pearson, executive director of the National Women's Health Network.

Policy analyst Sarah Lipton-Lubet of the American Civil Liberties Union said the rule appeared to meet the ACLU's goal of providing "seamless coverage."

Health and Human Services Secretary Kathleen Sebelius said in a statement that the compromise would provide "women across the nation with coverage of recommended preventive care at no cost, while respecting religious concerns."

The birth-control rule, first introduced a year ago, became an election issue, with some advocates for women praising the mandate as a victory but some religious leaders decrying it as an attack on faith groups.

The health care law requires most employers, including faith-affiliated hospitals and nonprofits, to provide preventive care at no charge to employees. Scientific advisers to the government recommended that artificial contraception, including sterilization, be included in a group of services for women. The goal, in part, is to help women space out pregnancies to promote health.

Under the original rule, only those religious groups that primarily employ and serve people of their own faith — such as churches — were exempt. But other religiously affiliated groups, such as church-affiliated universities, Catholic Charities and hospitals, were told they had to comply.

Catholic bishops, evangelicals and some religious leaders who have generally been supportive of Obama's policies lobbied fiercely for a broader exemption. The Catholic Church prohibits the use of artificial contraception. Evangelicals generally accept the use of birth control, but some object to specific methods such as the morning-after contraceptive pill, which they argue is tantamount to abortion, and is covered by the policy.

Obama had promised to change the birth control requirement so insurance companies — and not faith-affiliated employers — would pay for the coverage, but religious leaders said more changes were needed to make the plan work.

Since then, more than 40 lawsuits have been filed by religious nonprofits and secular for-profit businesses contending the mandate violates their religious beliefs. As expected, this latest regulation does not provide any accommodation for individual business owners who have religious objections to the rule.

Questions remain about how the services ultimately will be funded. The Health and Human Services Department has not tallied an overall cost for the plan, according to Chiquita Brooks-LaSure, an HHS deputy policy director.

However, in its new version of the rule, the department argues that the change won't impose new costs on insurers because it will save them money "from improvements in women's health and fewer child births."

The latest version of the mandate is now subject to a 60-day public comment period. The overall mandate is to take effect for religious nonprofits in August.

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Zoll reported from New York. Associated Press writer David Crary in New York contributed.

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Hedgehog Alert! Prickly pets can carry salmonella

NEW YORK (AP) — Add those cute little hedgehogs to the list of pets that can make you sick.

In the last year, 20 people were infected by a rare but dangerous form of salmonella bacteria, and one person died in January. The illnesses were linked to contact with hedgehogs kept as pets, according to a report released Thursday by the Centers for Disease Control and Prevention.

Health officials on Thursday say such cases seem to be increasing.

The CDC recommends thoroughly washing your hands after handling hedgehogs and cleaning pet cages and other equipment outside.

Other pets that carry the salmonella bug are frogs, toads, turtles, snakes, lizards, chicks and ducklings.

Seven of the hedgehog illnesses were in Washington state, including the death — an elderly man from Spokane County who died in January. The other cases were in Alabama, Illinois, Indiana, Michigan, Minnesota, Ohio and Oregon.

In years past, only one or two illnesses from this salmonella strain have been reported annually, but the numbers rose to 14 in 2011, 18 last year, and two so far this year.

Children younger than five and the elderly are considered at highest risk for severe illness, CDC officials said.

Hedgehogs are small, insect-eating mammals with a coat of stiff quills. In nature, they sometimes live under hedges and defend themselves by rolling up into a spiky ball.

The critters linked to recent illnesses were purchased from various breeders, many of them licensed by the U.S. Department of Agriculture, CDC officials said. Hedgehogs are native to Western Europe, New Zealand and some other parts of the world, but are bred in the United States.

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Online:

CDC report: http://www.cdc.gov/mmwr

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APNewsBreak: EPA moves to ban some rodent poisons

WASHINGTON (AP) — The Environmental Protection Agency is moving to ban the sale of a dozen rat and mouse poisons sold under the popular D-Con brand in an effort to protect children and pets.

The agency said Wednesday it hopes to reduce the thousands of accidental exposures that occur every year from rodent-control products. Children and pets are at risk for exposure because the products typically are placed on floors.

