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. 2019 Mar 20;5(3):e01360. doi: 10.1016/j.heliyon.2019.e01360

The demographics of dog bites in the United States

Randall T Loder 1,∗
PMCID: PMC6431755  PMID: 30957043

Abstract

Dog bites are a significant public health issue. There is no comprehensive study of dog bite demographics. It was the purpose of this study to perform such an analysis across the US. The National Electronic Injury Surveillance System All Injury Program data for the years 2005 through 2013 was accessed; dog bite injuries were extracted and analyzed. Statistical analyses were performed with SUDAAN 11.0.01™ software to account for the weighted, stratified nature of the data. Incidence values were calculated using population data from the US Census Bureau. A P < 0.05 was considered significant. There was an average 337,103 ED visits each year for dog bites. The average age was 28.9 years; 52.6% were male and 47.4% female. The bites were located on the upper extremity in 47.3%, head/neck in 26.8%, lower extremity in 21.5%, and trunk in 4.4%. Younger patients had more bites involving the head/neck, while older patients the upper extremity. More occurred in the summer and on weekends and 80.2% occurred at home. Hospital admission occurred in 1.7%. Logistic regression analysis demonstrated that the odds of admission was solely dependent upon the age group. The OR for admission was 11.03 [4.68, 26.01] for those >85 years of age, 4.88 [2.89, 8.24] 75–84 years, and 2.79 [1.77, 4.39] those ≤4 years of age, with the 10–14 year age group the reference group. The average annual incidence was 1.1 per 1,000, and was slightly higher in males (1.18 vs 1.02 per 1,000). The estimated cost was at least 400 million US$ per year. Potential prevention strategies are educational programs directed at both children and parents/caretakers outlining the responsibilities of owning a dog. This information can be disseminated in health care facilities, radio/TV/Internet venues, and dog kennels/shelters.

Keyword: Epidemiology

1. Introduction

In 2018 48% of the US population owned a dog [1], and in the United Kingdom 26% of the population owned a dog [2]. These numbers reflect the feeling that a dog is man's best friend: “The one absolutely unselfish friend that man can have . . . is his dog” [3]. Nevertheless, human dog bite injuries from “man's best friend” are a significant public health issue [4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18] and are in the top 15 causes of non-fatal injuries [19]. Dog bites often occur in younger children [11, 12, 13, 16, 20, 21, 22], although some have noted a predominance in other age groups [5, 8, 10]. Children, especially younger ones, typically sustain bites to the head and neck [13, 14, 15, 16, 23, 24], while the extremities are often more involved in older children [15]. There is no in depth study of human dog bites encompassing the entire United States for all age groups, especially adults, studying anatomic location of injury, gender, race, month/weekday of injury, and other demographic variables. It was the purpose of this study to perform such an analysis using a national data base which can hopefully assist in further development of prevention programs.

2. Materials and methods

2.1. Data source

The data for this study comes from the National Electronic Injury Surveillance System (NEISS) All Injury Program (AIP). The NEISS is a dataset managed by the US Consumer Product Safety Commission (USCPSC) which collects emergency department (ED) injury data from ∼100 hospitals in the United States and its territories that have an ED. It was initially directed at injuries resulting from consumer products. However, not all injuries are from consumer products; thus the USCPSC selected ∼65 of these hospitals to obtain data for all injuries, regardless of the association with consumer products. This has been designated as the All Injury Program (AIP). This data is in the public domain and housed by the Inter-University Consortium for Political and Social Research (ICPSR) and can be downloaded from their website. Use of this publicly available de-identified data was considered exempt by our local Institutional Review Board.

The data base includes hospital size (strata), date of ED visit, gender/race/age of the injured patient, diagnosis, disposition from the ED, incident locale, and body part injured. The hospital strata are comprised of 5 hospital categories; 4 are based on size (the total number of ED visits reported by the hospital, which are small [0–16,830], medium [16,831–21,850], large [28,151–41,130], and very large [>41,130]), and one consisting of children's hospitals of all sizes. With appropriate statistical techniques, an estimated number of injuries is then calculated from this weighted, stratified data.

