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A Peer-Reviewed Journal Tracking and Analyzing Disease Trends pages 561–770 EDITOR-IN-CHIEF D. Peter Drotman EDITORIAL STAFF EDITORIAL BOARD Founding Editor Dennis Alexander, Addlestone Surrey, United Kingdom Joseph E. McDade, Rome, Georgia, USA Ban Allos, Nashville, Tennessee, USA Michael Apicella, Iowa City, Iowa, USA Managing Senior Editor Barry J. Beaty, Ft. Collins, Colorado, USA Polyxeni Potter, Atlanta, Georgia, USA Martin J. Blaser, New York, New York, USA Associate Editors David Brandling-Bennet, Washington, D.C., USA Charles Ben Beard, Ft. Collins, Colorado, USA Donald S. Burke, Baltimore, Maryland, USA David Bell, Atlanta, Georgia, USA Charles H. Calisher, Ft. Collins, Colorado, USA Patrice Courvalin, Paris, France Arturo Casadevall, New York, New York, USA Stephanie James, Bethesda, Maryland, USA Thomas Cleary, Houston, Texas, USA Anne DeGroot, Providence, Rhode Island, USA Brian W.J. Mahy, Atlanta, Georgia, USA Vincent Deubel, Providence, Rhode Island, USA Takeshi Kurata, Tokyo, Japan Ed Eitzen, Washington, D.C., USA Martin I. Meltzer, Atlanta, Georgia, USA Duane J. Gubler, Ft. Collins, Colorado, USA David Morens, Washington, D.C., USA Scott Halstead, Arlington, Virginia, USA J. Glenn Morris, Baltimore, Maryland, USA David L. Heymann, Geneva, Switzerland Tanja Popovic, Atlanta, Georgia, USA Sakae Inouye, Tokyo, Japan Patricia M. Quinlisk, Des Moines, Iowa, USA Charles King, Cleveland, Ohio, USA Keith Klugman, Atlanta, Georgia, USA Gabriel Rabinovich, Buenos Aires, Argentina S.K. Lam, Kuala Lumpur, Malaysia Didier Raoult, Marseilles, France Bruce R. Levin, Atlanta, Georgia, USA Pierre Rollin, Atlanta, Georgia, USA Myron Levine, Baltimore, Maryland, USA Mario Raviglione, Geneva, Switzerland Stuart Levy, Boston, Massachusetts, USA David Walker, Galveston, Texas, USA John S. MacKenzie, Brisbane, Australia Copy Editors Tom Marrie, Edmonton, Alberta, Canada Angie Frey, Ronnie Henry, Anne Mather, Carol Snarey, John E. McGowan, Jr., Atlanta, Georgia, USA Stephen S. Morse, New York, New York, USA Cathy Young Philip P. Mortimer, London, United Kingdom Production Fred A. Murphy, Davis, California, USA Reginald Tucker, Ann Kitchen, Maureen Marshall Barbara E. Murray, Houston, Texas, USA Editorial Assistant P. Keith Murray, Ames, Iowa, USA Carolyn Collins Stephen Ostroff, Atlanta, Georgia, USA Rosanna W. Peeling, Geneva, Switzerland www.cdc.gov/eid David H. Persing, Seattle, Washington, USA Gianfranco Pezzino, Topeka, Kansas, USA Emerging Infectious Diseases Richard Platt, Boston, Massachusetts, USA Emerging Infectious Diseases is published monthly by the Leslie Real, Atlanta, Georgia, USA National Center for Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop D61, David Relman, Palo Alto, California, USA Atlanta, GA 30333, USA. Telephone 404-371-5329, Nancy Rosenstein, Atlanta, Georgia, USA fax 404-371-5449, email [email protected]. Connie Schmaljohn, Frederick, Maryland, USA Tom Schwan, Hamilton, Montana, USA The opinions expressed by authors contributing to this journal Ira Schwartz, Valhalla, New York, USA do not necessarily reflect the opinions of the Centers for Disease Control and Prevention or the institutions with which the authors Tom Shinnick, Atlanta, Georgia, USA are affiliated. Bonnie Smoak, Bethesda, Maryland, USA Rosemary Soave, New York, New York, USA All material published in Emerging Infectious Diseases is in P. Frederick Sparling, Chapel Hill, North Carolina, USA the public domain and may be used and reprinted without special Jan Svoboda, Prague, Czech Republic permission; proper citation, however, is required. Bala Swaminathan, Atlanta, Georgia, USA Use of trade names is for identification only and does not Robert Swanepoel, Johannesburg, South Africa imply endorsement by the Public Health Service or by the U.S. Phillip Tarr, Seattle, Washington, USA Department of Health and Human Services. Timothy Tucker, Cape Town, South Africa Elaine Tuomanen, Memphis, Tennessee, USA ∞ Emerging Infectious Diseases is printed on acid-free paper that meets Mary E. Wilson, Cambridge, Massachusetts, USA the requirements of ANSI/NISO 239.48-1992 (Permanence of Paper) Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 4, April 2004 A Peer-Reviewed Journal Tracking and Analyzing Disease Trends Vol.10, No.4, April 2004 On the Cover Paul Gauguin (1848–1903). I Raro te Oviri (Under the Pandanus) (1891) Oil on canvas (73.03 cm x 91.44 cm). Dallas Museum of Art, Foundation for the Arts Collection, gift of the Adele R. Levy Fund, Inc. About the Cover pg. 766 Perspectives 637 Coccidioidomycosis at Archeological Site, Utah 561 Economics and Preventing Hospital L.R. Petersen et al. Infection N. Graves 643 Malaria and Perinatal HIV pg. 616 Transmission 567 Sleeping Sickness Epidemic, J.G. Ayisi