RSV fills hospitals with wheezing babies each fall and winter, and the virus struck earlier than usual and especially hard in the U.S. this past year.

If the vaccine pans out, many infants and their parents will breathe easier in the coming years, said Dr. Jay Portnoy, a member of the Food and Drug Administration advisory panel from Childrens Mercy Hospital in Kansas City, Missouri.

The idea: Give women a single injection late in pregnancy, between 24 weeks and 36 weeks, so they develop RSV-fighting antibodies that pass through the placenta just like they pass protection against other bugs to their babies.

In Pfizers international study of nearly 7,400 pregnant women, maternal vaccination proved 82% effective at preventing severe RSV during babies most vulnerable first three months of life. At age 6 months, it still was proving 69% protective against severe illness.

Pfizer said there were no signs of safety problems but the FDA did ask its scientific advisers to consider whether a slight difference in premature birth between vaccinated moms and those given a dummy shot was of concern. Debate over whether that was really a hint of trouble or just due to chance dominated the panels daylong meeting.

Pfizer pledged to closely track the vaccines real-world use for more evidence. Ultimately the advisers unanimously decided that the shot is effective and voted 10-4 that theres adequate safety data. The FDA will consider Thursdays recommendations in making the final decision on approval.

If youre in any sense risking premature births with this vaccine, I think there will be a big price to pay, said Dr. Paul Offit of the Childrens Hospital of Philadelphia, among the panelists who voted no on the safety question.

If the FDA ultimately approves the maternal shot, it would mark a second milestone in the decades-long quest to prevent the respiratory syncytial virus. Earlier this month the FDA approved the worlds first RSV vaccine, rival GSKs shot for older adults, who also are at high risk. There isnt a vaccine yet for children, but Pfizer is about to begin testing one.

Here are some things to know:

RSV is a common threat

For most healthy people, RSV is a cold-like nuisance. But it can be life-threatening for the very young - infecting deep in the lungs to cause pneumonia or impeding babies breathing by inflaming their tiny airways. In the U.S. alone, between 58,000 and 80,000 children younger than 5 are hospitalized each year, and between 100 and 300 die, according to the Centers for Disease Control and Prevention.

All young infants are at risk of severe disease with RSV, but postponing infection even by a few months lessens that risk, said CDCs Dr. Katherine Fleming-Dutra.

Vaccines potential impact

Pfizers vaccine isnt intended to prevent RSV infection but to avoid the worst outcomes. In late-stage testing, six infants born to vaccinated mothers had a severe RSV illness in their first three months of life compared to 33 infants whose mothers received a dummy shot. In addition, the vaccine cut in half the chances of needing any medical attention for an RSV infection by age 6 months.

The company predicts the U.S. could prevent as many as 20,000 infant hospitalizations a year, and 320,000 doctor visits, if enough pregnant women were vaccinated.

Safety data

Vaccine reactions included typically mild injection-site pain and fatigue. As for the prematurity question, vaccinated mothers had slightly more preterm infants - 5.7% versus 4.7%. The vast majority were born just a few weeks early. Thats better than the nations preterm birth rate overall in the U.S., 1 in 10 babies were born premature last year - and the study imbalance wasnt statistically significant, meaning it could be due to chance.

Competitor GSK halted its own trials of a maternal RSV vaccine because of prematurity concerns, spurring questions about Pfizers shot. Pfizer said the preterm difference in its study was fueled by participants in South Africa for unknown reasons and there was no difference spotted in the U.S. or other high-income countries.

Do you hold hostage the potential benefits of the vaccine without clear evidence of a problem, Dr. William Gruber, Pfizers senior vice president, asked the panelists.

There is certainty that the vaccine works and will keep infants out of the hospital in the United States as soon as this winter, he said.

A total of 17 infants died during the study, five born to vaccinated mothers and 12 to those given a dummy shot. Researchers deemed none of the deaths related to the vaccine but FDA said it is unable to exclude the possibility that one infants death, stemming from extreme prematurity, might be related.

Vaccines always get close safety scrutiny but regulators are especially mindful of a major setback in the 1960s when an experimental RSV shot worsened infections in children. Eventually scientists figured out the problem and the RSV vaccines in the pipeline today are made with safer, modern methods yet still were tested first in older adults.

Another open question

FDAs advisers also cautioned that its not clear which other vaccines given to pregnant women can be administered during the same doctors visit. They pointed to data suggesting that a vaccine against whooping cough doesnt seem as strong if pregnant women receive it at the same time as the RSV shot.

What happens next?

FDAs advisers already have recommended approving Pfizers vaccine for older adults, and the agency is expected to make a decision by months end. Whether to use the same shot in pregnant women will be a separate FDA decision, expected in August.