The NEISS-AIP data for the years 2005 through 2013 was used. These years were chosen because 2013 was the last available year at the time the study was performed beginning in early 2018, and data before 2005 was coded differently for many variables, making it difficult to combine the years before 2005 with those afterwards. Injuries due to dog bites were identified by the NEISS AIP codes PCAUSE_C = 16 and/or ICAUSE_C = 16. Race was classified according to Eveleth and Tanner [25] as White, Black, Amerindian (Hispanic and Native American), Asian, Indo-Mediterranean (Middle Eastern and Indian subcontinent), and Polynesian. Due to the small numbers of Polynesian and Indo-Mediterranean peoples in the data set, race/ethnicity is only reported for the White, Black, Amerindian and Asian groups.

2.2. Statistical analysis

Statistical analyses were performed with SUDAAN 11.0.01™ software (RTI International, Research Triangle Park, North Carolina, 2013) which accounts for the weighted, stratified nature of the data. The estimated value and 95% confidence limits [lower, upper] are calculated across the entire population encompassed by the data set. Analyses between groups of continuous data were performed with the t-test (2 groups) or ANOVA (3 or more groups). Differences between groups of categorical data were analyzed by the χ2 test. Multivariate logistic regression was used to determine predictors of dog bites for various parameters, giving an odds ratio (OR), 95% confidence limits and associated P values. Incidence values were calculated using population data from the US Census Bureau for each year 2005–2013. For all statistical analyses, P < 0.05 was considered to be significant. It must be remembered that with a large data set such as this that there may be many statistical differences but which are not clinically meaningful.

3. Results

The actual number of ED visits for injuries over the nine year period was 4,664,468 giving a nationwide estimate of 275,014,511 ED visits. Dog bite injuries accounted for 51,486 of the actual 4.6 million ED injury visits, or an estimated 3,033,931 [2,832,649, 3,245,171] million ED visits (1.1%). This equates to an estimated 337,103 dog bite visits per year to US EDs. To put this 1.1% into perspective, the top 20 reasons for ED visits for injuries were determined (Table 1). Dog bites were the 13th most common injury, and exceeded those occurring on motorcycles (14th), to pedestrians (15th) and firearm gunshot injuries (16th).

Table 1.

The top 20 injuries seen in USA EDs from 2005 through 2013 using the NEISS AIP data.

Injury n N L 95% CL U 95% CL %
Fall 1,154,655 68,739,406 65,480,955 72,108,805 25.0
Struck by/against an object 1,085,883 62,228,114 59,678,149 64,848,422 22.6
Overexertion 471,199 30,485,345 28,298,993 32,809,231 11.1
Motor vehicle occupant 431,154 23,992,846 20,818,598 27,611,457 8.7
Cut/pierced 364,231 23,173,426 21,891,155 24,503,793 8.4
Unspecified 332,793 18,226,592 15,950,842 20,818,598 6.6
Other bite/sting 174,168 10,499,289 9,598,006 11,468,105 3.8
Poisoning 158,996 9,421,120 7,947,919 11,138,088 3.4
Other transport injury 83,952 5,423,411 4,895,258 5,995,316 2.0
Foreign body 95,913 5,403,619 5,115,270 5,720,302 2.0
Pedal cyclist 81,649 4,537,927 3,960,209 5,170,273 1.7
Fire/burn 67,582 3,977,581 3,822,702 4,125,218 1.4
Dog bite 51,486 3,033,931 2,832,649 3,245,171 1.1
Motorcyclist 35,857 2,298,615 1,815,096 2,915,154 0.8
Pedestrian 36,914 1,763,852 1,347,571 2,310,122 0.6
Firearm gunshot 16,846 669,514 412,522 1,072,557 0.2
Inhalation/suffocation 8,605 450,939 385,020 522,528 0.2
Natural/environmental 8,096 444,119 330,017 577,530 0.2
BB/pellet gunshot 2,950 161,012 137,507 192,510 0.1
Drowning/near drowning 1,192 58,064 27,501 82,504 0.0
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n = actual number, N = estimated number, L 95% CL is the lower 95% confidence limit of the estimate, U 95% CL is the upper 95% confidence limit of the estimate.

