OB/GYNs back over-the-counter birth control pills

WASHINGTON (AP) — No prescription or doctor's exam needed: The nation's largest group of obstetricians and gynecologists says birth control pills should be sold over the counter, like condoms.

Tuesday's surprise opinion from these gatekeepers of contraception could boost longtime efforts by women's advocates to make the pill more accessible.

But no one expects the pill to be sold without a prescription any time soon: A company would have to seek government permission first, and it's not clear if any are considering it. Plus there are big questions about what such a move would mean for many women's wallets if it were no longer covered by insurance.

Still, momentum may be building.

Already, anyone 17 or older doesn't need to see a doctor before buying the morning-after pill — a higher-dose version of regular birth control that can prevent pregnancy if taken shortly after unprotected sex. Earlier this year, the Food and Drug Administration held a meeting to gather ideas about how to sell regular oral contraceptives without a prescription, too.

Now the influential American College of Obstetricians and Gynecologists is declaring it's safe to sell the pill that way.

Wait, why would doctors who make money from women's yearly visits for a birth-control prescription advocate giving that up?

Half of the nation's pregnancies every year are unintended, a rate that hasn't changed in 20 years — and easier access to birth control pills could help, said Dr. Kavita Nanda, an OB/GYN who co-authored the opinion for the doctors group.

"It's unfortunate that in this country where we have all these contraceptive methods available, unintended pregnancy is still a major public health problem," said Nanda, a scientist with the North Carolina nonprofit FHI 360, formerly known as Family Health International.

Many women have trouble affording a doctor's visit, or getting an appointment in time when their pills are running low — which can lead to skipped doses, Nanda added.

If the pill didn't require a prescription, women could "pick it up in the middle of the night if they run out," she said. "It removes those types of barriers."

Tuesday, the FDA said it was willing to meet with any company interested in making the pill nonprescription, to discuss what if any studies would be needed.

Then there's the price question. The Obama administration's new health care law requires FDA-approved contraceptives to be available without copays for women enrolled in most workplace health plans.

If the pill were sold without a prescription, it wouldn't be covered under that provision, just as condoms aren't, said Health and Human Services spokesman Tait Sye.

ACOG's opinion, published in the journal Obstetrics & Gynecology, says any move toward making the pill nonprescription should address that cost issue. Not all women are eligible for the free birth control provision, it noted, citing a recent survey that found young women and the uninsured pay an average of $16 per month's supply.

The doctors group made clear that:

—Birth control pills are very safe. Blood clots, the main serious side effect, happen very rarely, and are a bigger threat during pregnancy and right after giving birth.

—Women can easily tell if they have risk factors, such as smoking or having a previous clot, and should avoid the pill.

—Other over-the-counter drugs are sold despite rare but serious side effects, such as stomach bleeding from aspirin and liver damage from acetaminophen.

—And there's no need for a Pap smear or pelvic exam before using birth control pills. But women should be told to continue getting check-ups as needed, or if they'd like to discuss other forms of birth control such as implantable contraceptives that do require a physician's involvement.

The group didn't address teen use of contraception. Despite protests from reproductive health specialists, current U.S. policy requires girls younger than 17 to produce a prescription for the morning-after pill, meaning pharmacists must check customers' ages. Presumably regular birth control pills would be treated the same way.

Prescription-only oral contraceptives have long been the rule in the U.S., Canada, Western Europe, Australia and a few other places, but many countries don't require a prescription.

Switching isn't a new idea. In Washington state a few years ago, a pilot project concluded that pharmacists successfully supplied women with a variety of hormonal contraceptives, including birth control pills, without a doctor's involvement. The question was how to pay for it.

Some pharmacies in parts of London have a similar project under way, and a recent report from that country's health officials concluded the program is working well enough that it should be expanded.

And in El Paso, Texas, researchers studied 500 women who regularly crossed the border into Mexico to buy birth control pills, where some U.S. brands sell over the counter for a few dollars a pack. Over nine months, the women who bought in Mexico stuck with their contraception better than another 500 women who received the pill from public clinics in El Paso, possibly because the clinic users had to wait for appointments, said Dr. Dan Grossman of the University of California, San Francisco, and the nonprofit research group Ibis Reproductive Health.

"Being able to easily get the pill when you need it makes a difference," he said.

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Online:

OB/GYN group: http://www.acog.org

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Clinton’s high-profile swan song

Secretary of State Hillary Rodham Clinton at a meeting with President Barack Obama, second from left, and Japan's …Secretary of State Hillary Rodham Clinton was supposed to be heading for the exit, even as the fight over who should succeed her escalated. Instead, America's top diplomat sped Tuesday to the Middle East on an urgent mission to douse flaring violence between Israel and Hamas, the Islamist Palestinian group that controls Gaza.

Amid early, disputed reports of a possible truce, Clinton had several major goals: Ease the violence, bolster Egyptian President Mohammed Morsi, and avoid an appearance of giving Hamas any sort of legitimacy on the world stage. The U.S. regards Hamas as a terrorist group and deals only with the Palestinian Authority of President Mahmoud Abbas, which controls the West Bank but has been relegated to the sidelines of the latest deadly clashes.

As Clinton winged her way to the troubled region, President Barack Obama—en route to Washington from a trip to Asia—spoke by telephone to Morsi from Air Force One, their third such conversation in 24 hours.

