Hospitals crack down on workers refusing flu shots

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Online:

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

CDC: http://www.cdc.gov

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

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Oprah Describes Intense Armstrong Interview

Oprah Winfrey said today that disgraced cyclist Lance Armstrong came well prepared for their highly anticipated interview, although he "did not come clean in the manner [she] expected."

Winfrey, who discussed the interview on "CBS This Morning" today, said, "We were mesmerized and riveted by some of his answers. I feel that he answered the questions in a way that he was ready. … He certainly had prepared himself for this moment. … He brought it. He really did."

Armstrong had apologized to staffers at the Livestrong Foundation before the Monday interview with Winfrey at a hotel in Austin, Texas, and reportedly admitted to them that he used performance-enhancing drugs throughout his storied career.

Armstrong also confessed to Winfrey to using the drugs, sources have told ABC News. Winfrey said this morning that the entire interview, for which she had prepared 112 questions, was difficult.

"I would say there were a couple of times where he was emotional," she said. "But that doesn't describe the intensity at times."

As for the cyclist's sense of remorse, Winfrey said that will be for viewers to decide.
"I would rather people make their own decisions about whether he was contrite or not," she said.

The interview will air on the OWN network for two nights, starting at 9 p.m. ET Thursday and continuing Friday.

Meanwhile, the federal government is likely to join a whistle-blower lawsuit against Armstrong, originally filed by his former cycling teammate Floyd Landis, sources told ABC News.

The government is seeking to recoup millions of dollars from Armstrong after years of his denying that he used performance-enhancing drugs, the sources said. The U.S. Postal Service, which is an independent agency of the federal government, was a longtime sponsor of Armstrong's racing career.

Joel Saget/AFP/Getty Images

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The deadline for the government's potentially joining in the matter was a likely motivation for Armstrong's interview with Winfrey, sources told ABC News.

The lawsuit remains sealed in federal court.

Armstrong is now talking with authorities about possibly paying back some of the Postal Service sponsorship money, a government source told ABC News Monday.

The deadline for the department to join the case is Thursday, the same day Armstrong's much-anticipated interview with Winfrey is set to air.

Armstrong is also talking to authorities about confessing and naming names, giving up others involved in illegal doping. This could result in a reduction of his lifetime ban, according to a source, if Armstrong provides substantial and meaningful information.

As for the Winfrey interview, it was Armstrong's first since officials stripped him of his world cycling titles in response to doping allegations.

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

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

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

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

Armstrong then took questions from the staff.

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

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

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

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Pakistan turmoil deepens as court orders PM's arrest

ISLAMABAD (Reuters) - Pakistan's Supreme Court ordered the arrest of the prime minister on Tuesday on corruption allegations, ratcheting up pressure on a government that is also facing street protests led by a cleric who has a history of ties to the army.

The combination of the arrest order and the mass protest in the capital Islamabad led by Muslim cleric Muhammad Tahirul Qadri raised fears among politicians that the military was working with the judiciary to force out a civilian leader.

"There is no doubt that Qadri's march and the Supreme Court's verdict were masterminded by the military establishment of Pakistan," Fawad Chaudhry, an aide to Prime Minister Raja Pervez Ashraf, told Reuters.

"The military can intervene at this moment as the Supreme Court has opened a way for it."

However, the ruling coalition led by the Pakistan Peoples' Party (PPP) has a majority in parliament and lawmakers can simply elect another prime minister if Ashraf is ousted. In June, Ashraf replaced Prime Minister Yusuf Raza Gilani, who was disqualified by the Supreme Court in a previous showdown between the government and the judiciary.

Also, elections are due in a few months and President Asif Ali Zardari hopes to lead the first civilian government in Pakistan's 65 years as an independent nation that will complete its full term.

But power struggles will distract the unpopular government from tackling an array of problems - a Taliban insurgency, economic stagnation and growing sectarian tensions triggered by bomb attacks and tit-for-tat shootings.

The military, which sees itself as the guarantor of Pakistan's stability, has long regarded the PPP-led government as corrupt, incompetent and unable to prevent the nuclear-armed country from falling apart.

Pakistan's powerful army has a long history of coups and intervening in politics. But these days generals seem to have little appetite for a coup. Army chief General Ashfaq Kayani has vowed to keep the military out of politics.

But many believe top military leaders still try to exert behind-the-scenes influence, and any moves by the military in the latest crisis could not happen without a green light from Kayani, arguably the most powerful man in Pakistan.

"Extra-constitutional regime change, or "outside of the political calendar" if you will, is only possible in Pakistan with the tacit nod of the military, on account of it being a long-time stakeholder in Pakistani politics," said Shamila Chaudhry, an analyst at Eurasia Group.