Meanwhile, rival GSK is gearing up for fall immunizations with its RSV vaccine for seniors. First, the CDCs advisers will debate next month whether all older adults or only those at high risk need vaccination.

Vaccines arent the only advance in the pipeline. High-risk infants can get monthly doses of a protective drug during RSV season, although CDC data shows too few receive it. European regulators recently approved the first one-dose option, from Sanofi and AstraZeneca, opening that type of protection to more infants. FDAs advisers will debate that drug next month, too.

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institutes Department of Science Education. The AP is solely responsible for all content.

2023 might be the last year you guys see me around on TikTok, he posted on one of his recent videos, where he goes by only his first name. If youve enjoyed the content over the years I have my YouTube linked and I am also gonna start an Instagram this summer. I am gonna be focusing on building those up and providing the same content Ive been pushing out over here. 

Isaac is one of many TikTok users adjusting to the implications of an announced ban in Montana. The states Republican governor, Greg Gianforte, signed a measure Wednesday that will prohibit the apps download by the general public beginning next year. 

The new law will impose the broadest and strictest limitations on use of the social media platform yet, spurred by widespread governmental concerns about Chinas access to American users personal data. TikTok will be fined $10,000 for every day its platform operates on devices in Montana once the law takes effect on Jan. 1. So will the mobile app stores offering it for download in the state.

A group of TikTok creators and viewers on Thursday sued Montana to challenge the ban, arguing it violates their First Amendment rights under the Constitution. The law attempts to exercise powers over national security that Montana does not have and to ban speech Montana may not suppress, according to the complaint filed in federal court in Missoula.

On TikTok, which has 150 million users in the US, an overwhelming number of people expressed confusion and opposition toward the Montana ban, arguing it has intruded on their right to free speech and disrespects the amount of time and effort content creators put into the platform. Some argued it wouldnt solve the US security problems either, as Montana is not a populous state with important people whose data would be susceptible to Chinese influence. 

Montana has a population of only 1.1 million people and about 200,000 TikTok users. 

The amount of work, the amount of time, the amount of effort people have made and put into this app to create things, its really just 2 steps forward 5 steps back, a music influencer who goes by Lilxlunatic, with 20,000 followers, said in his TikTok video. He said he doesnt feel he can speak as freely on other platforms, and that hes concerned government officials are doing it because they dont want to see uncomfortable TikTok content highlighting incidents of gun violence and oil spills. I understand it was made by China, but the fact that all our information goes through US branches, and our side of TikTok is completely different than the Chinese side of TikTok, just doesnt make sense to me. 

The TikTok app as Americans know it doesnt exist in China, where TikToks parent company, ByteDance Ltd., operates Douyin. Its content is similar but is restricted by Chinese censorship rules. TikTok Chief Executive Officer Shou Chew has said TikTok is independent of its Beijing-based owner and the platforms headquarters are in Singapore and Los Angeles. 

I think our governor is being a little goofy, said Christian Poole, a 20-year-old influencer with 418,500 followers who usually posts fun strings about living in Montana. His video got more than 3,000 likes. Poole wondered why the governor is worried about the Chinese Communist Party getting information of our fellow Montanans? He said nobody drastically important, or with any influence over politics, lives in the state and uses TikTok so much that the CCP would be able to gather enough information about them to the point that it becomes a liability for the United States security as a whole.  

While Montana is the first state to prohibit the general public from using the app, targeted bans focusing on government devices and networks cascaded across the country late last year. The US government and 38 states have issued such bans and President Joe Bidens administration is in negotiations with the company to resolve national security concerns. The European Union, UK, Canada, and a handful of other countries have more recently imposed similar restrictions.

The Montana laws current text doesnt explain how removing the app from devices on which its already installed would be enforced. It also fails to explain details on cross-state travel. And users are also discussing options to bypass the legislation, such as buying a virtual private network to get a fresh IP address. 

We hope this doesnt spread to actual states with real population. Time to invest in VPN companies, said Trey, an influencer who posts commentary and interviews and has 148,900 followers. 

One thing I know is that this is not the time to be quiet, said Fiona, an influencer in fashion and lifestyle with 14,600 followers on TikTok. Call your representatives call them, Tweet them, beep them anyway you can reach them. This is not the time to lay down and Montana is just the beginning.

An Associated Press analysis of a dozen countries most indebted to China including Pakistan, Kenya, Zambia, Laos and Mongolia found paying back that debt is consuming an ever-greater amount of the tax revenue needed to keep schools open, provide electricity and pay for food and fuel. And its draining foreign currency reserves these countries use to pay interest on those loans, leaving some with just months before that money is gone.