Obama "commended President Morsi's efforts to pursue a de-escalation," Deputy National Security Adviser Ben Rhodes told reporters aboard the presidential plane. "And he also underscored that President Morsi's efforts reinforce the important role that President Morsi and Egypt play on behalf of regional security and the pursuit of broader peace between the Palestinians and Israelis."

Morsi, whose country shares a peace accord with Israel and a border with Gaza, is thought to have sway with Hamas.

Clinton was to stop in Jerusalem for talks with Israeli Prime Minister Benjamin Netanyahu, in Ramallah to meet with Abbas and in Cairo for discussions with Morsi. State Department spokeswoman Victoria Nuland said Clinton aimed for a "de-escalation of violence and a durable outcome that ends the rocket attacks on Israeli cities and towns and restores a broader calm."

American officials have been leery of using the term "cease-fire," preferring variations on "de-escalation" of the conflict.

Clinton's visit came as the political battle over the Sept. 11 terrorist attack on the American compound in Benghazi, Libya, clouded the debate over who will succeed her.

Republicans have accused the Obama administration of covering up the role of suspected extremists in the assault, and questioned whether Clinton's State Department correctly handled requests for more security at the site. The president's foes have targeted Susan Rice, the U.S. ambassador to the United Nations, who at the request of the White House in several television interviews incorrectly tied the attack to protests sparked by an Internet video that ridiculed Islam.

The Benghazi strike claimed the lives of Ambassador Chris Stevens and three other Americans. It has also highlighted the uncertain fate of so-called Arab spring countries—like Egypt—where popular movements swept aside decades-old authoritarian regimes.

Ahead of Clinton's visit, the White House renewed its support for Israel's military operations but hinted at disapproval of a possible ground offensive. Netanyahu's government has called up thousands of troops in what could be preparations for such an onslaught.

Rhodes told reporters the U.S. would prefer to see the Israelis work "diplomatically and peacefully" to resolve the crisis, noting both Palestinian and Israeli civilians would be at risk in the event of a ground assault.

Clinton's stop in Ramallah underscored a diplomatic peculiarity of her trip: Top U.S. officials regard the Palestinian Authority as such minor players in the current crisis, neither Obama nor Clinton have spoken to Abbas since the violence escalated nearly a week ago.

While Clinton by Monday had reached out to leaders—including Jordan's King Abdullah; the foreign ministers of Israel, Egypt, France and Turkey; Egypt's prime minister; and U.N. Secretary-General Ban Ki-moon—she had not spoken to Abbas.

By refusing to deal directly with Hamas and reaching out to the Palestinian Authority instead, Clinton appeared to be trying to resolve the conflict without involving one of the key participants.

Rhodes on Tuesday reiterated U.S. conditions for dealing directly with Hamas: The group must renounce terrorism and recognize Israel's right to exist.

He also defended Clinton's trip to Ramallah, calling it a worthwhile investment "both as it relates to what's happening in Gaza and our efforts going forward to improve the situation in Gaza, but also in terms of our broader efforts to pursue peace between the Israelis and Palestinians."

Rhodes's message was implicit but unmistakable:  If the Palestinians want a lasting peace deal, they should align with the Palestinian Authority and not with Hamas or other extremist groups.

The U.S. has for years been steadfast in its posture toward Hamas. Massachusetts Sen. John Kerry, a top contender for Clinton's job, did not talk to Hamas when he made a surprise visit to Gaza in January 2009.

Clinton headed to the Middle East after traveling to Asia with Obama on what aides to both expected would be their final joint trip overseas, including a history-making stop in Myanmar.

Aboard Air Force One on a flight between Rangoon and Cambodia, the one-time political rivals sat in Obama's private office sharing memories of their work together.

"As the president said, it wasn't just the last four years; they have been through a lot together over the last five or six years," Rhodes said. "But right now there is urgent business to be done."

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Obama makes history with Myanmar, Cambodia visits

PHNOM PENH, Cambodia (AP) — On a history-making trip, President Barack Obama on Monday paid the first visit by an American leader to Myanmar and Cambodia, two Asian countries with troubled histories, one on the mend and the other still a cause of concern.

Obama's fast-paced, pre-Thanksgiving trip vividly illustrated the different paths the regional neighbors are taking to overcome legacies of violence, poverty and repression.

Cheered by massive flag-waving crowds, Obama offered long-isolated Myanmar a "hand of friendship" as it rapidly embraces democratic reforms. Hours later, he arrived in Cambodia to little fanfare, then pointedly criticized the country's strongman leader on the issue of human rights during a tense meeting.

Obama was an early champion of Myanmar's sudden transformation to civilian rule following a half-century of military dictatorship. He's rewarded the country, also known as Burma, with eased economic penalties, increased U.S. investment and now a presidential visit, in part to show other nations the benefits of pursuing similar reforms.

"You're taking a journey that has the potential to inspire so many people," Obama said during a speech at Myanmar's University of Yangon.

The Cambodians are among those Obama is hoping will be motivated. White House officials said he held up Myanmar, a once-pariah state, as a benchmark during his private meeting Monday evening with Prime Minister Hun Sen, the autocratic Cambodian leader who has held power for nearly 30 years. Hun Sen's rivals have sometimes ended up in jail or in exile.

