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Incidence of Dog Bite Injuries Treated in Emergency Departments (1992-1994)

Incidence of Dog Bite Injuries Treated in Emergency Departments (1992-1994)

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Incidence of Dog Bite Injuries Treated in Emergency Departments (1992-1994), by Harold B. Weiss, MS, MPH; Deborah I. Friedman; Jeffrey H. Coben, MD., Journal of American Medical Association (JAMA), 1998:279-1.

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Incidence of Dog Bite Injuries Treated in Emergency Departments (1992-1994), by Harold B. Weiss, MS, MPH; Deborah I. Friedman; Jeffrey H. Coben, MD., Journal of American Medical Association (JAMA), 1998:279-1.

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Brief Report
IncidenceofDogBiteInjuriesTreatedinEmergencyDepartments
Harold B. Weiss, MS, MPH; Deborah I. Friedman; Jeffrey H. Coben, MD
Context.—
Dogbitesthatresultininjuriesoccurfrequently,buthowfrequentlydogbiteinjuriesnecessitatemedicalattentionatahospitalorhospitaladmissionisunknown.
Objective.—
TodescribetheincidenceandcharacteristicsofdogbiteinjuriestreatedinUSemergencydepartments(EDs).
Design.
Emergency departmentsurvey fromtheNationalCenterforHealthStatisticsNationalHospitalAmbulatoryMedicalCareSurveyfor1992to1994.
Patients.—
NationalprobabilitysampleofpatientsvisitingEDs.
Main Outcome Measure.—
IncidenceofdogbitestreatedinEDs,denedasacauseofinjuryrecordedastheE-codeE906.0.
Results.—
The3-yearannualized,adjusted,andweightedestimateofnewdogbite–relatedinjuryvisitstoUSEDswas333687,arateof12.9per10000persons(95%confidenceinterval[CI],10.5-15.4).Thisrepresentsapproximately914newdogbiteinjuriesrequiringEDvisitsperday.Themedianageofpatientsbittenwas15years,withchildren,especiallyboysaged5to9years,havingthehighestin-cidencerate(60.7per10000personsforboysaged5to9years).ChildrenseeninEDsweremorelikelythanolderpersonstobebittenontheface,neck,andhead(73%vs30%).WeestimatedthatforeachUSdogbitefatalitythereareabout670hospitalizationsand16000EDvisits.
Conclusions.—
DogbiteinjuriesareanimportantsourceofinjuryintheUSpopu-lation,especiallyamongchildren.Improvedsurveillanceandpreventionofdogbiterelatedinjuries,particularlyamongchildren,areneeded.
JAMA.
1998;279:51-53
THECLOSEASSOCIATIONbetweenhumansanddomesticateddogsbeganatleast 12000 years ago.
1
Since then,people have been intimately involved indomesticating the wild dog into hunter,guard,andcompanion.However,thedo-mesticated dog retains many of its wildinstincts,includingbehaviorsthatalltoooften lead to human attacks. This riskhasalwaysbeenpresent.Onlynow,how-ever, are we beginning to gain a full un-derstandingoftheimpactofdogbitesonpopulations.
2
Estimates of dog bite injuries havebeen reported from data derived fromhouseholdsurveys,hospital-basedstud-ies, school-based surveys, local animalshelter monitoring, police reports, andnewspaper articles.
2-8
Because of lack of a national reporting system and varia-tion of local reporting procedures, accu-rate national incidence rates for dogbite–related emergency department(ED)visitsandhospitalizationshavenotbeen well quantified. The reported inci-dence of ED-treated dog bite injuries inthe United States ranges from 0.3% to1.1% of all ED visits.
3,9,10
With regard to overall morbidity, theannual number of total bites that occurintheUSpopulationhasbeenestimatedtorangefrom500000to4.5million.
11,12
Ithasbeenestimatedthatalmosthalfofallchildren have been bitten by a dog atsome point in their lives.
5
Among chil-dren, more than 50% of documentedbites have been to the head, face, orneck.
4,13,14
Unfortunately, most of thestudiesthatprovidedthisdescriptivein-formation were limited because of smallsample size and lack of consistent defi-nitions,ortheywerenotrepresentativeof the general population.Recent work by Sacks et al
2
has im-proved the precision of national esti-matesfordogbite–relatedmortalityandfor dog bites receiving any medical at-tention. For the 10-year period, 1979through1988,anannualaverageofabout15 fatal dog attacks was documented intheUnitedStates,withextrapolatedes-timates suggesting that as many as 20per year may have actually occurred.
11
Based on a random household survey,theInjuryControlandRiskSurveycon-ducted by the Centers for Disease Con-trol and Prevention, it was estimatedthat about 800000 bites occur annuallythat require medical attention.
2
How-ever,thisestimatewasnotabletobreakdown the proportion of patients seen inhospitals owing to the small size of thesample.Theonlynationwidestudyfromany country that examined both majormorbidity and mortality from dog biteinjuries was conducted in New Zeal-and.
15
This study predicted an incidenceof hospitalization due to dog bites in theyear 2000 of 9.6 per 100000 persons,twice the incidence for 1979.
15
From the Department of Emergency Medicine, Cen-ter for Injury Research and Control, University of Pitts-burgh, Pittsburgh, Pa. Mr Weiss, Ms Friedman, and DrCoben are now with the Department of EmergencyMedicine, Center for Violence and Injury Control, Al-legheny University of the Health Sciences, Pittsburgh.Presented in part at the American Public Health As-sociationannualmeeting,SanDiego,Calif,October30,1995, and the Pennsylvania Public Health Associationannual meeting, Pittsburgh, October 1, 1996.Reprints: Harold B. Weiss, MS, MPH, Center for Vio-lence and Injury Control, Allegheny University of theHealth Sciences, 1 Allegheny Center, Suite 510, 320East North Ave, Pittsburgh, PA 15212-4772 (e-mail:hweiss@injurycontrol.com).
JAMA, January 7, 1998Vol 279, No. 1 Dog Bites Treated in Emergency DepartmentsWeiss et al
51
©1998 American Medical Association. All rights reserved.
by guest on July 2, 2010www.jama.comDownloaded from 
 