The agency had targeted a handful of companies two years ago, saying they needed to develop new products that are safer for children, pets and wildlife. All but Reckitt Benckiser Inc., manufacturer of D-Con, did so.

The company will have at least 30 days to request a hearing before an administrative law judge. If no hearing is requested, the ban will take effect.

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Soldier looks forward to driving with new arms

BALTIMORE (AP) — A soldier who lost all four limbs in a roadside bombing in Iraq says he's looking forward to driving and swimming with new arms after undergoing a double-arm transplant.

"I just want to get the most out of these arms, and just as goals come up, knock them down and take it absolutely as far as I can," Brendan Marrocco said Tuesday.

The 26-year-old New Yorker spoke at a news conference at Johns Hopkins Hospital, where he was joined by surgeons who performed the operation.

After he was wounded, Marrocco said, he felt fine using prosthetic legs, but he hated not having arms.

"You talk with your hands, you do everything with your hands, basically, and when you don't have that, you're kind of lost for a while," he said.

Marrocco said his chief desire is to drive the black Dodge Charger that's been sitting in his garage for three years.

"I used to love to drive," he said. "I'm really looking forward to just getting back to that, and just becoming an athlete again."

Although he doesn't expect to excel at soccer, his favorite sport, Marrocco said he'd like to swim and compete in a marathon using a handcycle.

Marrocco joked that military service members sometimes regard themselves as poorly paid professional athletes. His good humor and optimism are among the qualities doctors cited as signs he will recover much of his arm and hand use in two to three years.

"He's a young man with a tremendous amount of hope, and he's stubborn — stubborn in a good way," said Dr. Jaimie Shores, the hospital's clinical director of hand transplantation. "I think the sky's the limit."

Shores said Marrocco has already been trying to use his hands, although he lacks feeling in the fingers, and he's eager to do more as the slow-growing nerves and muscles mend.

"I suspect that he will be using his hands for just about everything as we let him start trying to do more and more. Right now, we're the ones really kind of holding him back at this point," Shores said.

The procedure was only the seventh double-hand or double-arm transplant ever done in the United States.

The infantryman was injured by a roadside bomb in 2009. He is the first soldier to survive losing all four limbs in the Iraq War.

Marrocco also received bone marrow from the same donor to minimize the medicine needed to prevent rejection. He said he didn't know much about the donor but "I'm humbled by their gift."

The 13-hour operation on Dec. 18 was led by Dr. W.P. Andrew Lee, plastic surgery chief at Hopkins.

Marrocco was being released from the hospital Tuesday but will receive intensive therapy for two years at Hopkins and then at Walter Reed National Military Medical Center in Bethesda.

After a major surgery, human nerves regenerate at a rate of an inch per month, Lee said.

"The progress will be slow, but the outcome will be rewarding," he added.

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Associated Press Writer David Dishneau contributed to this story from Hagerstown, Md.

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Soldier who lost 4 limbs has double-arm transplant

The first soldier to survive after losing all four limbs in the Iraq war has received a double-arm transplant.

Brendan Marrocco had the operation on Dec. 18 at Johns Hopkins Hospital in Baltimore, his father said Monday. The 26-year-old Marrocco, who is from New York City, was injured by a roadside bomb in 2009.

He also received bone marrow from the same dead donor who supplied his new arms. That novel approach is aimed at helping his body accept the new limbs with minimal medication to prevent rejection.

The military is sponsoring operations like these to help wounded troops. About 300 have lost arms or hands in the wars.

"He was the first quad amputee to survive" from the wars in Iraq and Afghanistan, and there have been four others since then, said Brendan Marrocco's father, Alex Marrocco. "He was really excited to get new arms."

The Marroccos want to thank the donor's family for "making a selfless decision ... making a difference in Brendan's life," the father said.

Surgeons plan to discuss the transplant at a news conference with the patient on Tuesday.

The 13-hour operation was led by Dr. W.P. Andrew Lee, plastic surgery chief at Johns Hopkins, and is the seventh double-hand or double-arm transplant done in the United States. Lee led three of those earlier operations when he previously worked at the University of Pittsburgh, including the only above-elbow transplant that had been done at the time, in 2010.

Marrocco's "was the most complicated one" so far, Lee said in an interview Monday. It will take more than a year to know how fully Marrocco will be able to use the new arms, Lee said.