Unlike the arrangement after Obama's meetings with Myanmar's President Thein Sein and democracy leader Aung Sun Suu Kyi, the U.S. and Cambodian leaders did not speak to the press following their one-on-one talks. They did step before cameras briefly before their meeting to greet each other with a brisk handshake and little warmth.

In private, U.S. officials said, Obama pressed Hun Sen to release political prisoners, stop land seizures and hold free and fair elections. Aides acknowledged the meeting was tense, with the Cambodian leader defending his practices, even as he professed to seek a deeper relationship with the U.S.

Ben Rhodes, Obama's deputy national security adviser, said the president told Hun Sen that without reforms, Cambodia's human rights woes would continue to be "an impediment" to that effort.

White House officials emphasized that Obama would not have visited Cambodia had it not been hosting two regional summit meetings the U.S. attends, a rare admonishment of a country on its own soil.

The Cambodian people appeared to answer Obama's cold shoulder in kind. Just a few small clusters of curious Cambodians gathered on the streets to watch his motorcade speed though the streets of Phnom Penh.

A welcome sign did greet Obama upon his arrival — but it heralded Chinese Premier Wen Jiabao, not the American president.

Human rights groups fear that because Obama delivered his condemnation of Hun Sen in private, government censors will keep his words from reaching the Cambodian people. And they worry the prime minister will then use Obama's visit to justify his grip on power and weaken the will of opposition groups.

"If Hun Sen's narrative about this visit is allowed to gel, it will create a perception that the United States and other international actors stand with Hun Sen, and not with the Cambodian people," said John Sifton, Asia director at Human Rights Watch. "It will be a tremendous blow to Cambodians who challenge his rule."

Obama's visit to Myanmar was also viewed critically by some international organizations, which saw the trip as a premature reward for a country that still holds political prisoners and has been unable to contain ethic violence.

Aware of that criticism, Obama tempered some of his praise for Myanmar during his six-hour visit. He underscored that the reforms that have taken hold over the past year are "just the first steps on what will be a long journey."

Perhaps the sharpest calls for caution came from Suu Kyi, Myanmar's longtime democracy champion. After meeting with Obama at the home where she spent years under house arrest, she warned that the most difficult part of the transition will be "when we think that success is in sight."

"Then we have to be very careful that we're not lured by the mirage of success," Suu Kyi said, speaking with Obama by her side.

The president, winding down his first foreign trip after winning re-election, had meetings scheduled in Cambodia Tuesday with his counterparts in the East Asia Summit. Obama has added the summit to his annual list of high-priority international meetings as he seeks to expand U.S. influence in the region.

Obama will also meet separately on the sidelines of the summit with Japanese Prime Minister Yoshihiko Noda and with Wen, the Chinese premier. It's likely to be Obama's last bilateral meetings with both men.

Noda dissolved his country's parliament last week, setting the stage for new elections his party is unlikely to win. And China is undergoing its first leadership transition in a decade, with Wen and President Hu Jintao stepping down to clear the way for new leaders in the country's Communist Party.

Obama will return to Washington before dawn Wednesday, in time for the ceremonial pardoning of the Thanksgiving turkey.

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Associated Press writers Jim Kuhnhenn and Grant Peck contributed to this report.

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Follow Julie Pace at http://twitter.com/jpaceDC

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Wranglers say 'Hobbit' animals died on unsafe farm

WELLINGTON, New Zealand (AP) — Animal wranglers involved in the making of "The Hobbit" movie trilogy say the production company is responsible for the deaths of up to 27 animals, largely because they were kept at a farm filled with bluffs, sinkholes and other "death traps."

The American Humane Association, which is overseeing animal welfare on the films, says no animals were harmed during the actual filming. But it also says the wranglers' complaints highlight shortcomings in its oversight system, which monitors film sets but not the facilities where the animals are housed and trained.

A spokesman for trilogy director Peter Jackson on Monday acknowledged that horses, goats, chickens and one sheep died at the farm near Wellington where about 150 animals were housed for the movies, but he said some of the deaths were from natural causes.

The spokesman, Matt Dravitzki, agreed that the deaths of two horses were avoidable, and said the production company moved quickly to improve conditions after they died.

"The Hobbit: An Unexpected Journey," the first movie in the planned $500 million trilogy, is scheduled to launch with a red-carpet premiere Nov. 28 in Wellington and will open at theaters in the U.S. and around the world in December.

The animal rights group People for the Ethical Treatment of Animals (PETA) says it's planning protests at the premieres in New Zealand, the U.S. and the U.K.

Kathy Guillermo, a senior vice president at PETA, said whistleblowers on The Hobbit contacted the organization after it had taken an active role in exposing problems on other movie sets. The organization sent a letter to Jackson last week outlining its concerns.

"We want to send a clear message to Hollywood that they need to be very careful when using animals and take all the precautions that need to be taken," Guillermo said.

The Associated Press spoke to four wranglers who said the farm near Wellington was unsuitable for horses because it was peppered with bluffs, sinkholes and broken-down fencing. They said they repeatedly raised concerns about the farm with their superiors and the production company, owned by Warner Bros., but it continued to be used. They say they want their story aired publicly now to prevent similar deaths in the future.

One wrangler said that over time he buried three horses, as well as about six goats, six sheep and a dozen chickens. The wranglers say two more horses suffered severe injuries but survived.