"The Qadri march was like a trial balloon. The military indirectly sent it out to see if it would work."

Some politicians believe the military will try to dominate the caretaker administration that will oversee the run-up to the polls after parliament is dissolved, which is due to happen in March. An election date has yet to be announced.

The protest by Qadri and his followers has also been seen by commentators as being orchestrated by the military to add to the pressure on Zardari's government, although the military has denied any ties to the cleric.

PEOPLE'S MONEY

Thousands of followers of the populist cleric camped near the federal parliament cheered and waved Pakistani flags as television channels broadcast news of the Supreme Court's order to arrest Ashraf on charges of corruption.

"We don't want any of those old politicians. They just take all the people's money," said 19-year-old student Mohammed Wasim. "We congratulate the whole nation (on the Supreme Court's order). Now we have to take the rest of the thieves to court."

Government officials said they were baffled by the arrest order, which came hours after Chief Justice Iftikhar Chaudhry said elections should go ahead as scheduled.

"This was totally unexpected," an official in Ashraf's office told Reuters. "The prime minister and two or three of his friends were watching Qadri speak on television and this suddenly happened."

Pakistan's stock exchange fell by more than 500 points, or nearly three percent, on news of the court order, due to fears over fresh political turmoil, which comes against a backdrop of militant bombings and tension on the border with India.

Qadri, who played a role in backing a military coup in 1999, threatened to remain camped out near the federal parliament with thousands of supporters until his demands for the resignation of the government were met.

The fiery orator returned home from Canada less than a month ago to lead a call for electoral reforms to bar corrupt politicians from office that has made him an instant hit among Pakistanis disillusioned with the state.

In a speech from behind a bullet-proof shield in front of parliament, Qadri praised the military and the judiciary, the country's two other power centers.

"(The government) has wasted and brought a bad end to our armed forces, those armed forces who are highly sincere, highly competent and highly capable and highly professional," he said, alternating between Urdu and English.

"Even they can't do anything because the political government isn't able to deliver anything from this land. Judgments are being passed by our great, independent judiciary but the government is not ready to implement them."

Qadri is demanding that the government dissolve the legislature and announce the formation of a caretaker government to oversee the run-up to elections.

One senior military officer, who said he was speaking in a purely personal capacity, said there was no appetite in the military to repeat the coups seen in Pakistan's past, but added the stand-off could be resolved if the army played a role in the formation of a caretaker government as a "moderator".

"We should try as far as possible to abide by the constitution and law in looking for change. The army chief has made this clear," the officer told Reuters.

"But things seem to be moving beyond control," the officer added. "It is totally incorrect to say the army is behind Qadri. But if he brings thousands of people to the streets and things get worse, there may be very few options."

(Additional reporting by Matthew Green and Mubasher Bukhari in ISLAMABAD and Jibran Ahmad in PESHAWAR; Writing by Michael Georgy; Editing by Raju Gopalakrishnan)

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Football: LionsXII fall to PKNS

SINGAPORE - After two confidence-boosting wins from their first two Malaysian Super League matches, V. Sundramoorthy's high-flying LionsXII side were brought down to earth on Tuesday night at the Shah Alam Stadium when they fell to their first defeat.

Ironically, PKNS Selangor, the team that defeated them on Tuesday, had entered the match in contrasting fashion - with two losses out of two matches.

But that did not stop PKNS Selangor from stunning the LionsXII and maintaining their 100 per cent home record against the Singapore side.

Last season, PKNS did the double over Sundram's men, beating them in Kuala Lumpur in the MSL as well as in the group stage of the Malaysia Cup.

Tuesday's match seemed headed for a 0-0 draw despite the LionsXII coming close through Fazrul Nawaz, Irwan Shah and Gabriel Quak in the first half which they had also dominated.

Fazrul sent his shot centimetres wide of the post after latching onto a pass by skipper Shahril Ishak. Irwan then missed another scoring opportunity during a goalmouth scramble minutes later, while Quak let himself down by shooting wide with only the keeper to beat after dribbling his way past several PKNS defenders.

In the second half, the two sides switched roles as PKNS attacked more, and had the LionsXII on the backfoot.

In the end, it was Nazrin Syamsul who made the difference when he blasted home the only goal of the game for PKNS.

The LionsXII's misery was further compounded when striker Fazrul was sent off in the dying minutes of the game for a nasty tackle.

The LionsXII's next match is on Saturday against Terengganu at the Jalan Besar Stadium.

