Age- and Sex-Related Differences in Nonfatal Dog Bite Injuries Among Persons Aged 0-19 Treated in Hospital Emergency Departments,United States,2001-2017

Abstract

Objective:

No studies using national data have evaluated changes in nonfatal dog bite injuries among children, adolescents, and young adults during the past 2 decades. We examined estimates of annual nonfatal dog bite injuries among persons aged 0-19 treated in US emergency departments (EDs) from 2001 through 2017.

Methods:

We examined data from the Web-based Injury Statistics Query and Reporting System to compare estimates of the annual rates of nonfatal dog bite injuries in EDs among all persons aged 0-19, by age group (0-4, 5-9, 10-14, and 15-19), and by sex. We determined significance by comparing 95% confidence intervals (CIs), and we standardized rate calculations to the year 2000 population.

Results:

During 2001-2017, an estimated 2 406 109 (95% CI, 2 102 643-2 709 573) persons aged 0-19 were treated in EDs for nonfatal dog bite injuries (age-adjusted rate of 173.1 per 100 000 persons aged 0-19). The estimated number of nonfatal dog bite injuries declined significantly, from 181 090 (95% CI, 158 315-203 864) in 2001 to 118 800 (95% CI, 97 933-139 667) in 2017. The highest rate was among children aged 5-9. Male children, adolescents, and young adults were significantly more likely than female children, adolescents, and young adults to be treated in the ED for nonfatal dog bite injuries, driven by male–female differences in children and adolescents aged 5-14.

Conclusions:

Although the estimated number of nonfatal dog bite injuries among persons aged 0-19 declined significantly in the past 2 decades, additional regulatory and educational efforts specific to age and sex may lead to further reductions in nonfatal dog bite injuries.

Keywords

animal bite dog bite child children injury

Dog bite injuries were among the top 10 causes of nonfatal injury treated in US emergency departments (EDs) for children aged 1-9 in 2017.¹ Bite injuries from dogs are the most common animal bite injuries treated in EDs.² Fatal dog bite injuries are rare compared with nonfatal dog bite injuries; from 1979 to 1994, approximately 18.6 dog bite–related deaths occurred annually in the United States.^3,4 Data from 1989-1994 estimated a fatal dog bite injury rate of 7.1 per 100 million population per year.³ Although more recent national estimates of annual fatal dog bite injuries have not been published in the peer-reviewed literature, studies have consistently shown that fatal dog bite injuries are concentrated among children and the elderly, with children aged 0-9 being more likely than any other age group to have a fatal dog bite injury.^3,5

Nonfatal dog bite injuries are more common than fatal dog bite injuries and are estimated to occur at an annual rate of 109.9 per 100 000 population in the United States, according to the most recent national estimates from 2009.⁶ Few studies have used national data to evaluate changes in the frequency of nonfatal dog bite injury over time. A study that used national data from the Centers for Disease Control and Prevention (CDC) for 2005-2009 found no significant decline in US population-based estimates of nonfatal dog bite injuries among persons aged 0-85 during the study period.⁶ Data from the 2010-2014 Nationwide Emergency Department Sample demonstrated that nonfatal dog bite injuries among children and adults decreased from 0.25% of all ED visits in 2010 to 0.19% of all ED visits in 2014, but that study did not include population estimates of injury.⁷

Few reports using national data have compared age- and sex-related differences in the frequency of nonfatal dog bite injuries.^6
-8 CDC data from 2001 found that children and adolescents aged ≤14 comprised 42% of all nonfatal dog bite injuries treated in EDs in the United States; the highest annual rate occurred among children aged 5-9. However, children aged <5 were also disproportionately affected.⁸ A review of the same CDC data source for 2005-2009 found that children aged 5-9 had the highest rate of nonfatal dog bite injuries among children and adults.⁶ Other national, statewide, and local studies have also found a disproportionate incidence of nonfatal dog bite injuries among children and adolescents aged 0-17.^3,5,7,9
-11