The average age of those with dog bites was 28.9 [28.0, 29.8] years and median age 24 [23.6, 26.2] years. The dog bite was unintentional in 98.8% [98.1, 99.2], due to legal intervention in 1.1% [0.7, 1.8], and an assault in 0.2% [0.1, 0.3]. The gender was male in 52.6% [51.5, 53.7] and female in 47.4% [46.3, 48.5]; the race was 71.6% [62.5, 81.0] White, 13.3% [9.3, 18.7] Black, 11.5% [6.3, 20.2] Amerindian, and 2.4% [1.0, 5.3] Asian. The bite occurred in the upper extremity in 47.3% [46.0, 48.7], head/neck in 26.8% [25.2, 28.5], lower extremity in 21.5% [19.9, 23.1], lower trunk in 2.9% [2.6, 3.2], and upper trunk in 1.5% [1.3, 1.6]. Detailed anatomic locations are shown in Fig. 1. The majority (80.2% [77.7, 82.4]) of the bites occurred at home, 7.1% [5.9, 9.2] on the street, 2.5% [2.0, 3.2] at schools or sporting places, and the remaining 10% [7.7, 12.1] at other locations. The patients were treated and released from the ED in 98.3% [97.8, 98.7] and hospitalized in 1.7% [1.3, 2.2]. Bites were more common in the summer and on weekends (Fig. 2). The overall annual incidence of dog bite injures seen in US EDs was 1.1 per 1,000 US population. There were significant differences by age and gender (Fig. 3), with males having a slightly higher incidence (1.18 vs 1.02 per 1,000). The peak incidence was 2.18 per 1,000 in the 5–9 year age group and the lowest 0.47 per 1,000 in those ≥85 years old. Detailed results are shown in Table 2. From here forward, only the estimated values are given, with the 95% confidence limits in the tables.

Fig. 1.

Fig. 1

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Anatomic location of the estimated 3.03 million non-fatal dog bites.

Fig. 2.

Fig. 2

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Temporal variation of dog bites. a. By month. b. By weekday.

Fig. 3.

Fig. 3

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Incidence of dog bite visits to US EDs in 1,000 per US population: differences by age and gender.

Table 2.

Demographic variables of the dog bite injuries over 9 years.