Behind the scenes is Chinas reluctance to forgive debt and its extreme secrecy about how much money it has loaned and on what terms, which has kept other major lenders from stepping in to help. On top of that is the recent discovery that borrowers have been required to put cash in hidden escrow accounts that push China to the front of the line of creditors to be paid.

Countries in APs analysis had as much as 50% of their foreign loans from China and most were devoting more than a third of government revenue to paying off foreign debt. Two of them, Zambia and Sri Lanka, have already gone into default, unable to make even interest payments on loans financing the construction of ports, mines and power plants.

In Pakistan, millions of textile workers have been laid off because the country has too much foreign debt and cant afford to keep the electricity on and machines running.

In Kenya, the government has held back paychecks to thousands of civil service workers to save cash to pay foreign loans. The presidents chief economic adviser tweeted last month, Salaries or default? Take your pick.

Since Sri Lanka defaulted a year ago, a half-million industrial jobs have vanished, inflation has pierced 50% and more than half the population in many parts of the country has fallen into poverty.

Experts predict that unless China begins to soften its stance on its loans to poor countries, there could be a wave of more defaults and political upheavals.

In a lot of the world, the clock has hit midnight, said Harvard economist Ken Rogoff.  China has moved in and left this geopolitical instability that could have long-lasting effects.

How its playing out

A case study of how it has played out is in Zambia, a landlocked country of 20 million people in southern Africa that over the past two decades has borrowed billions of dollars from Chinese state-owned banks to build dams, railways and roads.

The loans boosted Zambias economy but also raised foreign interest payments so high there was little left for the government, forcing it to cut spending on healthcare, social services and subsidies to farmers for seed and fertilizer.

In the past under such circumstances, big government lenders such as the U.S., Japan and France would work out deals to forgive some debt, with each lender disclosing clearly what they were owed and on what terms so no one would feel cheated.

But China didnt play by those rules. It refused at first to even join in multinational talks, negotiating separately with Zambia and insisting on confidentiality that barred the country from telling non-Chinese lenders the terms of the loans and whether China had devised a way of muscling to the front of the repayment line.

Amid this confusion in 2020, a group of non-Chinese lenders refused desperate pleas from Zambia to suspend interest payments, even for a few months. That refusal added to the drain on Zambias foreign cash reserves, the stash of mostly U.S. dollars that it used to pay interest on loans and to buy major commodities like oil. By November 2020, with little reserves left, Zambia stopped paying the interest and defaulted, locking it out of future borrowing and setting off a vicious cycle of spending cuts and deepening poverty.

Inflation in Zambia has since soared 50%, unemployment has hit a 17-year high and the nations currency, the kwacha, has lost 30% of its value in just seven months. A United Nations estimate of Zambians not getting enough food has nearly tripled so far this year, to 3.5 million.

I just sit in the house thinking what I will eat because I have no money to buy food, said Marvis Kunda, a blind 70-year-old widow in Zambias Luapula province whose welfare payments were recently slashed. Sometimes I eat once a day and if no one remembers to help me with food from the neighborhood, then I just starve.

A few months after Zambia defaulted, researchers found that it owed $6.6 billion to Chinese state-owned banks, double what many thought at the time and about a third of the countrys total debt.

Were flying blind, said Brad Parks, executive director of AidData, a research lab at William & Mary that has uncovered thousands of secret Chinese loans and assisted the AP in its analysis. When you look under the cushions of the couch, suddenly you realize, Oh, theres a lot of stuff we missed. And actually things are much worse.

Debt and upheaval

Chinas unwillingness to take big losses on the hundreds of billions of dollars it is owed, as the International Monetary Fund and World Bank have urged, has left many countries on a treadmill of paying back interest, which stifles the economic growth that would help them pay off the debt.

Foreign cash reserves have dropped in 10 of the dozen countries in APs analysis, down an average 25% in just a year. They have plunged more than 50% in Pakistan and the Republic of Congo. Without a bailout, several countries have only months left of foreign cash to pay for food, fuel and other essential imports. Mongolia has eight months left. Pakistan and Ethiopia about two.

As soon as the financing taps are turned off, the adjustment takes place right away, said Patrick Curran, senior economist at researcher Tellimer. The economy contracts, inflation spikes up, food and fuel become unaffordable.

Mohammad Tahir, who was laid off six months ago from his job at a textile factory in the Pakistani city of Multan, says he has contemplated suicide because he can no longer bear to see his family of four go to bed night after night without dinner.

Ive been facing the worst kind of poverty, said Tahir, who was recently told Pakistans foreign cash reserves have depleted so much that it was now unable to import raw materials for his factory. I have no idea when we would get our jobs back.