"The maximum speed is an inch a month for nerve regeneration," he explained. "We're easily looking at a couple years" until the full extent of recovery is known.

While at Pittsburgh, Lee pioneered the novel immune suppression approach used for Marrocco. The surgeon led hand transplant operations on five patients, giving them marrow from their donors in addition to the new limbs. All five recipients have done well and four have been able to take just one anti-rejection drug instead of combination treatments most transplant patients receive.

Minimizing anti-rejection drugs is important because they have side effects and raise the risk of cancer over the long term. Those risks have limited the willingness of surgeons and patients to do more hand, arm and even face transplants. Unlike a life-saving heart or liver transplant, limb transplants are aimed at improving quality of life, not extending it.

Quality of life is a key concern for people missing arms and hands — prosthetics for those limbs are not as advanced as those for feet and legs.

Lee has received funding for his work from AFIRM, the Armed Forces Institute of Regenerative Medicine, a cooperative research network of top hospitals and universities around the country that the government formed about five years ago. With government money, he and several other plastic surgeons around the country are preparing to do more face transplants, possibly using the new minimal immune suppression approach.

Marrocco expects to spend three to four months at Hopkins, then return to a military hospital to continue physical therapy, his father said. Before the operation, he had been living with his older brother in a handicapped-accessible home on New York's Staten Island built with the help of several charities.

The home was heavily damaged by Superstorm Sandy last fall.

Despite being in a lot of pain for some time after the operation, Marrocco showed a sense of humor, his father said. He had a hoarse voice from a tube in his throat during the long surgery, decided that he sounded like Al Pacino, and started doing movie lines.

"He was making the nurses laugh," Alex Marrocco said.

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AP writer Alex Dominguez contributed to this report.

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CDC: Flu seems to level off except in the West

New government figures show that flu cases seem to be leveling off nationwide. Flu activity is declining in most regions although still rising in the West.

The Centers for Disease Control and Prevention says hospitalizations and deaths spiked again last week, especially among the elderly. The CDC says quick treatment with antiviral medicines is important, in particular for the very young or old. The season's first flu case resistant to treatment with Tamiflu was reported Friday.

Eight more children have died from the flu, bringing this season's total pediatric deaths to 37. About 100 children die in an average flu season.

There is still vaccine available although it may be hard to find. The CDC has a website that can help.

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

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CDC: Flu seems to level off except in the West

New government figures show that flu cases seem to be leveling off nationwide. Flu activity is declining in most regions although still rising in the West.

The Centers for Disease Control and Prevention says hospitalizations and deaths spiked again last week, especially among the elderly. The CDC says quick treatment with antiviral medicines is important, in particular for the very young or old. The season's first flu case resistant to treatment with Tamiflu was reported Friday.

Eight more children have died from the flu, bringing this season's total pediatric deaths to 37. About 100 children die in an average flu season.

There is still vaccine available although it may be hard to find. The CDC has a website that can help.

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

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Penalty could keep smokers out of health overhaul

WASHINGTON (AP) — Millions of smokers could be priced out of health insurance because of tobacco penalties in President Barack Obama's health care law, according to experts who are just now teasing out the potential impact of a little-noted provision in the massive legislation.

The Affordable Care Act — "Obamacare" to its detractors — allows health insurers to charge smokers buying individual policies up to 50 percent higher premiums starting next Jan. 1.

For a 55-year-old smoker, the penalty could reach nearly $4,250 a year. A 60-year-old could wind up paying nearly $5,100 on top of premiums.

Younger smokers could be charged lower penalties under rules proposed last fall by the Obama administration. But older smokers could face a heavy hit on their household budgets at a time in life when smoking-related illnesses tend to emerge.

Workers covered on the job would be able to avoid tobacco penalties by joining smoking cessation programs, because employer plans operate under different rules. But experts say that option is not guaranteed to smokers trying to purchase coverage individually.

Nearly one of every five U.S. adults smokes. That share is higher among lower-income people, who also are more likely to work in jobs that don't come with health insurance and would therefore depend on the new federal health care law. Smoking increases the risk of developing heart disease, lung problems and cancer, contributing to nearly 450,000 deaths a year.

Insurers won't be allowed to charge more under the overhaul for people who are overweight, or have a health condition like a bad back or a heart that skips beats — but they can charge more if a person smokes.