Wrangler Chris Langridge said he was hired as a horse trainer in November 2010, overseeing 50 or so horses, but immediately became concerned that the farm was full of "death traps." He said he tried to fill in some of the sinkholes, made by underground streams, and even brought in his own fences to keep the horses away from the most dangerous areas. Ultimately, he said, it was an impossible task.

He said horses run at speeds of up to 30 mph and need to be housed on flat land: "It's just a no-brainer."

The first horse to die, he said, was a miniature named Rainbow.

"When I arrived at work in the morning, the pony was still alive but his back was broken. He'd come off a bank at speed and crash-landed," Langridge said. "He was in a bad state."

Rainbow, who had been slated for use as a hobbit horse, was euthanized. A week later, a horse named Doofus got caught in some fencing and sliced open its leg. That horse survived, but Langridge said he'd had enough.

He and his wife, Lynn, who was also working as a wrangler, said they quit in February 2011. The following month, they wrote an email to Brigitte Yorke, the Hobbit trilogy's unit production manager, outlining their concerns.

Chris Langridge said he responded to Yorke's request for more information but never received a reply after that.

Wrangler Johnny Smythe said that soon after Langridge left, a horse named Claire was found dead, its head submerged in a stream after it fell over a bluff. After that, he said, the horses were put in stables, where a third horse died.

Smythe said no autopsy was performed on the horse, which was named Zeppelin. Veterinary records say the horse died of natural causes, from a burst blood vessel, but Smythe said the horse was bloated and its intestines were full of a yellow liquid; he believes it died of digestive problems caused by new feed.

Smythe said the six goats and six sheep he buried died after falling into sinkholes, contracting worms or getting new feed after the grass was eaten. He said the chickens were often left out of their enclosure and that a dozen were mauled to death by dogs on two separate occasions.

Smythe said he was fired in October 2011 after arguing with his boss about the treatment of the animals.

A fourth wrangler, who didn't want to be named because she feared it could jeopardize her future employment in the industry, said another horse, Molly, got caught in a fence and ripped her leg open, suffering permanent injuries.

Dravitzki, the spokesman for Peter Jackson, said the production company reacted swiftly after the first two horses died, spending hundreds of thousands of dollars upgrading housing and stable facilities in early 2011.

"We do know those deaths were avoidable and we took steps to make sure it didn't happen again," he said.

Dravitzki said Zeppelin died of a burst blood vessel and that he knew only of three goats, one sheep and about eight chickens that had died aside from that. He said two of the goats died in a cold snap but the third, like the sheep, was old and had likely died of natural causes. He said the chicken maulings were the result of careless staff oversight.

The American Humane Association said in its report on "An Unexpected Journey" that it investigated the farm at the production company's request. Dravitzki said the company contacted the AHA after Smythe alleged mistreatment of animals.

Mark Stubis, an association spokesman, said it investigated the farm in August 2011, months after the first deaths.

"We made safety recommendations to the animals' living areas. The production company followed our recommendations and upgraded fence and farm housing, among other things," the group said.

Dravitzki said the company had already made many of the recommended changes by the time the AHA made them.

Stubis said the association acknowledges that what happens off-set remains a blind spot in its oversight.

"We would love to be able to monitor the training of animals and the housing of animals," Stubis said. "It's something we are looking into. We want to make sure the animals are treated well all the time."

Dravitzki questioned the timing of the allegations with the premiere so close but said the producers are investigating all the claims "and are attempting to speak with all parties involved to establish the truth."

He said the company no longer leases the farm and has no animals left on the property. He said he didn't know if animals will be needed for future filming in the trilogy, but added that Jackson himself adopted three of the pigs used.

Hollywood has made animal welfare a stated priority for years.

In March, HBO canceled the horse racing series "Luck" after three thoroughbred horses died during production. The network said it canceled the show because it could not guarantee against future accidents.

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New push for most in US to get at least 1 HIV test

WASHINGTON (AP) — There's a new push to make testing for the AIDS virus as common as cholesterol checks.

Americans ages 15 to 64 should get an HIV test at least once — not just people considered at high risk for the virus, an independent panel that sets screening guidelines proposed Monday.

The draft guidelines from the U.S. Preventive Services Task Force are the latest recommendations that aim to make HIV screening simply a routine part of a check-up, something a doctor can order with as little fuss as a cholesterol test or a mammogram. Since 2006, the Centers for Disease Control and Prevention also has pushed for widespread, routine HIV screening.

Yet not nearly enough people have heeded that call: Of the more than 1.1 million Americans living with HIV, nearly 1 in 5 — almost 240,000 people — don't know it. Not only is their own health at risk without treatment, they could unwittingly be spreading the virus to others.

The updated guidelines will bring this long-simmering issue before doctors and their patients again — emphasizing that public health experts agree on how important it is to test even people who don't think they're at risk, because they could be.

"It allows you to say, 'This is a recommended test that we believe everybody should have. We're not singling you out in any way,'" said task force member Dr. Douglas Owens, of Stanford University and the Veterans Affairs Palo Alto Health Care System.

And if finalized, the task force guidelines could extend the number of people eligible for an HIV screening without a copay in their doctor's office, as part of free preventive care under the Obama administration's health care law. Under the task force's previous guidelines, only people at increased risk for HIV — which includes gay and bisexual men and injecting drug users — were eligible for that no-copay screening.