Poor countries have been hit with foreign currency shortages, high inflation, spikes in unemployment and widespread hunger before, but rarely like in the past year.

Along with the usual mix of government mismanagement and corruption are two unexpected and devastating events: the war in Ukraine, which has sent prices of grain and oil soaring, and the U.S. Federal Reserves decision to raise interest rates 10 times in a row, the latest this month. That has made variable rate loans to countries suddenly much more expensive.

All of it is roiling domestic politics and upending strategic alliances.

In March, heavily indebted Honduras cited financial pressures in its decision to establish formal diplomatic ties to China and sever those with Taiwan.

Last month, Pakistan was so desperate to prevent more blackouts that it struck a deal to buy discounted oil from Russia, breaking ranks with the U.S.-led effort to shut off Vladimir Putins funds.

In Sri Lanka, rioters poured into the streets last July, setting homes of government ministers aflame and storming the presidential palace, sending the leader tied to onerous deals with China fleeing the country.

Chinas response

The Chinese Ministry of Foreign Affairs, in a statement to the AP, disputed the notion that China is an unforgiving lender and echoed previous statements putting the blame on the Federal Reserve. It said that if it is to accede to IMF and World Bank demands to forgive a portion of its loans, so should those multilateral lenders, which it views as U.S. proxies.

We call on these institutions to actively participate in relevant actions in accordance with the principle of joint action, fair burden and make greater contributions to help developing countries tide over the difficulties, the ministry statement said.

China argues it has offered relief in the form of extended loan maturities and emergency loans, and as the biggest contributor to a program to temporarily suspend interest payments during the coronavirus pandemic. It also says it has forgiven 23 no-interest loans to African countries, though AidDatas Parks said such loans are mostly from two decades ago and amount to less than 5% of the total it has lent.

In high-level talks in Washington last month, China was considering dropping its demand that the IMF and World Bank forgive loans if the two lenders would make commitments to offer grants and other help to troubled countries, according to various news reports. But in the weeks since there has been no announcement and both lenders have expressed frustration with Beijing.

My view is that we have to drag them maybe thats an impolite word we need to walk together, IMF Managing Director Kristalina Georgieva said earlier this month. Because if we dont, there will be catastrophe for many, many countries.

The IMF and World Bank say taking losses on their loans would rip up the traditional playbook of dealing with sovereign crises that accords them special treatment because, unlike Chinese banks, they already finance at low rates to help distressed countries get back on their feet. The Chinese foreign ministry noted, however, that the two multilateral lenders have made an exception to the rules in the past, forgiving loans to many countries in the mid-1990s to save them from collapse.

As time runs out, some officials are urging concessions.

Ashfaq Hassan, a former debt official at Pakistans Ministry of Finance, said his countrys debt burden is too heavy and time too short for the IMF and World Bank to hold out. He also called for concessions from private investment funds that lent to his country by purchasing bonds.

Every stakeholder will have to take a haircut, Hassan said.

China has also pushed back on the idea, popularized in the Trump administration, that it has engaged in debt trap diplomacy, leaving countries saddled with loans they cannot afford so that it can seize ports, mines and other strategic assets.

On this point, experts who have studied the issue in detail have sided with Beijing. Chinese lending has come from dozens of banks on the mainland and is far too haphazard and sloppy to be coordinated from the top. If anything, they say, Chinese banks are not taking losses because the timing is awful as they face big hits from reckless real estate lending in their own country and a dramatically slowing economy.

But the experts are quick to point out that a less sinister Chinese role is not a less scary one.

There is no single person in charge, said Teal Emery, a former sovereign loan analyst who now runs consulting group Teal Insights.

Adds AidDatas Parks about Beijing, Theyre kind of making it up as they go along. There is no master plan.

Loan sleuth

Much of the credit for dragging Chinas hidden debt into the light goes to Parks, who over the past decade has had to contend with all manner of roadblocks, obfuscations and falsehoods from the authoritarian government.

The hunt began in 2011 when a top World Bank economist asked Parks to take over the job of looking into Chinese loans. Within months, using online data-mining techniques, Parks and a few researchers began uncovering hundreds of loans the World Bank had not known about.

China at the time was ramping up lending that would soon become part of its $1 trillion Belt and Road Initiative to secure supplies of key minerals, win allies abroad and make more money off its U.S. dollar holdings. Many developing countries were eager for U.S. dollars to build power plants, roads and ports and expand mining operations.

But after a few years of straightforward Chinese government loans, those countries found themselves heavily indebted, and the optics were awful. They feared that piling more loans atop old ones would make them seem reckless to credit rating agencies and make it more expensive to borrow in the future.

