Thats the implication of research suggesting that something in an obese womans womb can program her fetus toward becoming a fat child and adult. Its not about simply passing along genes that promote obesity; its some sort of still-mysterious signal.

The idea has only recently entered conversations between doctors and female patients, and scientists are scrambling to track down a biological explanation. That knowledge, in turn, may provide new ways to block obesity from crossing generations.

While theres some disagreement on how important the womb signal is, “the evidence is building and building that it is a substantial issue,” said Dr. Matthew Gillman of Harvard Medical School, who studies prevention of obesity.

Others agree. “I think it could be a hugely significant factor,” said Robert Waterland of the Baylor College of Medicine in Houston, who studies the effect in mice.

Dr. Rudy Leibel, an obesity expert at Columbia University, says he doubts it plays a huge role, but still believes its worth studying. If scientists can uncover its biological underpinnings, he said, they may be able to use that knowledge to prevent or treat obesity from other causes.

Perusse, 39, of Three Rivers, Quebec, knows the effects of being very fat. Before her weight-loss surgery in 1995, she packed 284 pounds on her 5-foot-2 frame. She could not ride a bike or climb stairs to her second-floor home without stopping to rest.

Now, although shes still overweight, those limitations are history, she said through an interpreter.

But her older children struggle with their weight. At 5-foot-3 and 300 pounds, her 22-year-old daughter cant bathe her own two children, Perusse said. Her 16-year-old son weighs 230 pounds and stands 5-foot-6.

They were born before she had the weight-loss surgery. Her two younger daughters, ages 4 and 7, came along afterward. Their weights are normal so far, though Perusse said her older children werent overweight at those ages either.

So shes using diet and exercise to try to protect them against what she called rotten genes, including those from their 400-pound father. She said she isnt optimistic.

But Dr. John Kral of the SUNY Downstate Medical Center in New York says his research suggests that obese women who lose weight before pregnancy may be helping the next generation keep off excess pounds - even if fat-promoting genes run in the family.

In addition, those born afterward showed lower levels of blood fats and indicators of future diabetes.

Kral says families typically dont change lifestyle or diet after surgery, so that doesnt explain the outcome.

Instead, he says, the surgical bypass operation made the womens bodies less efficient at digesting and absorbing food, and lowered levels of sugar and fat in the blood. That, in turn, would reduce the number of calories delivered to the fetus to levels like those provided by a normal-weight mother, he said.

And the womens shedding of pounds before the pregnancy would also help, he said.

While scientists are still trying to explain just how obesity could be transmitted from the womb, it makes sense that a mothers obesity could affect her childrens long-term weight, Waterland said. Cues in early life, including some in the womb, guide the development of a persons brain circuitry for controlling the balance between calories consumed and those burned away, he said. So a signal there could have a long-lasting impact.

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In less than four minutes at the microphone, Lownsdale helped the Obama administration mark Breast Cancer Awareness Month and, more importantly, provide a flesh-and-blood illustration for why President Barack Obama wants to overhaul the system.

First lady Michelle Obama said the U.S. has come a long way from the days when people thought breast cancer was something to be ashamed of and kept a secret, when it was treated as something not discussed in polite company.

More women are getting mammograms, the five-year survival rate is above 90 percent and research spending is at $900 million - 30 times the amount spent in 1982. But 1 in 8 women will still be diagnosed with breast cancer in her lifetime and 40,000 women a year still die from the disease, she said, and the current health care system doesnt work for many women who are living with the cancer.

“Its a system that only adds to the fear and stress that already comes with the disease,” the first lady said.

At the end of her treatment for a pea-sized tumor, Lownsdale said her doctor said she had a 94 percent chance of remaining cancer free, “very similar to a woman whos never had breast cancer.” Then in 2005, her insurer notified her that her health care premiums would more than double.

The married, 40-something graphic designer shopped around for new coverage and repeatedly was denied. She ended up with coverage through Illinois high-risk pool, and currently pays $600 a month for her coverage alone.

Despite her good health, she said the diagnosis “left a target on my back.”