Starting next Jan. 1, the federal health care law will make it possible for people who can't get coverage now to buy private policies, providing tax credits to keep the premiums affordable. Although the law prohibits insurance companies from turning away the sick, the penalties for smokers could have the same effect in many cases, keeping out potentially costly patients.

"We don't want to create barriers for people to get health care coverage," said California state Assemblyman Richard Pan, who is working on a law in his state that would limit insurers' ability to charge smokers more. The federal law allows states to limit or change the smoking penalty.

"We want people who are smoking to get smoking cessation treatment," added Pan, a pediatrician who represents the Sacramento area.

Obama administration officials declined to be interviewed for this article, but a former consumer protection regulator for the government is raising questions.

"If you are an insurer and there is a group of smokers you don't want in your pool, the ones you really don't want are the ones who have been smoking for 20 or 30 years," said Karen Pollitz, an expert on individual health insurance markets with the nonpartisan Kaiser Family Foundation. "You would have the flexibility to discourage them."

Several provisions in the federal health care law work together to leave older smokers with a bleak set of financial options, said Pollitz, formerly deputy director of the Office of Consumer Support in the federal Health and Human Services Department.

First, the law allows insurers to charge older adults up to three times as much as their youngest customers.

Second, the law allows insurers to levy the full 50 percent penalty on older smokers while charging less to younger ones.

And finally, government tax credits that will be available to help pay premiums cannot be used to offset the cost of penalties for smokers.

Here's how the math would work:

Take a hypothetical 60-year-old smoker making $35,000 a year. Estimated premiums for coverage in the new private health insurance markets under Obama's law would total $10,172. That person would be eligible for a tax credit that brings the cost down to $3,325.

But the smoking penalty could add $5,086 to the cost. And since federal tax credits can't be used to offset the penalty, the smoker's total cost for health insurance would be $8,411, or 24 percent of income. That's considered unaffordable under the federal law. The numbers were estimated using the online Kaiser Health Reform Subsidy Calculator.

"The effect of the smoking (penalty) allowed under the law would be that lower-income smokers could not afford health insurance," said Richard Curtis, president of the Institute for Health Policy Solutions, a nonpartisan research group that called attention to the issue with a study about the potential impact in California.

In today's world, insurers can simply turn down a smoker. Under Obama's overhaul, would they actually charge the full 50 percent? After all, workplace anti-smoking programs that use penalties usually charge far less, maybe $75 or $100 a month.

Robert Laszewski, a consultant who previously worked in the insurance industry, says there's a good reason to charge the maximum.

"If you don't charge the 50 percent, your competitor is going to do it, and you are going to get a disproportionate share of the less-healthy older smokers," said Laszewski. "They are going to have to play defense."

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Online:

Kaiser Health Reform Subsidy Calculator — http://healthreform.kff.org/subsidycalculator.aspx

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US hit by new stomach bug spreading around globe

NEW YORK (AP) — A new strain of stomach bug sweeping the globe is taking over in the U.S., health officials say.

Since September, more than 140 outbreaks in the U.S. have been caused by the new Sydney strain of norovirus. It may not be unusually dangerous; some scientists don't think it is. But it is different, and many people might not be able to fight off its gut-wrenching effects.

Clearly, it's having an impact. The new strain is making people sick in Japan, Western Europe, and other parts of the world. It was first identified last year in Australia and called the Sydney strain.

In the U.S., it is now accounting for about 60 percent of norovirus outbreaks, according to report released Thursday by the Centers for Disease Control and Prevention.

Norovirus — once known as Norwalk virus — is highly contagious and often spreads in places like schools, cruise ships and nursing homes, especially during the winter. Last month, 220 people on the Queen Mary II were stricken during a Caribbean cruise.

Sometimes mistakenly called stomach flu, the virus causes bouts of vomiting and diarrhea for a few days.

Every two or three years, a new strain evolves — the last was in 2009. The Sydney strain's appearance has coincided with a spike in influenza, perhaps contributing to the perception that this is a particularly bad flu season in the U.S.

Ian Goodfellow, a prominent researcher at England's University of Cambridge, calls norovirus 'the Ferrari of viruses' for the speed at which it passes through a large group of people.

"It can sweep through an environment very, very quickly. You can be feeling quite fine one minute and within several hours suffer continuous vomiting and diarrhea," he said.