n N L 95% CL U 95% CL %
Average age (yrs) 28.9 28 29.8
Median age (yrs) 24.3 23.6 26.2
Age group (yrs)
0 to 4 7,379 352,370 322,198 384,999 11.6
5 to 9 8,020 393,264 371,043 416,551 13
10 to 14 6,138 306,753 286,095 328,872 10.1
15 to 19 3,769 217,612 200,843 235,732 7.2
20 to 24 3,647 235,112 219,046 252,115 7.7
25 to 34 5,912 377,188 356,177 398,955 12.4
35 to 44 5,343 361,431 343,131 380,448 11.9
45 to 54 5,298 363,934 338,884 390,763 12
55 to 64 3,192 219,792 202,360 238,766 7.2
65 to 74 1,592 115,155 103,759 128,030 3.8
75 to 84 915 69,867 60,981 80,094 2.3
>85 278 21,398 18,203 25,181 0.7
Sex
Male 27,686 1,595,929 1,562,982 1,628,814 52.6
Female 23,795 1,437,810 1,404,925 1,470,757 47.4
Race
White 25,412 1,725,572 1,506,841 1,951,858 71.6
Black 7,884 321,477 283,364 567,335 13.3
Amerindian 5,468 278,162 191,438 612,540 11.5
Asian 946 57,193 31,552 161,402 2.4
Anatomic location of injury
Head/neck 15,483 809,455 760,779 860,103 26.8
Upper trunk 807 43,926 39,744 49,149 1.5
Lower trunk 1,535 86,876 79,184 96,477 2.9
Arm/hand 22,382 1,429,428 1,396,494 1,476,588 47.3
Leg/foot 10,900 647,863 602,528 701,736 21.5
Other 25 1,597 910 2,730 0.1
Detailed anatomic locations
Head 528 26,109 21,133 32,001 0.9
Ear 827 44,650 40,654 49,452 1.5
Eye 41 2,429 1,517 3,641 0.1
Face 10,361 535,380 500,590 577,650 17.7
Mouth 3,520 190,615 177,785 206,304 6.3
Neck 206 10,273 8,495 12,742 0.3
Upper trunk 576 31,436 27,608 36,103 1
Lower trunk 1,379 78,390 71,296 87,072 2.6
Shoulder 231 12,490 10,315 15,169 0.4
Upper arm 945 58,478 52,486 65,835 1.9
Elbow 353 22,796 19,417 27,002 0.8
Lower arm 5,874 373,518 356,481 395,314 12.4
Wrist 1,171 76,374 70,386 83,735 2.5
Hand 9,196 591,706 566,728 623,462 19.6
Finger 4,843 306,555 294,893 321,894 10.2
Pubic 156 8,486 6,675 11,225 0.3
upper leg 2,994 173,653 160,189 189,921 5.8
Knee 645 37,304 31,856 43,991 1.2
Lower leg 5,794 351,092 323,411 384,696 11.6
Ankle 647 38,533 33,373 44,901 1.3
Foot 705 40,525 345,862 47,632 1.3
Toe 115 6,575 4,854 9,102 0.2
25–50% body 4 276 0 910 0
All body 20 1,296 607 2,427 0
Internal 1 25 0 303 0
Diagnosis
Contusion/abrasion 3,422 184,953 150,208 226,827 6.1
Fracture 417 23,540 19,382 28,467 0.8
Laceration 18,349 955,588 836,440 1,087,038 31.6
Puncture 15,877 840,057 681,409 1,023,023 27.7
Other 13,318 1,024,258 761,807 1,328,231 33.8
Incident locale
Home/Apt/mobile 28,281 1,719,945 1,666,554 1,768,689 80.2
School/sports 955 53,501 42,270 67,804 2.5
Street 2,634 151,846 125,523 198,261 7.1
Other property 3,564 210,475 167,364 263,061 9.8
Farm 45 3,619 2,575 5,364 0.2
Disposition from ED
Treated/released 49,333 2,937,229 2,922,113 2,949,006 98.3
Admitted 1,360 50,922 39,145 66,038 1.7
Stratum (Hospital size)
Small 6,332 763,029 589,493 967,217 25.1
Medium 7,331 909,989 682,016 1,175,931 30
Large 9,136 817,104 599,494 1,078,543 26.9
Very large 20,808 474,939 354,660 626,496 15.7
Children's 7,879 68,869 46,722 101,028 2.3
Year
2005 5,530 321,980 296,415 349,205 10.6
2006 5,064 310,892 282,459 341,924 10.2
2007 5,350 312,561 285,493 341,924 10.3
2008 5,656 333,256 311,281 356,487 11
2009 5,932 337,483 323,417 352,239 11.1
2010 5,891 346,943 330,698 363,768 11.4
2011 6,051 360,362 339,193 382,579 11.9
2012 6,157 363,456 335,249 393,804 12
2013 5,855 346,997 323,720 371,657 11.4
Month
Jan 3,609 211,386 193,565 230,882 7
Feb 3,170 185,831 175,058 197,206 6.1
Mar 4,231 244,772 234,523 255,457 8.1
Apr 4,624 269,031 256,974 281,549 8.9
May 5,209 302,343 285,493 320,080 10
June 5,201 293,715 279,122 308,854 9.7
July 5,380 318,355 307,641 329,182 10.5
Aug 4,798 284,510 274,874 294,595 9.4
Sep 4,128 250,045 239,984 260,615 8.2
Oct 3,893 235,245 222,994 248,176 7.8
Nov 3,549 215,274 206,307 224,511 7.1
Dec 3,694 223,424 213,892 233,309 7.4
Day
Sun 8,692 504,930 490,890 519,106 16.6
Mon 7,217 421,953 410,491 433,549 13.9
Tue 6,763 402,448 392,287 412,918 13.3
Wed 6,558 386,790 375,904 398,052 12.7
Thur 6,642 386,991 371,960 402,603 12.8
Fri 7,009 421,032 409,581 432,639 13.9
Sat 8,605 509,786 494,227 525,780 16.8
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n = actual number, N = estimated number, U 95% CL is upper 95% confidence limit of the estimate, L 95% CL is the lower 95% confidence limit of the estimate.