“I will most likely be cancer free for the rest of my life, but having the word cancer written on my medical chart is enough to generate an automatic rejection from insurance coverage,” Lownsdale told a gathering of breast cancer survivors, advocates, members of Congress and Jill Biden, the vice presidents wife. Mrs. Biden started a breast cancer education program in Delaware after some close friends were diagnosed.

Mrs. Obama said health care changes the president is pushing Congress to pass would help consumers by barring insurers from denying coverage because of pre-existing conditions, like breast cancer, and require coverage for preventive screenings like mammograms.

“Perhaps most heartbreaking of all is the fact that right now, today in America, there are people in this country who have breast cancer but dont even know it because they cant afford a mammogram,” said Mrs. Obama, a former hospital administrator in Chicago.

One in five women age 50 or older havent had a mammogram in the past two years, she said, citing a Health and Human Services Department report.

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So far, Brailer has invested more than $120 million in 30 companies, and said he plans to spend $150 million to $200 million a year beginning in 2010. One company aims to save hospitals up to $1.6 million a year each, using a centralized center to read radiology images. Others make electronic chemotherapy pumps that save time and curb treatment errors, run pharmacy chains that blend alternative therapies with traditional drugs, or match consumers to insurance plans based on their medical history.

“What Brailer and Calpers are doing is unique and possibly revolutionary,” said Robert Galvin, chief medical officer of General Electric Co., which buys health care for 152,000 U.S. employees. “We hadnt seen capital going into opportunities to both provide new treatments and also promote efficiency and quality.”

Pain Points

Brailer said his investments focus on areas of the health- care system where waste and inefficiency are rampant. These systemic trouble spots, which Brailer calls “pain points,” cost the U.S. medical system about $700 billion a year, according to the New England Healthcare Institute, a nonprofit policy research organization in Cambridge, Massachusetts.

“We look for big pain points, really big, important pain for really big money,” Brailer said. “The broad cultural trend is for people to take more responsibility for their care.”

Five congressional panels have passed bills to extend health-care coverage to as many as 37 million uninsured Americans, through a mix of taxpayer subsidies and restrictions on insurers. Debate may begin as soon as next week on one measure being crafted by Senate leaders and aides to President Barack Obama.

Americans will have to navigate a more complex system even if Obamas health-care overhaul doesnt pass, Brailer said. Patients and doctors will need help controlling costs without sacrificing the quality of care, which offers an opportunity for companies with technologies that help doctors manage work better or let consumers comparison-shop, he said.

10-Year Trends

“There are 10-year trends that will change decision- making in health care, change drugs, change our entire conception of disease,” said Brailer, a physician who also has a Ph.D. in economics from the University of Pennsylvanias Wharton School. “Legislation wont affect secular trends, so the best way to put it is that were looking past it.”

Some of Obamas proposals build on Brailers work for Bush. Brailer worked as National Coordinator of Health Care Information Technology in the Bush administration from 2004 to 2006. He planned a national electronic medical-record network, which is now being built out with money from Obamas stimulus plan. The network will help control medical inflation and expand coverage, Obama has said.

Brailer, a registered Republican, said he chafed at some Bush administration policies, including its opposition to universal health insurance. He said some party members also privately criticized his work to create a national health- records network, using agreed-upon technical standards coordinated by the government, as interfering in free markets. Congressional Republicans cut his offices budget to zero for fiscal 2005, before the President used his executive authority to reallocate other money for the Department of Health and Human Services to keep the project going, Brailer said.

Brailers White House work was one reason the California pension system bet on someone who had never run a fund, said Calpers portfolio manager Mike Dutton, who helps oversee $42.3 billion in private-equity commitments.

“We wanted deep medical and policy expertise, working with our existing private equity but positioned a little different,” Dutton said. Brailer and his 12-person team at Health Evolution Partners are “more attuned to health-care operations, policy, trends, all the elements in the witches brew,” Dutton said.

Largest Investment

Calperss portfolio lost 23 percent of its value in the year ending June 30, the worst year since its founding in 1932. Its private equity bets dropped 31 percent in value, the system said July 21. It responded by raising the percentage of its $180.9 billion in assets it plans to put into private equity, taking advantage of a time when prices for the investments were low, Dutton said.