So China started setting up shell companies for some infrastructure projects and lent to them instead, which allowed heavily indebted countries to avoid putting that new debt on their books. Even if the loans were backed by the government, no one would be the wiser.

In Zambia, for example, a $1.5 billion loan from two Chinese banks to a shell company to build a giant hydroelectric dam didnt appear on the countrys books for years.

In Indonesia, Chinese loans of $4 billion to help build a railway also never appeared on public government accounts. That all changed years later when, overbudget by $1.5 billion, the Indonesian government was forced to bail out the railroad twice.

When these projects go bad, what was advertised as a private debt becomes a public debt, Parks said. There are projects all over the globe like this.

In 2021, a decade after Parks and his team began their hunt, they had gathered enough information for a blockbuster finding: At least $385 billion of hidden and underreported Chinese debt in 88 countries, and many of those countries were in far worse shape than anyone knew.

Among the disclosures was that China issued a $3.5 billion loan to build a railway system in Laos, which would take nearly a quarter of the countrys annual output to pay off.

Another AidData report around the same time suggested that many Chinese loans go to projects in areas of countries favored by powerful politicians and frequently right before key elections. Some of the things built made little economic sense and were riddled with problems.

In Sri Lanka, a Chinese-funded airport built in the presidents hometown away from most of the countrys population is so barely used that elephants have been spotted wandering on its tarmac.

Cracks are appearing in hydroelectric plants in Uganda and Ecuador, where in March the government got judicial approval for corruption charges tied to the project against a former president now in exile.

In Pakistan, a power plant had to be shut down for fear it could collapse. In Kenya, the last key miles of a railway were never built due to poor planning and a lack of funds.

Jumping to the front of the line

As Parks dug into the details of the loans, he found something alarming: Clauses mandating that borrowing countries deposit U.S. dollars or other foreign currency in secret escrow accounts that Beijing could raid if those countries stopped paying interest on their loans.

In effect, China had jumped to the front of the line to get paid without other lenders knowing.

In Uganda, Parks revealed a loan to expand the main airport included an escrow account that could hold more than $15 million. A legislative probe blasted the finance minister for agreeing to such terms, with the lead investigator saying he should be prosecuted and jailed.

Parks is not sure how many such accounts have been set up, but governments insisting on any kind of collateral, much less collateral in the form of hard cash, is rare in sovereign lending. And their very existence has rattled non-Chinese banks, bond investors and other lenders and made them unwilling to accept less than theyre owed.

The other creditors are saying, Were not going to offer anything if China is, in effect, at the head of the repayment line, Parks said. It leads to paralysis. Everyone is sizing each other up and saying, Am I going to be a chump here?

Loans as currency exchanges

Meanwhile, Beijing has taken on a new kind of hidden lending that has added to the confusion and distrust. Parks and others found that Chinas central bank has effectively been lending tens of billions of dollars through what appear as ordinary foreign currency exchanges.

Foreign currency exchanges, called swaps, allow countries to essentially borrow more widely used currencies like the U.S. dollar to plug temporary shortages in foreign reserves. They are intended for liquidity purposes, not to build things, and last for only a few months.

But Chinas swaps mimic loans by lasting years and charging higher-than-normal interest rates. And importantly, they dont show up on the books as loans that would add to a countrys debt total.

Mongolia has taken out $1.8 billion annually in such swaps for years, an amount equivalent to 14% of its annual economic output. Pakistan has taken out nearly $3.6 billion annually for years and Laos $300 million .

The swaps can help stave off default by replenishing currency reserves, but they pile more loans on top of old ones and can make a collapse much worse, akin to what happened in the runup to 2009 financial crisis when U.S. banks kept offering ever-bigger mortgages to homeowners who couldnt afford the first one.

Some poor countries struggling to repay China now find themselves stuck in a kind of loan limbo: China wont budge in taking losses, and the IMF wont offer low-interest loans if the money is just going to pay interest on Chinese debt.

For Chad and Ethiopia, its been more than a year since IMF rescue packages were approved in so-called staff-level agreements, but nearly all the money has been withheld as negotiations among its creditors drag on.

Youve got a growing number of countries that are in dire financial straits, said Parks, attributing it largely to Chinas stunning rise in just a generation from being a net recipient of foreign aid to the worlds largest creditor.

Somehow theyve managed to do all of this out of public view, he said. So unless people understand how China lends, how its lending practices work, were never going to solve these crises.

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Condon reported from New York and Washington. AP writers Munir Ahmed in Islamabad and Noel Sichalwe in Lusaka, Zambia, contributed to this report.