Health officials have grown better at detecting new strains and figuring out which one is the culprit. They now know that norovirus is also the most common cause of food poisoning in the U.S.

It's spread by infected food handlers who don't do a good job washing their hands after using the bathroom. But unlike salmonella and other foodborne illnesses, norovirus can also spread in the air, through droplets that fly when a sick person vomits.

"It's a headache" to try to control, said Dr. John Crane, a University of Buffalo infectious disease specialist who had to deal with a norovirus outbreak in a hospital ward a couple of years ago.

Each year, noroviruses cause an estimated 21 million illnesses and 800 deaths, the CDC says.

For those infected, there's really no medicine. They just have to ride it out for the day or two of severe symptoms, and guard against dehydration, experts said.

The illness even got the attention of comedian Stephen Colbert, who this week tweeted: "Remember, if you're in public and have the winter vomiting bug, be polite and vomit into your elbow."

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Online:

CDC report: http://www.cdc.gov/mmwr

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Scientists to resume work with lab-bred bird flu

WASHINGTON (AP) — International scientists who last year halted controversial research with the deadly bird flu say they are resuming their work as countries adopt new rules to ensure safety.

The outcry erupted when two labs — in the Netherlands and the U.S. — reported they had created easier-to-spread versions of bird flu. Amid fierce debate about the oversight of such research and whether it might aid terrorists, those scientists voluntarily halted further work last January — and more than three dozen of the world's leading flu researchers signed on as well.

On Wednesday, those scientists announced they were ending their moratorium because their pause in study worked: It gave the U.S. government and other world health authorities time to determine how they would oversee high-stakes research involving dangerous germs.

A number of countries already have issued new rules. The U.S. is finalizing its own research guidelines, a process that Dr. Anthony Fauci of the National Institutes of Health said should be completed within several weeks.

In letters published in the journals Science and Nature this week, scientists wrote that those who meet their country's requirements have a responsibility to resume studying how the deadly bird flu might mutate to become a bigger threat to people — maybe even the next pandemic. So far, the so-called H5N1 virus mostly spreads among poultry and other birds and rarely infects people.

"The risk exists in nature already. Not doing the research is really putting us in danger," said Yoshihiro Kawaoka of the University of Wisconsin-Madison. He and Ron Fouchier of Erasmus University in the Netherlands separately created the new virus strains that could spread through the air.

The controversy flared just over a year ago, when U.S. officials, prompted by the concerns of a biosecurity advisory panel, asked the two labs not to publish the results. They worried that terrorists might use the information to create a bioweapon. More broadly, scientists debated whether creating new strains of disease is a good idea, and if so, how to safeguard against laboratory accidents.

Ultimately, the flu researchers prevailed: The government decided the data didn't pose any immediate terrorism threat after all, and the two labs' work was published last summer.

Fouchier said that within weeks, he will begin new research in the Netherlands, with European funding, to explore exactly which mutations are the biggest threat. He said the work could enable scientists today to be on the lookout as bird flu continually evolves in the wild.

U.S.-funded scientists cannot resume their studies until the government's policy is finalized.

But the NIH had paid for the original research — and it would have been approved under the soon-to-come expanded policy as well, Fauci told The Associated Press. That policy will add an extra layer of review to higher-risk research, to ensure that it is scientifically worth doing and that safety and bioterrorism concerns are fully addressed up-front, he said.

Had that policy been in place over a year ago, it could have averted the bird flu debate, Fauci said: "Our answer simply would have been, yes, we vetted it very carefully and the benefit is worth any risk. Period, case closed."

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Flu season fuels debate over paid sick time laws

NEW YORK (AP) — Sniffling, groggy and afraid she had caught the flu, Diana Zavala dragged herself in to work anyway for a day she felt she couldn't afford to miss.

A school speech therapist who works as an independent contractor, she doesn't have paid sick days. So the mother of two reported to work and hoped for the best — and was aching, shivering and coughing by the end of the day. She stayed home the next day, then loaded up on medicine and returned to work.

"It's a balancing act" between physical health and financial well-being, she said.

An unusually early and vigorous flu season is drawing attention to a cause that has scored victories but also hit roadblocks in recent years: mandatory paid sick leave for a third of civilian workers — more than 40 million people — who don't have it.