There are a number of ways to get tested. If you're having blood drawn for other exams, the doctor can merely add HIV to the list, no extra pokes or swabs needed. Today's rapid tests can cost less than $20 and require just rubbing a swab over the gums, with results ready in as little as 20 minutes. Last summer, the government approved a do-it-yourself at-home version that's selling for about $40.

Free testing is available through various community programs around the country, including a CDC pilot program in drugstores in 24 cities and rural sites.

Monday's proposal also recommends:

—Testing people older and younger than 15-64 if they are at increased risk of HIV infection,

—People at very high risk for HIV infection should be tested at least annually.

—It's not clear how often to retest people at somewhat increased risk, but perhaps every three to five years.

—Women should be tested during each pregnancy, something the task force has long recommended.

The draft guidelines are open for public comment through Dec. 17.

Most of the 50,000 new HIV infections in the U.S. every year are among gay and bisexual men, followed by heterosexual black women.

"We are not doing as well in America with HIV testing as we would like," Dr. Jonathan Mermin, CDC's HIV prevention chief, said Monday.

The CDC recommends at least one routine test for everyone ages 13 to 64, starting two years younger than the task force recommended. That small difference aside, CDC data suggests fewer than half of adults under 65 have been tested.

"It can sometimes be awkward to ask your doctor for an HIV test," Mermin said — the reason making it routine during any health care encounter could help.

But even though nearly three-fourths of gay and bisexual men with undiagnosed HIV had visited some sort of health provider in the previous year, 48 percent weren't tested for HIV, a recent CDC survey found. Emergency rooms are considered a good spot to catch the undiagnosed, after their illnesses and injuries have been treated, but Mermin said only about 2 percent of ER patients known to be at increased risk were tested while there.

Mermin calls that "a tragedy. It's a missed opportunity."

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Online:

Task force recommendation: http://www.uspreventiveservicestaskforce.org

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Children of Gaza caught in the crossfire

GAZA (Reuters) - Barefoot boys chase each other in circles around the street, pointing pretend guns made out of rubber pipes up at the Gaza sky, which is thick with Israeli F-16s and surveillance drones.

"We're not afraid of the Jews' bombs!" said Sharif al-Ewad, whose plump cheeks make him look younger than his 15 years. "Al-Qassam (Hamas's armed wing) has raised its head high, and is really beating them up this time!" he smiled.

But beneath the swagger and bravado there is also a yearning for peace and quiet after five days of Israeli airstrikes that killed at least 65 Palestinians, including 20 children.

With one of the youngest populations in the world, over half of Gaza's 1.7 million residents are aged under 18 and they have little to comfort them beside the heady local culture of armed struggle against Israel.

The Jewish state pulled its troops and settlers out of the coastal territory in 2005 but ever since has come under regular rocket fire from Islamist group Hamas and its allies in the Gaza Strip, which refuse to recognize Israel's right to exist.

Israel launched its latest widescale operation last Wednesday with the stated aim of putting a halt to the attacks.

Psychiatrist Hasan Zeyada says the constant exposure to shocking violence has left many children suffering trauma and all that it entails -- bed-wetting, nightmares, flashbacks, and fear of going out in public.

"Part of this is related to our culture and religion, which values sacrifice and duty. The other part is a kind of denial. it's normal to be scared, but in the messages they've watched and heard, they're taught just to show strength," said Zeyada, manager of the Gaza Community Mental Health Program.

"When there's no safe place to go, they respond naturally with denial. In a situation like Gaza's, the best families and the community can do for children is to keep them close and go about life as normally as possible," he said.

That isn't very easy.

SMALL VICTIMS

With schools shut while the fighting rages, some children express delight at their newfound freedom. "Of course we're happy!" squealed one boy, drawing out giggles from his mates.

Looking more serious, Sharif shook his head. "No, it's no good. We want to learn. It's boring, and our parents try to make us stay inside. But we're not scared," he insisted.

On the other side of the fence, Israeli schools are also shuttered within a 40-km radius of Gaza because of an incessant rain of incoming rockets, with children confined to their homes.

Tragically, some young Gazans will never get to see school.

Tamer, 1, and Joumana Abu Sefan, 3, were blasted from their beds by an Israeli strike early on Sunday. Their father Salama, blood gushing down his face from his owns wounds, rushed them to hospital, where they were pronounced dead.

Male relatives stared on in tears, women cried out and swooned while the little bodies were swaddled in white cloth and gauze was placed in their nostrils to keep still-flowing blood from staining their faces.

At their joint funeral march just hours later, Salama cradled their heads as uncles held them aloft at his side.

Green Hamas flags were suddenly draped over their shrouds, and the militant group's religious songs, playing in the background, announced that the tiny pair had achieved martyrdom and that heaven would be their reward.

"What does Israel want with their blood?" Salama heaved, inconsolable and seeming to sleepwalk through the spectacle.

For its part, Israel denies targeting civilians and says it is constantly warning residents, who it says are used by as human shields, away from areas where militants operate.

Abdullah Zumlot, 15, the first hints of moustache speckling his upper lip, scoffed at this as he loitered around the hospital where the Abu Sefan children were earlier carried away.

"It's not fair what we have to live through, we're not happy. All my family and I do is sit at home and watch the news 24 hours," he complained.