3.1. Analyses by anatomic area of injury

There were notable differences by age and incident locale (P < 10−4). Younger patients had more bites involving the head/neck, while older patients the upper extremity (Fig. 4a). The average age for those with head/neck bites was 15.3, upper trunk 20.7, lower trunk 24.0, upper extremity 36.0, and lower extremity 31.5 years. Lower extremity bites more commonly occurred on the street (41.8%) compared to other locations (17.1%–30.9%) (P < 10−4) (Fig. 4b). Detailed results are shown in Supplemental Table 1.

Fig. 4.

Fig. 4

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Differences in dog bites by anatomic location of injury (all P < 10−4). a. By age. b. By incident locale.

3.2. Analyses by race

There were differences by race for age, incident locale, and anatomic location of the bite (Fig. 5). Although all age groups demonstrated a White predominance (71.6% White, 24.9% Black/Amerindian), Amerindians and Blacks comprised a larger proportion of those 10–34 years of age (31.6%–27.3%) (P < 10−4) (Fig. 5a), bites to the trunk (P < 10−4) (3.6% Whites, 6.4% Black/Amerindian) (Fig. 5b), and those occurring on the street (P = 0.017) (60% White, 14.3% Black/Amerindian) (Fig. 5c). White patients were 75.7% female and 70.0% male (P < 10−4) (Fig. 5d). Detailed results are shown in Supplemental Table 2.

Fig. 5.

Fig. 5

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Differences in dog bites by race (all P < 10−4). a. By age group. b. By anatomic location of injury. c. By incident locale. d. By gender.

3.3. Analyses by gender

The most striking differences were by age. The average age for males was 26.9 years and for females 31.1 years (P < 10−4), with males having a higher proportion in those <35 years old and females in those ≥45 years old (Fig. 6). Detailed results are shown in Supplemental Table 3.

Fig. 6.

Fig. 6

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Number of ED visits for dog bites by gender and age group (P < 10−4).

3.4. Analyses by incident locale

In addition to the above findings, there was a significant difference by age group (Fig. 7). For those <10 years of age the bite nearly always occurred in the home (P < 10−4).

Fig. 7.

Fig. 7

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Differences in incident locale by age group (P < 10−4).

3.5. Outcome predictors from multivariate logistic regression analysis

The most common bite locations were the head/neck, upper, and lower extremity. A hospital admission was used as a surrogate for a serious injury. Multivariate logistic regression was used to determine predictors of the following outcomes: a hospital admission, and bite to the head/neck, upper, and lower extremities. The variables entered into the model were gender, race, age group, and incident locale.

The only predictor (Table 3) for hospital admission was the age group. The OR for admission was greater for the older and younger patients, and lowest for those 10–14 years of age. The OR for those >85 years of age was 11.03 [4.68, 26.01], 75–84 years 4.88 [2.89, 8.24], and those ≤4 years of age 2.79 [1.77, 4.39] with the 10–14 year age group the reference group. Predictors of a bite to the head/neck, upper extremity, and lower extremity were all dependent upon the age group, race, and incident locale. A bite to the head neck was most common in those ≤4 years of age (OR 100.2 [43.2, 232.4]) and decreased with increasing age, with the reference group those >85 years of age. Such bites most commonly occurred in the home (OR 3.13 [2.74, 3.58] with the street the reference group. They were more likely in Whites (OR 2.06 [1.69, 2.50]) with Blacks the reference group. By contrast, a bite to the upper extremity was most likely in the oldest group >85 years of age (OR 15.49 [9.17, 26.15] with the reference group those ≤4 years of age. Upper extremity bites occurred most commonly at home (OR 1.54 [1.30, 1.81]) with the street the reference group. They were also more likely in Whites (OR 1.36 [1.12, 1.66]) with Asians the reference group. A bite to the lower extremity was most common in those 10-14 years (OR 5.82 [4.49, 7.56]) and 15-19 years (OR 5.69 [4.17, 7.77]) of age with the reference group those ≤4 years of age. They were most likely to occur on the street (OR 2.48 [2.22, 2.77]) with home being the reference group, and in Amerindians (OR 2.06 [1.43, 2.96]) and Asians (OR 2.07 [1.78, 2.38] with Whites the reference group.

Table 3.