Thepurposeofthepresentstudyistoestimate the incidence and characteris-tics of dog bite injuries treated in USEDs using a 3-year population-basedstratified random sample of US ED vis-its. This study also fills the gaps in ourunderstanding of the patterns of medi-cal care for dog bite victims. With suchanunderstanding,thebroadmedicalandpublic health impact of dog bite–relatedinjuries can be better appreciated andtargeted for preventive efforts.
Methods
Data Source.—
Data were obtainedfrom the ED component of the 1992-1994 National Hospital AmbulatoryMedical Care Survey (NHAMCS), apopulation-basedstratifiedsampleofUSEDvisits.Thissurvey,conductedannu-ally since 1992, is directed by the Cen-tersforDiseaseControlandPreventionNationalCenterforHealthStatistics.Thecombined 1992-1994 data set repre-sented estimates applying to approxi-mately274millionEDvisits
16-18
(about91million visits per year). The NHAMCSis a national probability sample of non-institutionalgeneralandshort-stayhos-pitals (excludes federal, Veterans Af-fairs,andmilitaryhospitals).Itusesa4-stage probability sample that coversgeographicprimarysamplingunits,hos-pitalswithinprimarysamplingunits,EDswithinhospitals,andpatientswithinEDs.Datacollectiontakesplaceduringaran-domly assigned 4-week data period foreachofthesampledhospitals.TheUSBu-reau of the Census regional staff over-seesthedatacollectionprocess,whileac-tual data collection is the responsibilityof hospital staff. A separate data collec-tion form is filled out at or close to thetime of visit for each sampled patient. Afullreportofthemethodsusedinthissur-vey is available from the National Cen-ter for Health Statistics (NCHS).
16
After the forms are completed, theyare sent to NCHS where
InternationalClassification of Disease, Ninth Revi-sion,ClinicalModification
(
ICD-9-CM 
)coding takes place by experienced no-sologists. A maximum of 3 E-codes areassigned to each case. The nosologistswork from the data collection form, notthe original medical record. For 1992-1994,atotalof91935patientformswerecollected.
DefinitionandCaseSelection.—
Adogbite injury was defined as any ED visitwithan
ICD-9-CM 
E-codeofE906.0(“dogbite”) in the primary, secondary, or ter-tiary E-code field. More than 99% of thecaseswereidentifiedfromtheprimaryE-code field. To obtain incidence estimates(ie,newcases)recordsfromthe1992datasetwereexcludediftheywerenotmarkedas“Injury,firstvisit”inthedatasettopre-vent counting follow-up visits. This ex-cluded 17.9% of the dog bite–related in- juries from the 1992 data. The 1993 and1994 data collection instruments did notcontain information on whether the visitwasafirstvisitforinjuryorfollow-upvisit.Therefore,thesampleweightsfromeachof these latter 2 years were reduced by17.9%basedonthepercentageoffollow-up visits found in 1992. All 3 years werethen combined and averaged to producemean annual national estimates. TheNCHSsuggeststheminimumreliablees-timateforthiscombineddatasetis30000visits (Catherine W. Burt, EdD, Ambu-latoryCareStatisticsBranch,NCHS,oralcommunication,August30,1996).Placeof injury(home,work,school,street,etc)wasonly collected in 1993 and 1994. An addi-tion was made to the NHAMCS data setbyimputinganInjurySeverityScorefromthe primary and secondary diagnosisfields.TheInjurySeverityScoreranksin- juryseveritymainlyintermsofthreattolife.InthisstudytheInjurySeverityScorewasderivedbyautomatedtranslationof the
ICD-9-CM 
diagnoses using Tricodesoftware(Tri-AnalyticsInc,BelAir,Md).
Data Analysis.—