(Editing by Crispian Balmer)

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US, Britain warn of risks of Israeli ground war

BANGKOK (AP) — The U.S. and Britain on Sunday warned about the risks of Israel expanding its air assault on the Gaza Strip into a ground war, while vigorously defending the Jewish state's right to protect itself against rocket attacks.

The remarks by President Barack Obama and Britain Foreign Secretary William Hague were part of a diplomatic balancing act by the West as it desperately seeks an end to the escalating violence without alienating its closest ally in the region.

"Israel has every right to expect that it does not have missiles fired into its territory," President Barack Obama said at a news conference in Bangkok at the start of a three-nation visit to Asia.

"If that can be accomplished without a ramping up of military activity in Gaza, that's preferable," Obama said. "It's not just preferable for the people of Gaza. It's also preferable for Israelis, because if Israeli troops are in Gaza, they're much more at risk of incurring fatalities or being wounded."

The president spoke shortly before an Israeli airstrike leveled a home in a residential neighborhood. Palestinian medical officials said at least 11 civilians, mostly women and children, were killed. The attack was the single deadliest incident of the 5-day-old Israeli operation.

The Israeli military said the target was a top rocket mastermind of the Islamic Jihad militant group. The claim could not be immediately verified, and the attack raised speculation that Israel could face increased international pressure if the civilian death toll continued to rise.

Hague said Hamas, Gaza's militant rulers, "bears principal responsibility" for initiating the violence and must stop all rocket attacks on Israel. But Hague also made clear the diplomatic risks of an Israeli escalation.

"A ground invasion is much more difficult for the international community to sympathize with or support, including the United Kingdom," he said.

Israeli officials say the airstrikes are aimed at ending months of rocket fire out of the Hamas-ruled territory. Israel began the offensive with an unexpected airstrike that killed Hamas' military chief, and since then has targeted suspected rocket launchers and storage sites.

The Mideast ally is now at a crossroads: launch a ground invasion or pursue Egyptian-led truce efforts. But with Israel and Hamas far apart on any terms of cease-fire, Israeli Prime Minister Benjamin Netanyahu declared at the start of the weekly Cabinet meeting, "The Israeli military is prepared to significantly expand the operation."

The crisis threatened to overshadow Obama's trip to Asia, which includes stops in Myanmar and Cambodia as part of a broader effort to expand the U.S. economic and military presence in a region long dominated by China.

So far, the U.S. has thrown its weight behind Israel, and Obama has called on Egypt and Turkey to intervene on Israel's behalf. Obama said he has told Egypt's president, Mohammed Morsi, and Turkey's prime minister, Recep Tayyip Erdogan that "those who champion the cause of the Palestinians should recognize that if we see a further escalation of the situation in Gaza, then the likelihood of us getting back on any kind of peace track that leads to a two-state solution is going to be pushed off way into the future."

Obama also pointed to the next 48 hours "to see what kind of progress we can make."

Members of the U.S. Congress, which overwhelmingly supports Israel, criticized Egypt and Turkey for not doing enough to intervene. They said all eyes were on Morsi, Egypt's first civilian and freely elected leader.

"Egypt, watch what you do and how you do it," said Sen. Sen. Lindsey Graham, R-S.C., in an interview on NBC's "Meet the Press." ''You're teetering with the Congress on having your aid cut off if you keep inciting violence between the Israelis and the Palestinians."

In a separate interview on ABC's "This Week," Sen. Carl Levin, chairman of the Armed Services Committee, called Egypt's response to the crisis "pretty weak" so far.

"I think that they're going to have to take some very serious steps diplomatically to make it clear to Hamas that they're going to lose support in the Arab world if they continue these rocket attacks on Israel," said Levin, D-Mich.

Lawmakers also blamed Iran for arming Hamas militants, and questioned Egypt's role in that.

"My guess is there has to be some tacit involvement in Egypt and the border or these things wouldn't be getting in to Gaza," said Rep. C.A. "Dutch" Ruppersberger of Maryland, the top Democrat on the House Intelligence Committee.

Sen. Joseph Lieberman, I-Conn., said he thinks the threat of a ground war is overblown.

"I don't think the Israelis really want a ground war," he told "Fox News Sunday." ''They'll go into Gaza if they feel they need to, to eliminate the remainder of the missiles. ... So really, the decision is up to Hamas, as to whether there will be a ground invasion of Gaza or not."

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Flaherty reported from Washington. Associated Press writer Gregory Katz in London contributed to this report.

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'Twilight' finale dawns with $141.3M weekend

LOS ANGELES (AP) — The sun has set on the "Twilight" franchise with one last blockbuster opening for the supernatural romance.

"The Twilight Saga: Breaking Dawn — Part 2" sucked up $141.3 million domestically over opening weekend and $199.6 million more overseas for a worldwide debut of $340.9 million, according to studio estimates Sunday.

The finale ranks eighth on the list of all-time domestic debuts, and leaves "Twilight" with three of the top-10 openings, joining 2009's "New Moon" (No. 7 with $142.8 million) and last year's "Breaking Dawn — Part 1" (No. 9 with $138.1 million).

Last May's "The Avengers" is No. 1 with $207.4 million. "Batman" is the only other franchise with more than one top-10 opening: last July's "The Dark Knight Rises" (No. 3 with $160.9 million) and 2008's "The Dark Knight" (No. 4 with $158.4 million).