Multivariate logistic regression analyses predicting a hospital admission, and a dog bite to the head/neck, upper extremity, or lower extremity over 9 years.

Head/neck bite
 Upper extremity bite
 Lower extremity bite
 Hospital admission
OR L 95% CL U 95% CL p value OR L 95% CL U 95% CL p value OR L 95% CL U 95% CL p value OR L 95% CL U 95% CL p value
Age group (yrs)
0 to 4 100.2 43.21 232.43 <10−4 R - - - R - - - 2.79 1.77 4.39 <10−4
5 to 9 36.29 17.46 75.42 <10−4 1.67 1.4 1.99 <10−4 3.34 2.64 4.21 <10−4 1.56 1 2.44 0.052
10 to 14 16.12 7.94 32.75 <10−4 2.7 2.17 3.35 <10−4 5.82 4.49 7.56 <10−4 R - - -
15 to 19 9.67 4.77 19.62 <10−4 4.51 3.62 5.61 <10−4 5.69 4.17 7.77 <10−4 1.54 0.81 2.91 0.19
20 to 24 10.06 5.21 19.43 <10−4 5.41 4.25 6.89 <10−4 4.62 3.6 5.93 <10−4 1.33 0.8 2.24 0.27
25 to 34 7.25 3.64 14.45 <10−4 6.41 5.18 7.93 <10−4 4.71 3.69 6.03 <10−4 1.6 1.1 2.31 0.014
35 to 44 5.12 2.8 9.21 <10−4 7.7 5.84 10.15 <10−4 4.84 3.74 6.24 <10−4 2.04 1.22 3.43 0.008
45 to 54 5.25 2.63 10.48 <10−4 7.68 5.75 10.25 <10−4 4.83 3.86 6.03 <10−4 2.72 1.55 4.76 0.0007
55 to 64 3.99 2.06 7.74 0.0001 9.27 6.85 12.54 <10−4 4.75 3.84 5.88 <10−4 3.66 2.3 5.83 <10−4
65 to 74 1.92 1.06 3.49 0.033 11.11 8.8 14.04 <10−4 5.15 3.77 7.03 <10−4 3 1.79 5.05 0.0001
75 to 84 1.89 1.1 3.24 0.022 15.02 10.69 21.09 <10−4 3.68 2.7 5.03 <10−4 4.88 2.89 8.24 <10−4
>85 R - - - 15.49 9.17 26.15 <10−4 4.67 2.98 7.32 <10−4 11.03 4.68 26.01 <10−4
Incident locale
Home 3.13 2.74 3.58 <10−4 1.54 1.3 1.81 <10−4 R - - -
Street R - - - R - - 2.48 2.22 2.77 <10−4
Other property 1.54 1.2 1.98 0.001 1.33 1.15 1.54 0.00002 1.78 1.56 2.04 <10−4
Race
White 2.06 1.69 2.5 <10−4 1.36 1.12 1.66 0.003 R - - -
Black R - - - 1.3 1.08 1.57 0.006 1.72 1.48 1.98 <10−4
Amerindian 1.25 0.96 1.62 0.092 1.07 0.8 1.43 0.65 2.06 1.43 2.96 0.0002
Asian 1.23 0.92 1.64 0.16 R - - 2.07 1.78 2.38 <10−4
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OR = odds ratio, L95% CL = lower 95% confidence limit of the OR, U95% CL = upper 95% confidence limit of the OR, R = reference group.

4. Discussion

This is the first study to the author's knowledge to analyze the demographics of non-fatal human dog bite ED visits across the entire US for all age groups, geographic locations (ie. both rural and urban), and ED disposition (released/admitted). It likely portrays the most representative national analysis of dog bite injuries, which is the major strength of this study. There are certain limitations as well. First, the NEISS only identifies individuals who sought care in an ED. It does not include those who might have been treated in urgent care centers, physician offices, or those persons who did not seek medical care. Thus the overall number of injuries in this study is likely lower than the true number. Another potential limitation is the accuracy of the NEISS data. However two studies have demonstrated over 90% accuracy [26, 27]. Other limitations are lack of detailed data. The severity of the injury, aside from either the patient being treated and released or admitted, is unknown. As the vast majority of the patients were released from the ED, injury severity is likely minor overall. Another area lacking information is the diagnosis, and was given as “other” in 33.8% of the cases. This likely represents the injury being a dog bite, as that is a valid NEISS data base code as a cause of injury. However, this can not be confirmed.