The systems investment in Brailer is among the largest it has ever given a first-time private-equity manager. The commitment is bigger than virtually any Calpers has made to firms other than veteran buyout groups such as the Carlyle Group, Blackstone Group LP and Texas Pacific Group Ltd.

“No matter how you look at it, $1 billion is a lot to allocate to someone with no track record,” said Susan Mangiero, a Trumbull, Connecticut-based pension consultant.

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Snowes stance is crucial because Democrats such as Nebraska Senator Ben Nelson say a bill has to have Republican support to win his vote. She might also bring along more Republicans, such as fellow Maine Senator Susan Collins.

While the establishment of a so-called public option to compete with private insurers is opposed by all Republicans and has divided Democrats, the idea is getting fresh attention from Senate Democratic leaders, lawmakers say. It was the main topic of discussion all day on Capitol Hill and was brought up at a meeting that Majority Leader Harry Reid and other lawmakers had later with President Barack Obama at the White House.

Senator Kent Conrad, a North Dakota Democrat whos played a leading role in seeking a bipartisan compromise, said Reid and Obama administration officials are tilting in favor of including a version in a Senate bill.

States would be free to opt out of the insurance program and the plan would pay health-care providers at higher rates than does the Medicare insurance system for the elderly, Conrad, a member of the finance committee, told reporters.

“What Im hearing is this is the direction of the conversation,” he said, adding that no decision had been made.

Reids spokesman, Jim Manley, declined to comment.

60 Votes Needed

A Democratic aide familiar with the discussions said while a public option is being considered, it wont be included in legislation unless Reid can get 60 votes, the number needed to avoid Republican stalling tactics. Another possibility is Snowes plan to start a government plan only if there isnt enough competition for private insurers to keep rates low, said the aide, who requested anonymity.

Meanwhile, House Democratic leaders are trying to gain consensus among the partys rank and file for a public option that would peg doctor reimbursements to lower Medicare rates, which would present a stronger challenge to private insurers.

In the Senate, Democrats including Charles Schumer of New York and Jay Rockefeller of West Virginia say a public option is vital to bringing costs down. Snowe and some Democrats such as Nelson say theyre worried about undermining the market.

Biggest Changes

Lawmakers are considering the biggest health-care changes since the creation of Medicare in 1965. The legislation, Obamas top domestic priority, attempts to curb medical costs while covering tens of millions of uninsured Americans.

Obama has told Congress he wants to sign legislation this year, a goal that may slip, Snowe said.

“Christmas might be too soon,” she said in the Bloomberg interview. “We should give it the time it deserves.”

Reid is combining a measure passed by the Senate health committee in July with an $829 billion proposal approved by the Senate finance panel on Oct. 13 with Snowes vote. The Senate has to debate and vote on a plan before it can be merged with a bill from the House, which is going through the same process.

Legislative Timeline

House Speaker Nancy Pelosi said Democrats hope to introduce their combined legislation next week. Senate Finance Committee Chairman Max Baucus said he doesnt expect a Senate bill to be ready for floor debate in his chamber.

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The research suggests that liraglutide may be more effective than currently available treatments for obesity. About half of Europeans and two-thirds of Americans are overweight, and 30 percent are considered obese, studies show. Few treatments are available. Novo Nordisk, based in Bagsvaerd, Denmark, funded the research that appears in the journal Lancet and has another trial under way.

“Overall, the results of this study indicate the potential benefit of liraglutide, in conjunction with an energy-deficit diet, in the treatment of obesity and associated risk factors,” said the researchers, led by Arne Astrup, from the University of Copenhagens department of human nutrition. “Liraglutide offers a new mode of action for the treatment of obesity and improved efficacy compared with currently available therapies.”

The research is the second of three phases of trials generally needed to win regulatory approval. Novo Nordisk said it is waiting to hear from U.S. regulators this quarter about the use of the drug for diabetes before it starts additional weight loss trials. Liraglutide is already approved for diabetics in Europe, where its marketed under the name Victoza.

Lower Blood Pressure

Blood pressure levels dropped in all patients taking liraglutide, while signs of impending diabetes, marked by slightly elevated blood sugar levels, fell by as much as 96 percent, the study found.