- TODAY

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India to start visa-on-arrival for Pakistani elders at Attari

AMRITSAR: Indian authorities are all set for a historic move to issue visas on arrival to Pakistani nationals aged 65 and above, from Tuesday, immigration officials said here Monday.

This is the first time that Pakistani nationals will be allowed the facility of visa on arrival at the Attari-Wagah land border joint check post, 30 km from here.

However, the facility will only be for senior citizens 65 and above. They will be allowed to cross the border gates on foot, and can stay in India for 45 days during one visit. Two visits are proposed to be allowed for each person under the new rules.

India and Pakistan had signed a visa agreement September last year under which rules to issue visas to nationals of both countries were eased a little. It was under this agreement that both sides agreed to allow visa on arrival for senior citizens at the Attari-Wagah border.

However, those who are issued the visa on arrival will be allowed to go only to those places or states which are mentioned in the visa. They will not be allowed to stay in Punjab and can only transit from the state. Such people will also not be allowed to enter Jammu and Kashmir and some other states.

Those availing the visa on arrival will have to go back the same way (on foot) and cannot change the mode of travel.

People from both countries can travel by bus, train, air or through the sea route. A restricted number of people are allowed to cross the border on foot through the land route.

On an average, nearly 100 people cross the land border at Attari-Wagah on foot. Others travel by the Delhi-Lahore bus service or the Samjhauta Express peace train between both countries.

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Flu more widespread in US; eases off in some areas

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Online:

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

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Golden Globe Moments: A Night of Laughs, Surprises

Let's finally bury this idea that women can't be funny once and for all. Fey and Poehler were undeniably hilarious throughout the Globes, so much so that many fans on Twitter demanded more of them during the ceremony. From their opening bit -- Poehler: "Meryl Streep is not here tonight, she has the flu. And I hear she's amazing in it." -- to their pseudo drunk heckling of best TV comedy actress winner Lena Dunham, they were radiant, energetic, and above all, funny. More please.

Foster made her acceptance of the Cecil B. DeMille lifetime achievement award a coming out, of sorts. She first shocked the audience by leading them to think that she was about to make a huge public statement about her sexuality. Instead, she said she was single, adding "I already did my coming out in the stone age."

"Now, apparently, I'm told that every celebrity is expected to honor the details of their private life with a press conference ... You guys might be surprised, but I'm not Honey Boo Boo child," she said, to a flurry of laughter and applause.

"If you had been a public figure from the time that you were a toddler ... then maybe you too might value privacy above all else," she said. "Privacy."

But Foster did specifically thank her ex-partner Cydney Bernard, with whom she has two kids. Both boys gestured to her from the audience.

She also implied that she was retiring from acting when she said she would not be returning to the Globes stage or any stage. "It's just that from now on, I may be holding a different talking stick," Foster said, bringing many in the audience to tears.

But backstage, Foster clarified to reporters that she was not retiring from acting. "Oh that's so funny," she responded to reporters. "You couldn't drag me away. And I'd like to be directing tomorrow."

It takes a lot to make Hollywood star struck. Bill Clinton did it when he strutted on stage to introduce a clip of "Lincoln," which was up for best drama. He brought the crowd of A-listers to its feet and commended the 16th president. "We're all here tonight because he did it," he said of Lincoln's battle to end slavery.

If there was any doubt that Lena Dunham wasn't Hollywood's next big thing, it was obliterated Sunday night. The star and creator of HBO's "Girls" went home with two awards, best actress in a TV comedy and best TV comedy. Her heartfelt acceptance speech for best actress struck a chord: "This award is for everyone who feels like there wasn't a place for her," she said. "This show made a space for me."

Jessica Chastain won the Globe for best actress in a drama for "Zero Dark Thirty." She offered a moving tribute to director Kathryn Bigelow, the first woman to win a best director Oscar who failed to get a nomination for that award this year, though "ZDT" was up for a slew of other awards, including best picture. "I can't help but compare my character of Maya to you," Chastain said to Bigelow. "When you make a film that allows your character to disobey the conventions of Hollywood, you've done more for women in cinema than you take credit for."

Blame it on nerves, the spirit of spontaneity, or the a-a-a-a-alcohol (apologies to Jamie Foxx), but Jennifer Lawrence's acceptance speech was a tad insulting to a Hollywood icon, if totally hilarious. "Oh what does it say?" she asked, looking at her trophy. "I beat Meryl." She meant Meryl Streep, who was also up for the award.

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Syria war envelops region in "staggering" crisis: aid agency

BEIRUT (Reuters) - Syria's civil war is unleashing a "staggering humanitarian crisis" on the Middle East as hundreds of thousands of refugees flee violence including gang rape, an international aid agency said on Monday.