Supporters and opponents are particularly watching New York City, where lawmakers are weighing a sick leave proposal amid a competitive mayoral race.

Pointing to a flu outbreak that the governor has called a public health emergency, dozens of doctors, nurses, lawmakers and activists — some in surgical masks — rallied Friday on the City Hall steps to call for passage of the measure, which has awaited a City Council vote for nearly three years. Two likely mayoral contenders have also pressed the point.

The flu spike is making people more aware of the argument for sick pay, said Ellen Bravo, executive director of Family Values at Work, which promotes paid sick time initiatives around the country. "There's people who say, 'OK, I get it — you don't want your server coughing on your food,'" she said.

Advocates have cast paid sick time as both a workforce issue akin to parental leave and "living wage" laws, and a public health priority.

But to some business owners, paid sick leave is an impractical and unfair burden for small operations. Critics also say the timing is bad, given the choppy economy and the hardships inflicted by Superstorm Sandy.

Michael Sinensky, an owner of seven bars and restaurants around the city, was against the sick time proposal before Sandy. And after the storm shut down four of his restaurants for days or weeks, costing hundreds of thousands of dollars that his insurers have yet to pay, "we're in survival mode."

"We're at the point, right now, where we cannot afford additional social initiatives," said Sinensky, whose roughly 500 employees switch shifts if they can't work, an arrangement that some restaurateurs say benefits workers because paid sick time wouldn't include tips.

Employees without sick days are more likely to go to work with a contagious illness, send an ill child to school or day care and use hospital emergency rooms for care, according to a 2010 survey by the University of Chicago's National Opinion Research Center. A 2011 study in the American Journal of Public Health estimated that a lack of sick time helped spread 5 million cases of flu-like illness during the 2009 swine flu outbreak.

To be sure, many employees entitled to sick time go to work ill anyway, out of dedication or at least a desire to project it. But the work-through-it ethic is shifting somewhat amid growing awareness about spreading sickness.

"Right now, where companies' incentives lie is butting right up against this concern over people coming into the workplace, infecting others and bringing productivity of a whole company down," said John A. Challenger, CEO of employer consulting firm Challenger, Gray & Christmas.

Paid sick day requirements are often popular in polls, but only four places have them: San Francisco, Seattle, Washington, D.C., and the state of Connecticut. The specific provisions vary.

Milwaukee voters approved a sick time requirement in 2008, but the state Legislature passed a law blocking it. Philadelphia's mayor vetoed a sick leave measure in 2011; lawmakers have since instituted a sick time requirement for businesses with city contracts. Voters rejected a paid sick day measure in Denver in 2011.

In New York, City Councilwoman Gale Brewer's proposal would require up to five paid sick days a year at businesses with at least five employees. It wouldn't include independent contractors, such as Zavala, who supports the idea nonetheless.

The idea boasts such supporters as feminist Gloria Steinem and "Sex and the City" actress Cynthia Nixon, as well as a majority of City Council members and a coalition of unions, women's groups and public health advocates. But it also faces influential opponents, including business groups, Mayor Michael Bloomberg and City Council Speaker Christine Quinn, who has virtually complete control over what matters come to a vote.

Quinn, who is expected to run for mayor, said she considers paid sick leave a worthy goal but doesn't think it would be wise to implement it in a sluggish economy. Two of her likely opponents, Public Advocate Bill de Blasio and Comptroller John Liu, have reiterated calls for paid sick leave in light of the flu season.

While the debate plays out, Emilio Palaguachi is recovering from the flu and looking for a job. The father of four was abruptly fired without explanation earlier this month from his job at a deli after taking a day off to go to a doctor, he said. His former employer couldn't be reached by telephone.

"I needed work," Palaguachi said after Friday's City Hall rally, but "I needed to see the doctor because I'm sick."

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Associated Press writer Susan Haigh in Hartford, Conn., contributed to this report.

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Follow Jennifer Peltz at http://twitter.com/jennpeltz

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Flu season fuels debate over paid sick time laws

NEW YORK (AP) — Sniffling, groggy and afraid she had caught the flu, Diana Zavala dragged herself in to work anyway for a day she felt she couldn't afford to miss.

A school speech therapist who works as an independent contractor, she doesn't have paid sick days. So the mother of two reported to work and hoped for the best — and was aching, shivering and coughing by the end of the day. She stayed home the next day, then loaded up on medicine and returned to work.