“Liraglutide improved several factors associated with cardiovascular events over 20 weeks, which are regarded as more clinically relevant than weight loss per se,” the researchers said. “The long-term risk-benefit profile for liraglutide, as well as its weight maintenance capabilities, remain to be established.”

The most common side effects were nausea and vomiting, which generally occurred within the first month. There were no signs of other serious side effects, including pancreatitis, psychiatric complications or thyroid cancer. Participants in the study also followed a calorie-restricted diet and increased their physical activity.

Increased Obesity

The rising rates of obesity during the past two decades have coincided with a dramatic increase in diabetes, leading many public health officials to declare that epidemics are under way with both conditions.

Healthy patients in Astrups study lost more weight than diabetics in earlier studies who were taking the same doses of the drug, said George Bray, from Louisiana State Universitys division of clinical obesity and metabolism in Baton Rouge, in an editorial. It may be that people without diabetes are more responsive to the drug, which stimulates insulin production, slows the emptying of the stomach, and decreases food intake, he said.

“Whether long-term use of an injectable drug is palatable as a treatment for obesity is yet to be established,” Bray wrote. “From what we do know about GLP-1 agonists and their mechanisms, we can be optimistic that their promise for the treatment of obesity will be fulfilled.”

Past Setbacks

Efforts to develop obesity drugs have suffered setbacks. Sanofi-Aventis SA pulled Acomplia off European shelves last year after regulators recommended suspension of sales. The medicine failed to win the backing of a U.S. advisory panel in 2007 after it was linked to suicide.

Merck & Co. last year stopped development of taranabant, in the same class of medicine as Acomplia, because it made people depressed and irritable. Pfizer Inc., the worlds biggest drugmaker, also ended early-stage work on obesity treatments as part of a research overhaul last year.

GlaxoSmithKline Plc sells a form of Xenical, known chemically as orlistat, in a lower-dose, over-the-counter formulation known as Alli.

— Editors: Phil Serafino, Kristen Hallam

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“New evidence is showing that H1N1 can be especially virulent to pregnant women and young people - so they should get vaccinated first,” said Dr. Richard Daines, the state health commissioner.

Workers had protested Daines earlier order that health care workers receive the vaccine, arguing it was unfair to force them to put a substance into their body. Unions and health workers sued the state, and a judge issued a temporary restraining order last week.

“This is welcome news,” said Carl Korn, a spokesman for the New York State United Teachers union. “This suit was never about the safety of the vaccine, or the merits of it. The suit was always about giving individuals the choice, as adults, as to whether or not they wanted to be vaccinated without the threat of termination.”

Its unclear what will happen with the lawsuits. Thursdays action was a suspension of the order, and the Health Department plans to pursue making the order permanent in 2010, as long as theres enough vaccine for that flu season, said Diane Mathis, an agency spokeswoman.

The Health Department initially had said the workers must be vaccinated by November 30. Institutions had to determine how to enforce the mandate, leaving some workers concerned about possible disciplinary action, including dismissal.

“This was the proper and appropriate action for the state to take,” said Kenneth Brynien, president of the Public Employees Federation, one of the unions that sued. “This was an extremely passionate issue for many of our members.”

PEF said it encourages members to get flu vaccinations, but opposes the emergency regulation requiring the vaccine as a condition of employment.

This week the Centers for Disease Control and Prevention allowed the state to order 146,300 doses of vaccine, but health care providers across the state have requested more than 1.4 million doses.

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Every problem, it would seem, is a sales opportunity. Some of the products appear to have been pitched for other emergencies, such as one called “Quake Kare” and masks and purifiers sold during the SARS scare.

Federal officials have sent warning letters to promoters of more than 140 swine flu-related products, including well-known alternative medicine advocate Dr. Andrew Weil for his “Immune Support Formula.”

Consumer Reports also has warned subscribers to be wary.

“Its harmful, disappointing, frustrating to see folks take advantage of the public like this,” said Dr. John Santa, who evaluates health claims for Consumer Reports.