In this study the average annual incidence of dog bites seen in US EDs was 1.1 per 1,000. This is similar to the 1.05 per 1,000 in North Carolina [20], 1.3 per 1,000 in the US [13], 1.71 per 1,000 in Milwaukee [28], and 0.8 per 1,000 in Los Angles [10]. It is greater than the 0.4 per 1,000 [11] in New York City and less than the 2.35 per 1,000 in Bay County, Florida [8]. However the Florida study used ED visits as well as data from animal control agencies, schools, and county health departments which obviously increases the numbers. In Baltimore, Maryland, when using hospital and police records, the annual incidence was 6.42 per 1,000 [29]. A detailed Internet survey of dog owners in The Netherlands [5] found an ED visit incidence of 0.7 per 1,000 while the self reported incidence was 8.3 per 1,000. This much higher incidence, similar to the 6.43 in Baltimore, was due to the fact that 62% sought no treatment, 29% were treated by their personal physician, and only 8.3% were treated in the ED. Under reporting of dog bites has also been noted in Pennsylvania children, with up to 45% having been bitten during childhood [30]. These studies [5, 29] suggest that ED visits for dog bites account for only ∼8% of all dog bites. Another study suggested that 17% of dog bites were reported [31]. It must be remembered, however, that these unreported cases, which likely constitute the majority of dog bite incidents, as well as those that did not seek medical attention, were likely very minor in severity. They were most likely treated at home with simple cleansing and a dressing. In fact, what the individuals in these questionnaire studies considered a dog bite is not known. Even in those that presented to the ED for medical care in this study, only 1.7% were admitted to the hospital. Finally, many may visit the ED not for the severity of the injury but for other concerns, such as infection, concern for rabies, etc.

There are several notable findings in this study. The first is the rapid change in anatomic location of the bite by age (Fig. 4a). Several authors [14, 21, 32, 33] have noted that children are more likely to sustain bites to the head and neck, while adults are more likely to sustain bites to the extremities. However, a breakdown of anatomic location by detailed age groups has not been described until now. The rapid drop in the percentage of bites to the head/neck with a corresponding increase in upper extremity bites is likely due to the size and motor ability of the patient. Children are shorter than adults which places their head/neck at the same level as the dog's mouth; for adults, the dog's mouth is at the level of the lower extremity, or the hand if reaching toward the dog [34]. Children, especially younger ones, are not as agile or fast, and thus when encountered with a dog beginning to bite, likely can not defend themselves as quickly due their inability to rapidly raise their upper extremity and/or run away as means of defense. Thus the dog could easily bite their head/face/neck due to anatomic proximity.

Using hospital admission as a proxy for severity, logistic regression demonstrated analysis that the OR for admission was the age group. The OR for admission was greater for the older and younger patients, and lowest for those 10–14 years of age. It is likely that the very young, having more bites to the head/neck, might require general anesthesia for repair, thus resulting in a higher admission. Similarly, the elderly typically have more medical comorbidities, and thus were likely admitted more frequently for aggressive medical care (eg intravenous antibiotics, monitoring of systemic diseases [diabetes, cardiac, peripheral vascular disease]). These are however suppositions, as the data is not adequately detailed to prove these postulates.

The financial burden of dog bites is large. According to the Health Care Cost Institute, the average price of an ED visit in the US in 2016 was $1917.20, the average cost of a surgical admission was $41,701.60, and the average cost of a medical admission was $18,464.62 [35, 36]. Assuming that the costs for those admitted with dog bites in this study was the average of the surgical and medical groups ($30,083.11), then the overall expenditure in 2016 US$ for these nine years was $7.163 billion ($5.631 billion for those treated and released from the ED and $1.532 billion for those admitted to the hospital), or an annual $795 million in the US alone. This is likely an inflated estimate as the average ED cost is likely skewed by more expensive cases. In 2006–2008, the median ED charge for an open wound of an extremity (likely similar to a dog bite) was $979 [37]. This equates to $1,146 in 2016 dollars (CPI Inflation Calculator, Bureau of Labor Statistics https://data.bls.gov/cgi-bin/cpicalc.pl). Using this value, then the ED cost for those treated and release is $3.366 billion over 9 years, or $374 million annually. It must be remembered that these cost estimates do not include those that were treated in non ED venues, costs of subsequent follow-up care, and medications (eg. antibiotics).