Though "Twilight" still is a female-driven franchise, with girls and women making up 79 percent of the opening-weekend audience, the finale drew the biggest male crowds in the series. Action-minded guys had more to root for in the finale as Kristen Stewart, Robert Pattinson and Taylor Lautner join in a colossal battle to end the story of warring vampires and werewolves.

"Our male audience particularly has enjoyed this film," said Richie Fay, head of distribution for Lionsgate, whose Summit Entertainment banner releases the "Twilight" movies. "With the action scenes in this one, we're hoping the holdover business will reflect the fact that males have kind of found it out."

The movie also helped lift Lionsgate into the big leagues among Hollywood studios. Paced by its $400 million smash with "The Hunger Games" and now the "Twilight" finale, Lionsgate surpassed $1 billion at the domestic box office for the first time.

Some box-office watchers had expected the last "Twilight" movie to open with a franchise record the way the "Harry Potter" finale did last year with $169.2 million, the second-best domestic debut on the charts.

"I thought that for the final installment, it might eclipse the franchise record, but to look at $141.3 million and say that's a disappointment, that's kind of crazy," said Paul Dergarabedian, an analyst for box-office tracker Hollywood.com. "It's one of the most consistently performing franchises of all time."

The "Twilight" finale took over the No. 1 spot from Sony's James Bond adventure "Skyfall," which slipped to second-place with $41.5 million domestically in its second weekend. "Skyfall" raised its domestic total to $161.3 million.

The franchise's third film starring Daniel Craig as Bond, "Skyfall" began rolling out overseas in late October and has hit $507.9 million internationally at the box office. The film's global total climbed to $669.2 million, helping to lift Sony to its best year ever with $4 billion worldwide, topping the studio's $3.6 billion haul in 2009.

"Skyfall" passed the previous franchise high of $599.2 million worldwide for 2006's "Casino Royale."

Steven Spielberg and Daniel Day-Lewis' Civil War drama "Lincoln" expanded nationwide after a week in limited release and came in at No. 3 with $21 million. Distributed by Disney, "Lincoln" lifted its domestic haul to $22.4 million.

The comic drama "Silver Linings Playbook," released by the Weinstein Co., got off to a good start in limited release, taking in $458,430 in 16 theaters for a solid average of $28,652 a cinema. By comparison, the "Twilight" finale averaged $34,717 in 4,070 theaters.

"Silver Linings Playbook" stars Bradley Cooper, Jennifer Lawrence and Robert De Niro in a quirky romance involving a man fresh out of a psychiatric hospital and an emotionally troubled young widow.

Keira Knightley's period drama "Anna Karenina" also started well in limited release with $315,395 in 16 theaters, for an average of $19,712. The Focus Features film stars Knightley in the title role of Leo Tolstoy's tragic romance.

Estimated ticket sales for Friday through Sunday at U.S. and Canadian theaters, according to Hollywood.com. Where available, latest international numbers are also included. Final domestic figures will be released Monday.

1. "The Twilight Saga: Breaking Dawn — Part 2," $141.3 million ($199.6 million international).

2. "Skyfall," $41.5 million ($49.6 million international).

3. "Lincoln," $21 million.

4. "Wreck-It Ralph," $18.3 million ($4.8 million international).

5. "Flight," $8.6 million ($1 million international).

6. "Argo," $4.1 million ($8.7 million international).

7. "Taken 2," $2.1 million ($2 million international).

8. "Pitch Perfect," $1.3 million ($4.1 million international).

9. "Here Comes the Boom," $1.2 million ($2.5 million international).

10 (tie). "Cloud Atlas," $900,000 ($5 million international).

10 (tie). "Hotel Transylvania," $900,000 ($7.8 million international).

10 (tie). "The Sessions," $900,000.

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Estimated weekend ticket sales at international theaters (excluding the U.S. and Canada) for films distributed overseas by Hollywood studios, according to Rentrak:

1. "The Twilight Saga: Breaking Dawn — Part 2," $199.6 million.

2. "Skyfall," $49.6 million.

3. "Argo," $8.7 million.

4. "Hotel Transylvania," $7.8 million.

5. "Evangelion: 3.0 You Can (Not) Redo," $7.5 million.

6. "A Werewolf Boy," $6.8 million.

7. "Cloud Atlas," $5 million.

8. "Wreck-It Ralph," $4.8 million.

9. "Confession of Murder," $3.5 million.

10. "Rise of the Guardians," $3.1 million.

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Online:

http://www.hollywood.com

http://www.rentrak.com

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Universal and Focus are owned by NBC Universal, a unit of Comcast Corp.; Sony, Columbia, Sony Screen Gems and Sony Pictures Classics are units of Sony Corp.; Paramount is owned by Viacom Inc.; Disney, Pixar and Marvel are owned by The Walt Disney Co.; Miramax is owned by Filmyard Holdings LLC; 20th Century Fox and Fox Searchlight are owned by News Corp.; Warner Bros. and New Line are units of Time Warner Inc.; MGM is owned by a group of former creditors including Highland Capital, Anchorage Advisors and Carl Icahn; Lionsgate is owned by Lions Gate Entertainment Corp.; IFC is owned by AMC Networks Inc.; Rogue is owned by Relativity Media LLC.