Fraudulent products emerged shortly after swine flu did last spring - about 10 a day, said Alyson Saben, head of a swine flu consumer fraud team formed by the Food and Drug Administration. The pace slowed over the summer as the flu abated, but “its picked up” in recent weeks, she said. “We are seeing new sites pop up.”

Most worrisome: sites that claim to sell Tamiflu without a prescription. The FDA bought and tested five such products. One contained powdered talc and generic Tylenol - no Tamiflu. Several others contained some Tamiflu but were not approved for sale in the U.S.

“We have no idea of the conditions under which they were manufactured. They could contain contaminated, counterfeit, impure or subpotent or superpotent ingredients,” Saben said.

Tamiflu and GlaxoSmithKlines Relenza are the only drugs recommended for treating swine flu.

Rogue Web sites are not the only ones trying to cash in on flu fears. Makers of some well-established products are making claims that may be close to the line, the FDA says.

This week, the makers of Dial Soap, Kleenex, Clorox and other big brands launched a joint promotional campaign costing up to $1 million. The FDA is reviewing the campaign, which includes a video that says:

“Germs are tiny organisms that can cause disease. According to the CDC, up to 80 percent of infectious diseases, like the flu, are spread by your hands. Thats why frequent, proper handwashing is so important in preventing spread of the flu, other viruses and germs. An antibacterial soap like Dial Complete foaming hand wash kills 99.9 percent of germs.”

The campaign is “not being specific down to swine flu,” said Scott Moffitt, an official with Dial Corp.s parent company, Germany-based Henkel AG. He also contends the video is not misleading, even though the germ-killing claim follows a sentence about flu and other viruses.

One product that drew a warning letter from the FDA is the Photon Genie, a gadget that delivers “energy waves.” Its Web site claimed it “helps strengthen the immune system, and a strong immune system is KEY to preventing swine flu symptoms and KEY to treating swine flu.”

The site has since removed the swine flu claim but “other claims remain,” Saben said.

The group behind the Web site, the Skilling Institute of Phoenix, “is not marketing, and will not market in the future, any product that is intended to diagnose, mitigate, prevent, treat or cure the H1N1 flu virus,” its director, Warren Starnes, wrote in an e-mail.

Some products the FDA warned about contain silver, such as “Swine Flu…Gone,” made by Secrets of Eden.

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Easing the way for hospital borrowers are a drop this year in fixed-rate borrowing costs and lower penalties for canceling derivatives contracts linked to types of adjustable-rate debt popular before the credit crisis, according to Concord, Massachusetts-based research firm Municipal Market Advisors.

“The health-care book is jumping up in size,” said Matt Dalton, chief executive of Belle Haven Investments, a fixed- income management firm in White Plains, New York. “Hopefully, the market can hold together” for the deals to be completed.

The yield gap between Merrill Lynch & Co. indexes of hospital bonds and AAA municipal debt tightened to a 10-month low of 186 basis points since Oct. 14, before rising to 191 basis points yesterday. A basis point is 0.01 percentage point.

Municipal Market Advisors daily survey of benchmark 10- year bond yields slid 3 basis points to 3.18 percent yesterday after reaching a three-month high of 3.22 percent last week.

Hospital Sales

Health-care bond sales in the municipal market fell 38 percent to $30.1 billion during the first three quarters of 2009, compared with the year-earlier period, which was boosted by hospitals refinancing debt that jumped in cost, according to data compiled by Thomson Reuters.

Denver-based Catholic Health Initiatives plans to issue almost $890 million of fixed-rate bonds and about $275 million of so-called put bonds, whose rates may change on agreed-upon dates when the nonprofit buys them back.

“We are very optimistic that we will be able to issue the $1.16 billion,” Diane Albrecht, director of capital finance for the health-care system, said in an e-mail. “We had an investor call earlier this week that we believe went very well.”

The health-care system operates 78 hospitals in 20 states and has annual revenue of $8.2 billion, according to its Web site. It carries credit grades of AA from Fitch Ratings and Standard & Poors, and Aa2 from Moodys Investors Service.

30-Year Bonds

Intermountain Healthcare, rated AA+ by S&P and Aa1 by Moodys, borrowed $250 million in a deal arranged by Riverton, Utah. Bonds set to mature in 2041 had a 5.1 percent yield.