"It's a balancing act" between physical health and financial well-being, she said.

An unusually early and vigorous flu season is drawing attention to a cause that has scored victories but also hit roadblocks in recent years: mandatory paid sick leave for a third of civilian workers — more than 40 million people — who don't have it.

Supporters and opponents are particularly watching New York City, where lawmakers are weighing a sick leave proposal amid a competitive mayoral race.

Pointing to a flu outbreak that the governor has called a public health emergency, dozens of doctors, nurses, lawmakers and activists — some in surgical masks — rallied Friday on the City Hall steps to call for passage of the measure, which has awaited a City Council vote for nearly three years. Two likely mayoral contenders have also pressed the point.

The flu spike is making people more aware of the argument for sick pay, said Ellen Bravo, executive director of Family Values at Work, which promotes paid sick time initiatives around the country. "There's people who say, 'OK, I get it — you don't want your server coughing on your food,'" she said.

Advocates have cast paid sick time as both a workforce issue akin to parental leave and "living wage" laws, and a public health priority.

But to some business owners, paid sick leave is an impractical and unfair burden for small operations. Critics also say the timing is bad, given the choppy economy and the hardships inflicted by Superstorm Sandy.

Michael Sinensky, an owner of seven bars and restaurants around the city, was against the sick time proposal before Sandy. And after the storm shut down four of his restaurants for days or weeks, costing hundreds of thousands of dollars that his insurers have yet to pay, "we're in survival mode."

"We're at the point, right now, where we cannot afford additional social initiatives," said Sinensky, whose roughly 500 employees switch shifts if they can't work, an arrangement that some restaurateurs say benefits workers because paid sick time wouldn't include tips.

Employees without sick days are more likely to go to work with a contagious illness, send an ill child to school or day care and use hospital emergency rooms for care, according to a 2010 survey by the University of Chicago's National Opinion Research Center. A 2011 study in the American Journal of Public Health estimated that a lack of sick time helped spread 5 million cases of flu-like illness during the 2009 swine flu outbreak.

To be sure, many employees entitled to sick time go to work ill anyway, out of dedication or at least a desire to project it. But the work-through-it ethic is shifting somewhat amid growing awareness about spreading sickness.

"Right now, where companies' incentives lie is butting right up against this concern over people coming into the workplace, infecting others and bringing productivity of a whole company down," said John A. Challenger, CEO of employer consulting firm Challenger, Gray & Christmas.

Paid sick day requirements are often popular in polls, but only four places have them: San Francisco, Seattle, Washington, D.C., and the state of Connecticut. The specific provisions vary.

Milwaukee voters approved a sick time requirement in 2008, but the state Legislature passed a law blocking it. Philadelphia's mayor vetoed a sick leave measure in 2011; lawmakers have since instituted a sick time requirement for businesses with city contracts. Voters rejected a paid sick day measure in Denver in 2011.

In New York, City Councilwoman Gale Brewer's proposal would require up to five paid sick days a year at businesses with at least five employees. It wouldn't include independent contractors, such as Zavala, who supports the idea nonetheless.

The idea boasts such supporters as feminist Gloria Steinem and "Sex and the City" actress Cynthia Nixon, as well as a majority of City Council members and a coalition of unions, women's groups and public health advocates. But it also faces influential opponents, including business groups, Mayor Michael Bloomberg and City Council Speaker Christine Quinn, who has virtually complete control over what matters come to a vote.

Quinn, who is expected to run for mayor, said she considers paid sick leave a worthy goal but doesn't think it would be wise to implement it in a sluggish economy. Two of her likely opponents, Public Advocate Bill de Blasio and Comptroller John Liu, have reiterated calls for paid sick leave in light of the flu season.

While the debate plays out, Emilio Palaguachi is recovering from the flu and looking for a job. The father of four was abruptly fired without explanation earlier this month from his job at a deli after taking a day off to go to a doctor, he said. His former employer couldn't be reached by telephone.

"I needed work," Palaguachi said after Friday's City Hall rally, but "I needed to see the doctor because I'm sick."

___

Associated Press writer Susan Haigh in Hartford, Conn., contributed to this report.

___

Follow Jennifer Peltz at http://twitter.com/jennpeltz

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