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EU drug regulator OKs Novartis' meningitis B shot

LONDON (AP) — Europe's top drug regulator has recommended approval for the first vaccine against meningitis B, made by Novartis AG.

There are five types of bacterial meningitis. While vaccines exist to protect against the other four, none has previously been licensed for type B meningitis. In Europe, type B is the most common, causing 3,000 to 5,000 cases every year.

Meningitis mainly affects infants and children. It kills about 8 percent of patients and leaves others with lifelong consequences such as brain damage.

In a statement on Friday, Andrin Oswald of Novartis said he is "proud of the major advance" the company has made in developing its vaccine Bexsero. It is aimed at children over two months of age, and Novartis is hoping countries will include the shot among the routine ones for childhood diseases such as measles.

Novartis said the immunization has had side effects such as fever and redness at the injection site.

Recommendations from the European Medicines Agency are usually adopted by the European Commission. Novartis also is seeking to test the vaccine in the U.S.

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Obama: Historic Myanmar visit underscores democratic progress

BANGKOK (AP) — On the eve of his landmark trip to Myanmar, President Barack Obama tried to assure critics that his visit was not a premature reward for a long-isolated nation still easing its way toward democracy.

"This is not an endorsement of the government," Obama said Sunday in Thailand as he opened a three-country dash through Asia. "This is an acknowledgement that there is a process under way inside that country that even a year and a half, two years ago, nobody foresaw."

Obama was set to become the first U.S. president to visit Myanmar with Air Force One scheduled to touch down in Yangon on Monday morning. Though Obama planned to spend just six hours in the country, the much-anticipated stop came as the result of a remarkable turnaround in the countries' relationship.

The president's Asia tour also marks his formal return to the world stage after months mired in a bruising re-election campaign. For his first postelection trip, he tellingly settled on Asia, a region he has deemed the region as crucial to U.S. prosperity and security.

Aides say Asia will factor heavily in Obama's second term as the U.S. seeks to expand its influence in an attempt to counter China.

China's rise is also at play in Myanmar, which long has aligned itself with Beijing. But some in Myanmar fear that China is taking advantage of its wealth of natural resources, so the country is looking for other partners to help build its nascent economy.

Obama has rewarded Myanmar's rapid adoption of democratic reforms by lifting some economic penalties. The president has appointed a permanent ambassador to the country, also known as Burma, and pledged greater investment if Myanmar continues to progress following a half-century of military rule.

But some human rights groups say Myanmar's government, which continues to hold hundreds of political prisoners and is struggling to contain ethnic violence, hasn't done enough to earn a personal visit from Obama.

Speaking from neighboring Thailand, Obama said Sunday he was under no illusions that Myanmar had done all it needed to do. But he said the U.S. could play a critical role in helping ensure the country doesn't slip backward.

"I'm not somebody who thinks that the United States should stand on the sidelines and not want to get its hands dirty when there's an opportunity for us to encourage the better impulses inside a country," Obama said during a joint press conference Sunday with Thailand's prime minister.

Even as Obama turned his sights on Asia, widening violence in the Middle East competed for his attention.

Obama told reporters Sunday that Israel had the right to defend itself against missile attacks from Gaza. But he urged Israel not to launch a ground assault in Gaza, saying it would put Israeli soldiers, as well as Palestinian citizens, at greater risk and hamper an already vexing peace process.

"If we see a further escalation of the situation in Gaza, the likelihood of us getting back on any kind of peace track that leads to a two-state solution is going to be pushed off way into the future," Obama said.

The ongoing violence is likely to trail Obama as he makes his way from Thailand to Myanmar to Cambodia, his final stop before returning to Washington early Wednesday.

Obama will meet separately in Myanmar with Prime Minister Thein Sein, who has orchestrated much of his country's recent reforms. The president will also meet with longtime Myanmar democracy activist Aung Sun Suu Kyi in the home where she spent years under house arrest.

The president, as he seeks to assuage critics, has trumpeted Suu Kyi's support of his outreach efforts, saying Sunday that she was "very encouraging" of his trip.

The White House says Obama will express his concern for the ongoing ethnic tensions in Myanmar's western Rakhine state, where more than 110,000 people — the vast majority of them Muslims known as Rohingya — have been displaced.

The U.N. has called the Rohingya — who are widely reviled by the Buddhist majority in Myanmar — among the world's most persecuted people.

The White House says Obama will press the matter Monday with Thein Sein, along with demands to free remaining political prisoners as the nation transitions to democracy.

The president will cap his trip to Myanmar with a speech at Rangoon University, the center of the country's struggle for independence against Britain and the launching point for many pro-democracy protests. The former military junta shut the dormitories in the 1990s fearing further unrest and forced most students to attend classes on satellite campuses on the outskirts of town.

Obama began his Asian tour on a steamy day in Bangkok with a visit to the Wat Pho Royal Monastery. In stocking feet, the president and Secretary of State Hillary Rodham Clinton walked around a golden statue of a sitting Buddha. The complex is a sprawling display of buildings with colorful spires, gardens and waterfalls.

Obama then paid a courtesy call to the ailing, 84-year-old U.S.-born King Bhumibol Adulyadej in his hospital quarters. The king, the longest serving living monarch, was born in Cambridge, Mass., and studied in Europe.

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Associated Press writer Jim Kuhnhenn contributed to this report.

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