Municipal issuers in Indiana, Michigan, Mississippi, North Carolina and Tennessee also planned hospital borrowings this week, according to data compiled by Bloomberg.

Following are descriptions of some pending sales of municipal bonds; the timing and amounts may change.

MINNESOTA is negotiating the sale of about $535 million of general obligation bonds today through a group of underwriters led by Barclays Plc, according to state officials. The proceeds will refinance debt and fund about $470 million in projects for parks, education, pollution control, transportation, natural resources and agriculture. The states full faith, credit and taxing power pledge carries S&P and Fitchs top rating of AAA and Moodys second-highest grade, Aa1. (Updated Oct. 22)

PENNSYLVANIA TURNPIKE COMMISSION, operator of the states toll roads, plans to issue $524 million of revenue bonds through Goldman Sachs Group Inc. this week. The commission is financing a payment, set by a 2007 law called Act 44, to the Pennsylvania Department of Transportation for capital projects. The debt, secured by a subordinate lien on turnpike revenue, is rated A2 by Moodys and A- by S&P. (Added Oct. 19)

SOUTH CAROLINAS SANTEE COOPER, the largest producer of electricity in the state, plans to sell almost $420 million of debt this week through Goldman Sachs Group Inc. Taxable bonds will make up $100 million of the deal; the rest will be tax- exempt. The state-owned electric and water utility will use the money raised to cover costs related to the expansion of the Summer nuclear power plant and refinance debt issued a decade ago. The Moncks Corner-based agency is known officially as the South Carolina Public Service Authority. (Added Oct. 20)

CALIFORNIA, the largest borrower among U.S. states, plans to sell $3 billion of bonds to refinance debt that patched previous state budget deficits. Underwriters led by Barclays Plc will market the so-called economic recovery bonds to investors next week. They are payable primarily from revenue of a dedicated 0.25 percent sales tax and also supported by Californias general pledge to meet its obligations. The deal will level out its repayment schedule through 2023, after a record 11 percent decline in sales tax revenue forced the state to tap a reserve account to meet debt service. The new issue is rated A+ by S&P, A1 by Moodys and A by Fitch. (Added Oct. 22)

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At the same time, Democratic leaders said they can win passage for a government program to compete with private insurers and drive down prices, one of the most contentious issues dividing Democrats and Republicans.

“We have the votes to pass a robust public option,” said Connecticut Representative John Larson, chairman of the House Democratic Caucus. A Congressional Budget Office estimate that the House measure would cut the deficit over 20 years “has placed us in a good spot with the caucus,” he said.

Democratic leaders in the Senate had a tougher time yesterday, when they lost a bid to stave off Medicare-payment cuts to doctors because Republicans and even some Democrats objected to the $247 billion cost. Democrats have been courting the doctors to support the revamp of the medical system.

Lawmakers are considering the biggest changes to U.S. health care since the creation of Medicare in 1965. The legislation, President Barack Obamas top domestic priority, attempts to curb health-care costs while covering tens of millions of uninsured Americans.

Showdown With Senate

The proposal to create a public option is dividing House and Senate Democrats. While the idea has met resistance in the Senate, House Speaker Nancy Pelosi has insisted on keeping it in her version, setting up a clash between the two chambers later when they must reconcile their legislation.

Under one House plan, the public option would peg rates to 5 percent above those paid by Medicare, the government program for the elderly.

An alternative plan would negotiate rates, as private insurers do. A group of fiscally conservative Democrats known as Blue Dogs supports that idea, saying it would provide fairer competition for insurers such as Indianapolis-based WellPoint Inc.

Preliminary Congressional Budget Office estimates show that the legislation with a public option pegged to Medicare rates would cost $871 billion over 10 years, while a bill requiring negotiated reimbursements would be $895 billion, a House leadership aide said on condition of anonymity.

To raise money, House Democratic leaders are considering an annual fee for medical-device manufacturers that would bring in $20 billion over 10 years, the aide said.

“We have a couple of good options,” Pelosi said in a Bloomberg Television interview yesterday. “I dont think we have a bad option in the mix.”