More needs to be done to prevent dog bite injuries [38] for both the patient and society. According to the American Veterinary Medical Association [18], dogs bite for a variety of reasons, “but most commonly as a reaction to something. If the dog finds itself in a stressful situation, it may bite to defend itself or its territory. Dogs can bite because they are scared or have been startled. They can bite because they feel threatened. They can bite to protect something that is valuable to them, like their puppies, their food or a toy. Dogs might bite because they aren't feeling well. They could be sick or sore due to injury or illness and might want to be left alone. Dogs also might nip and bite during play. Even though nipping during play might be fun for the dog, it can be dangerous for people. It's a good idea to avoid wrestling or playing tug-of-war with your dog. These types of activities can make your dog overly excited, which may lead to a nip or a bite.” Understanding these reasons is the first step in prevention [18]. The various avenues suggested to prevent dog bites are socialization, responsible pet ownership, education, avoiding risky situations, and paying attention to the dog's body language.

In this study, 35% of the injuries occurred in those <14 years old, with the vast majority occurring at home (Fig. 7). Directing education to this age group is thus important. Education can occur in schools and/or the Internet [30, 39, 40]. One opportune time is just before school finishes for the summer break, as there were more bites in the summer. Education should also be directed to the parents/care takers. This could occur in many ways: pamphlets in medical offices (human and veterinary) and emergency departments [41, 42]; radio, television, and Internet public service announcements; and prospective dog owners visiting animal shelters, kennels, breeders, etc. The manner of education has been previously outlined and consists of denoting the responsibilities of owning a dog [17, 31], appropriate handling of the dog [5]; and potential dangers of the dog [28], as well as the American Veterinary Medical Association guidelines [18]. Simply ensuring that young children are not in the presence of a dog (Fig. 3) without supervision would be a very simple way to minimize these injuries.

5. Conclusion

Non-fatal human dog bites account for 1.1% of ED injury visits in the US with an average annual incidence of 1.1 per 1000; 98.8% were unintentional and 80.2% occurred at home. The average age of those was 28.9 years with a slight male predominance (52.6%), especially in those <35 years of age. The bite was located in the upper extremity in 47.3%, head/neck in 26.8%, lower extremity in 21.5%, and trunk in 4.4%. Hospital admission was rare 1.7%, and there was a higher occurrence in the summer and on weekends. Potential prevention strategies are educational programs directed at both those children able to comprehend the information as well as all parents/caretakers outlining the responsibilities of owning a dog along with appropriate handling and potential dangers of a dog. Information can also be disseminated in health care facilities, radio/TV/Internet venues, and dog kennels/shelters. One of the easiest prevention methods is to ensure that young children are never the unsupervised presence of a dog. Dog bite injuries represent a significant financial burden to society with a conservative estimate of an annual 400 million US$ in the USA alone.

Declarations

Author contribution statement

Randall T. Loder: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.

Funding statement

This work was supported in part by the Garceau Professorship Fund and the Rapp Pediatric Orthopaedic Research Fund, Riley Children's Foundation.

Competing interest statement

The authors declare no conflict of interest.

Additional information

No additional information is available for this paper.

Acknowledgements

This study was supported in part by the Garceau Professorship Fund and the Rapp Pediatric Orthopaedic Research Fund, Riley Children's Foundation.

Appendix A. Supplementary data

The following are the supplementary data related to this article:

Supplemental Table 1.xls
mmc1.xls (33.5KB, xls)
Supplemental Table 2.xls
mmc2.xls (33KB, xls)
Supplemental Table 3.xls
mmc3.xls (31.5KB, xls)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Table 1.xls
mmc1.xls (33.5KB, xls)
Supplemental Table 2.xls
mmc2.xls (33KB, xls)
Supplemental Table 3.xls
mmc3.xls (31.5KB, xls)

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