Data were obtainedfrom NCHS on floppy diskettes inASCIIformatandcombinedforanalysisonadesktopcomputerusingSPSSsoft-ware (SPSS Inc, Chicago, Ill). Rateswerecomputedbydividingincidencees-timates by the appropriate populationestimate. The 1993 total US populationestimates were used as enumerated bythe NCHS. The results are presentedusingweightedvaluestoproduceannualnational estimates. Approximate rela-tivestandarderrorsinpercentagesusedfor calculating 95% confidence intervals(CIs) for reported aggregate estimatesandratesarebasedonamodelsuggestedby NCHS (Catherine W. Burt, EdD,Ambulatory Care Statistics Branch,NCHS, oral communication, August 30,1996).
Results
The annualized weighted estimate of theincidenceofnewdogbite–relatedin- juries seen in US EDs was 333687 (95%CI, 269950-397424) for a rate of 12.9(95% CI, 10.5-15.4) per 10000 persons.These injuries comprised about 0.4% of all ED visits during the study period.(Numbers and rates for race, sex, age,age and sex, geographic region, season,and day of month are available from theauthors on request).Agesofvictimsofdogbite–relatedin- juries ranged from younger than 1 yearto 91 years (median age, 15 years). Inci-dence rates were significantly higheramong children aged 0 to 9 years, espe-cially among boys. The 5- to 9-year-oldmaleagegrouphadthehighestrate,60.7ED visits per 10000 persons (95% CI,34.8-86.6). The estimated 57580 dogbite–related visits for boys aged 5 to 9years represent 3.6% of all injury-re-latedEDvisitsinthisageandsexgroup.Among the cases in which body partarea could be determined (about twothirds of the cases), the face, neck, andhead (combined) were the leading bodypartsitesaffected(29%),followedbytheupper limbs and lower limbs. Amongchildren aged 0 to 9 years, 73% of theinjurieswithattributedinjurysiteweretotheface,head,andneck,whileallotherageshadonly30%oftheinjuriesoccurtothe face, head, and neck. There was anonsignificant trend toward a seasonaldistribution of the incidence of dog biteinjuries,withthehighestratesbeingob-served during the summer months. Al-thoughthehighestnumberofcaseswasseeninthesouthernregionoftheUnitedStates (Alabama, Arkansas, Delaware,District of Columbia, Florida, Georgia,Kentucky,Louisiana,Maryland,Missis-sippi, North Carolina, Oklahoma, SouthCarolina, Tennessee, Texas, Virginia,and West Virginia), the population-ad- justed rates were similar by geographicregion and not significantly differentfrom one another.Overhalfthedogbiteinjuries(58.0%)were reported to have occurred at ahome. Dog bite–related ED visits weremore likely to occur on the weekends.DogbiteinjuriesweretriagedintheEDas urgent-emergent in 46.1% of the vis-its and nonurgent for the remainder.Ninety-six percent of patients makingdogbite–relatedEDvisitsweretreatedand released from the ED; the remain-der were admitted to the hospital ortransferred to another facility. Amongthe 94% of the cases assigned a calcu-lated ISS score, 99% were of low sever-ity (Injury Severity Score, 1).
Comment
This study extends previous work indog bite epidemiology by adding moreprecise quantitative information aboutED visits and incidence. It fills the re-maining gap in our understanding of where people go for medical treatmentofdogbites,therebymoreclearlydefin-ingtheirburdenonthemedicalcaresys-tem.Usingthe(rounded)NCHSsurveydata reported here of 334000 dog bite–related ED visits with a 4% hospitaliza-tion rate, Centers for Disease Controland Prevention household survey esti-mates of 757000 medically treated and3.73 million nonmedically treated dogbites,
2
and averaged mortality data re-porting about 20 deaths per year,
11,19
itappearsthat,foreachUSdogbitefatal-ity,thereareabout670hospitalizations,16000 ED visits, 21000 other medical
52
JAMA, January 7, 1998Vol 279, No. 1 Dog Bites Treated in Emergency DepartmentsWeiss et al
©1998 American Medical Association. All rights reserved.
by guest on July 2, 2010www.jama.comDownloaded from 

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