Pelosi and Senate Majority Leader Harry Reid are blending versions passed by three House committees and two Senate panels. In all the measures, Americans would be required to buy insurance, helped by purchasing exchanges and government aid. Insurers would face new rules and have to accept all clients.

While House Democrats are nearing agreement, lawmakers in the Senate are debating other issues. Chief among them are whether to require that employers cover workers, and how to pay for legislation that will cost more than $800 billion over 10 years, as well as the public option.

Senator Ben Nelson, a Nebraska Democrat, said he met with Reid on Oct. 20 and pushed him to drop a “robust public option.” He and Maine Senator Olympia Snowe, the only Republican to support any measure so far, talked with Reid again yesterday about the employer requirement.

“There are a number of our colleagues who have concerns about the employer mandate,” Nelson said.

Biggest Hits

Insurers have taken some of the biggest hits in the debate. The industry opposes the public option, and Americas Health Insurance Plans, a Washington trade group, said action on the antitrust exemption isnt needed and might create “increased regulatory and legal uncertainty.”

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There have been other bottlenecks, too: Factories that put the precious liquid into syringes have become backed up. And the government itself ran into a delay in developing the tests required to assess each batch before it is cleared for use.

What effect the delays will have on the course of the outbreak is unclear, in part because scientists cannot say with any certainty just how dangerous the virus is, how easily it spreads, or whether it will mutate into a more lethal form.

Since April, swine flu has killed more than 800 people in the U.S., including 86 children, 39 of them in the past month and a half, according to the Centers for Disease Control and Prevention. More than half of all hospitalizations since the beginning of September were people 24 and under.

“Were in this race against the virus, and only Mother Nature knows how many cases are going to occur over the next six to 10 weeks,” said Michael Osterholm, a vaccine expert at the University of Minnesota.

In the meantime, many states have had to postpone mass vaccinations. Clinics around the country that managed to obtain doses of the vaccine have been swamped. And doctors are getting bombarded with calls from worried and angry parents.

“Nobody has it,” said AnnMarie OConnor, who waited more than four hours for the vaccine in Rockville, Md., standing in line with her two young children and about 1,000 other people. Health officials “said the shots would be here in early October. But where are they?”

Federal officials counsel patience, saying that eventually there should be enough of both vaccines for everyone who wants them.

“We wish we had better ways to produce vaccines perfectly predictably, but this is how influenza vaccine production often goes,” Dr. Anne Schuchat, who heads the CDCs immunization and respiratory disease section, said last week.

The delays have led to renewed demands for a quicker, more reliable way of producing vaccines than the chicken-egg method, which is 50-year-old technology and involves injecting the virus into eggs and allowing it to feed on the nutrients in the egg white.

Federal officials initially projected that as many as 120 million doses of the vaccine would be ready to dispense by mid-October. They later reduced their estimate to 45 million. As of Tuesday, only 12.8 million were available. (Health officials say a single dose will protect adults, while children under 10 will need two doses.)

In a sign of how rapidly the virus is spreading, education officials said 198 schools in 15 states were closed Wednesday because of swine flu, with more than 65,000 students affected. That was up from 88 school closings the day before.

The government now hopes to have about 50 million doses out by mid-November and 150 million in December, Dr. Nicole Lurie, assistant health and human services secretary for preparedness, told The Associated Press on Wednesday.

“By the end of November, I think were going to be pretty well back on track,” she said.

However, a study by Purdue University researchers said the vaccinations will probably come too late to significantly reduce the number of infections. The study, published last week, predicted that infections would peak in late October and that by the end of the year, 63 percent of the U.S. population will have caught the virus.

The blame for the delays has been placed in part on the chicken-egg technology. It is a slow process, and the pressure on manufacturers to produce two vaccines at the same time - for both swine flu and ordinary flu - has made it even slower.

Also, the virus on which the swine flu vaccine is based was found to reproduce very slowly in eggs - much more slowly than the ordinary flu virus. Health and Human Services Secretary Kathleen Sebelius, who on Wednesday was grilled about the delays by the Senate Homeland Security Committee, said the problem has been fixed.

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