Opposition activists said an air strike on rebel-held territory southwest of Damascus killed 20 people, including women and children, adding to the more than 60,000 people estimated to have been killed in the 21-month-old conflict.

Over 600,000 Syrians have fled abroad - many to neighboring Turkey, Lebanon and Jordan - as violence has spread and international efforts to find a political solution have sagged.

Refugees interviewed by the International Rescue Committee (IRC) cited sexual violence as a major reason they fled the country, the New York-based organization said in a 23-page report on the crisis published on Monday.

Gang rapes often happened in front of family members and women had been kidnapped, raped, tortured and killed, it said.

"After decades of working in war and disaster zones, the IRC knows that women and girls suffer physical and sexual violence in every conflict. Syria is no exception," the group added.

Rebels and government forces have both been accused of human rights abuses during the conflict, which began with peaceful protests against President Bashar al-Assad in March 2011.

The unrest turned violent after government forces fired on demonstrators and has since become a full-scale civil war.

Fierce winter weather has worsened the plight of hundreds of thousands of refugees. The IRC urged donors to step up planning and funding in the expectation that more Syrians will flee.

"Nearly two years into Syria's civil war, the region faces a staggering humanitarian disaster," the IRC report said.

AIR POWER

Despite advancing in Syria's north and east and winning support from regional powers like Turkey and Saudi Arabia, the Syrian rebels have been unable to break a military stalemate with government forces elsewhere.

They have struggled to counter government air power in particular, making it hard for them to take and hold territory crucial to Assad's grip on power, including major cities.

An activist in Moadamiyeh, a rebel-held town southwest of Damascus, said an air strike there killed 20 people on Monday.

Activist video footage showed images of the limp body of a boy being pulled out from broken concrete, his back covered in dust and his front in blood.

The Syrian Observatory for Human Rights, a Britain-based monitoring group, said at least 13 people had died in the air raid but the toll was likely to rise.

Syrian state television said "terrorists" - its word for rebels - had fired a mortar from the Damascus suburb of Daraya on a civilian building in Moadamiyeh, killing women and children.

The reports could not be independently verified because of government restrictions on independent media in Syria.

Syrian warplanes also bombarded the strategic Taftanaz air base that rebels seized last week, the Observatory said.

In another sign of escalating bloodshed, Human Rights Watch said it had evidence that government forces had used multi-barrel rocket launchers to deliver Egyptian-made cluster munitions in recent attacks.

"Syria is escalating and expanding its use of cluster munitions, despite international condemnation of its embrace of this banned weapon," it said.

DEADLOCK

Syria's rising death toll has brought international intervention no closer. The United States and Russia have been deadlocked over how to resolve the crisis.

Moscow - which has continued to back its long-standing ally and arms client Assad - urged the opposition on Sunday to make its own proposals in response to a speech by Assad a week ago.

The speech, which offered no concessions, was criticized by the United Nations and United States. Syrian rebels described it as a renewed declaration of war.

Talks between Russia and the United States in Geneva on Friday failed to produce a breakthrough.

As diplomatic efforts have stalled, the conflict has continued to draw in Syria's neighbors.

A mortar round apparently fired from Syria crashed in a field in Turkey overnight close to a refugee camp housing thousands of Syrians along the border, Turkish state media said.

NATO troops have begun deploying Patriot defense missiles in Turkey against a potential attack from its southern neighbor. The missiles are expected to be operational by the end of the month. Turkey is a strong supporter of the Syrian rebels.

NATO said Syrian government forces had launched a short-range, Scud-style ballistic missile on Sunday, bringing to more than 20 the number launched in the past month.

The missiles, apparently fired against opposition targets, landed in Syrian territory, mostly in northern Syria, a NATO spokeswoman said in Brussels, but some of the missiles landed "quite close" to the Turkish frontier.

(Additional reporting by Laila Bassam in Beirut and Adrian Croft in Brussels; Writing by Alexander Dziadosz; Editing by Mark Heinrich)

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Temporary sheltered linkways to be provided at Marina Bay

SINGAPORE: The Land Transport Authority (LTA) will be providing temporary sheltered pedestrian linkways along the roads between Marina Bay Financial Centre and Marina Bay Station.

Transport Minister Lui Tuck Yew said this in response to Mr Gan Thiam Poh's parliamentary question on whether the transport ministry will provide a sheltered or underground pedestrian walkway.

Mr Lui addded that the Urban Redevelopment Authority plans to build an extensive underground pedestrian network (UPN).

This is to link the developments in Marina Bay to the nearby MRT stations, including Marina Bay Station.

- CNA/xq

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Flu more widespread in US; eases off in some areas

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Online:

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

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