et al. 1900–1920, Uganda E.M. Fevre et al 653 Ixodid and Argasid Ticks and West Nile Virus Synopsis C.H. Lawrie et al. 574 Pediatric Influenza 658 Human Metapneumoviruses Variability N. Principi and S. Esposito B.G. Van den Hoogen et al. Research 667 Pneumocystis jirovecii DHPS Genotypes, France 581 SARS Coronavirus and Antiviral Drugs A. Totet et al. E.L.C. Tan et al. 674 Meningococcal PorA Variable Regions 587 SARS in Hong Kong J. E. Russell et al. J.T.F. Lau et al. 679 Antimicrobial Resistance Gene 593 Myanmar Dengue Outbreak H.M. Thu et al. Delivery in Animal Feeds K. Lu et al. 598 Leishmaniasis Variation, Colombia Flea-borne Bartonella Infections in R.J. King et al. 684 Bank Voles K.J. Brown et al. 608 Pneumonic Plague Outbreaks R. Gani and S. Leach 688 Restaurant Inspection and Foodborne 615 Dengue Patterns, French Guiana, 2001 Disease T.F. Jones et al. A. Tran et al. pg. 625 693 Virulence Shift in Avian Influenza 622 Babesia divergens–like Infection, Outbreak, Chile Washington State D.L. Suarez et al. B.L. Herwaldt et al. 700 Human Metapneumovirus in Children 630 Influenza A Virus PB1-F2 Gene, J.A. Mullins et al. Taiwan G.-W. Chen et al. A Peer-Reviewed Journal Tracking and Analyzing Disease Trends Vol.10, No.4, April 2004 747 Dengue Fever Outbreak, Bangladesh Dispatches Y. Wagatsuma et al. 706 West Nile Virus, Guadeloupe R. Quirin et al. pg. 713 Another Dimension 709 West Nile Virus in American Crows 751 Threat of the Spores S.A. Yaremych et al. S.K. Vora 712 West Nile Virus Encephalitis in Barbary Letters Macaque R.-A. Ølberg et al. 752 Mycobacterium tuberculosis, Italy G.B. Migliori et al. 715 Human Case of Lobomycosis S. Elsayed et al 753 West Nile Virus Infection G.W. Procop et al. 719 Dengue 3 Epidemic, Havana, 2001 O. Peláez et al. 754 Vibrio cholerae Non-O1, Non-O139 Phages B.L. Sarkar et al. 723 Phocine Distemper in German Seals 2002 756 Salmonella Agona Harboring Genomic G. Muller et al. Island 1-A B. Doublet et al. 726 Cyclospora cayetanensis Pilot Study E.M. Alfano-Sobsey et al. News & Notes 729 Human Herpesvirus 6 Conference Summary Encephalomyelitis 759 Bacterial Resistance to Antimicrobial E. Denes et al. Agents J.C. Desenclos and D. Guillemot 732 Ruling out Bacillus anthracis J. Papaparaskevas et al. 760 Vets, Meds, and Zoonotic Threats S. Pitlik 736 Tuberculosis Incidence in Immigrants, the Netherlands 761 Correction, Vol. 10, No. 3 A.M. Vos et al. pg. 715 762 In Memoriam, Robert Ellis Shope 740 Murine Typhus, Canary Islands (1929–2004) M. Hernández-Carera et al. F.A. Murphy et al. 744 Ixodes scapularis in Southern Coastal 766 About the Cover Maine P. Potter M.S. Holman et al. Search past issues of EID at www.cdc.gov/eid Economics and Preventing Hospital-acquired Infection Nicholas Graves* The economics of preventing hospital-acquired infec- stands to be gained than lost (5). We attempt to make tions is most often described in general terms. The under- explicit the concepts on which these arguments rely and, in lying concepts and mechanisms are rarely made explicit particular, concentrate on providing a framework for but should be understood for research and policy-making. answering two questions: how much in total should we We define the key economic concepts and specify an illus- invest in prevention for any given infection-control situa- trative model that uses hypothetical data to identify how two related questions might be addressed: 1) how much should tion, and how should this investment be allocated among be invested for infection control, and 2) what are the most competing infection-control strategies? Our aim is to make appropriate infection-control programs? We aim to make the economics of prevention explicit while using a mini- explicit the economics of preventing hospital-acquired mum of technical language, algebra, and economics jargon. infections. Concepts and Definitions pproximately 1 in 10 hospitalized patients will acquire Valuing Resources Attributable to an infection after admission, which results in substan- A Hospital-acquired Infection tial economic cost (1). The primary cost is that patients with Infection uses hospital resources. By preventing infec- hospital-acquired infections have their stay prolonged, dur- tion, these resources are saved. For some of these ing which time they occupy scarce bed-days and require resources, the associated expenditures may be terminated, additional diagnostic and therapeutic interventions (2). and the savings would be expressed in terms of cash-sav- Estimates of the cost of these infections, in 2002 prices, ings, for example saving on drugs, consumables, and suggest that the annual economic costs are $6.7 billion per nursing staff employed on a contract that can be terminat- year in the United States (3)1

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