Injuries of all types are more common among males than among females throughout childhood and adulthood.^12
-14 The sex-related differences in both fatal and nonfatal injury incidence are evident in all child and adult age groups, with differences accentuated during adolescence and young adult years.^13,14 Regional, statewide, and single-center studies, which provide detailed data on predictors of dog bite injury, found that nonfatal dog bite injuries occur at greater rates among males than among females^2,9,10,15; the age group with the largest number of cases was often children aged 5-12.^2,9,10,15,16

The objectives of this study were (1) to update national estimates of nonfatal dog bite injuries treated in EDs in the United States during a 17-year period (extent of data available through CDC) and (2) to evaluate differences in age- and sex-related risk of these injuries among children, adolescents, and young adults. We hypothesized that national estimates of nonfatal dog bite injuries treated in EDs among persons aged 0-19 declined from 2001 to 2017. Based on published data on all injuries and dog bite injuries specifically, we hypothesized that estimated rates of nonfatal dog bite injuries would be higher among males than among females and that this difference would be greatest between males and females aged 10-14.

Methods

This study used the Web-based Injury Statistics Query and Reporting System (WISQARS) database, an online injury data repository maintained by CDC.¹⁷ WISQARS is a public-use data interface that uses data collected as part of the National Electronic Injury Surveillance System–All Injury Program (NEISS-AIP).¹⁸ The NEISS-AIP, a collaboration between the US Consumer Product Safety Commission and CDC, obtains data from a stratified probability sample of EDs in the United States. Trained personnel at each reporting hospital abstract demographic and clinical data from the records of persons treated for injury. WISQARS uses input from the NEISS-AIP to calculate national estimates of injury based on the number of reported cases, adjusted to the calendar-year 2000 US population.¹⁹ The data output results include the number of cases reported, the relevant US Census population estimates, and the estimated number of injuries seen in US EDs per 100 000 population. WISQARS accounts for the complex survey weighting to produce national estimates of injury and accompanying 95% confidence intervals (CIs).

Seeking to update the 2005-2009 report using more recent data and focusing on children, adolescents, and young adults, we examined data on unintentional injuries due to nonfatal dog bite injuries treated in EDs in the United States from 2001 through 2017. We evaluated injuries among all persons aged 0-19 and among age groups (0-4, 5-9, 10-14, and 15-19). We examined sex-related differences between males and females among all ages combined and in each age group. We excluded cases in which sex was unknown (n = 10). Because WISQARS is a data interface, it does not provide raw data that can be used to compute statistical tests. Therefore, we compared 95% CIs to determine significant differences across calendar years and by age group and sex. We standardized rate calculations to the year 2000 population where appropriate. Finally, we used standard epidemiological formulas to calculate the relative risk ratio (RR) of nonfatal dog bite injuries between males and females.²⁰ Because we used publicly available, de-identified data, the Medical University of South Carolina Institutional Review Board deemed the study to be not human research; as such, it did not require review.

Results

During 2001-2017, a total of 48 166 nonfatal dog bite injuries treated in EDs in the United States were reported to the NEISS-AIP for children, adolescents, and young adults aged 0-19, corresponding to a national estimate of 2 406 109 (95% CI, 2 102 643-2 709 573) nonfatal dog bite injuries and an age-adjusted rate of 173.1 nonfatal dog bite injuries per 100 000 persons. During the study period, the estimated number of nonfatal dog bite injuries treated in US EDs among persons aged 0-19 declined significantly, from 181 090 (95% CI, 158 315-203 864) in 2001 to 118 800 (95% CI, 97 933-139 667) in 2017 (Table 1).

Table 1.

Annual estimates of nonfatal dog bite injuries treated in hospital emergency departments among children, adolescents, and young adults aged 0-19, United States, 2001-2017

Year	No. of Injuries Reported^a	National Estimate of Injuries, No.^b (95% CI)	Reference Population, No.^c	Crude Rate^d	Age-Adjusted Rate^d,e
2001	3481	181 090 (158 315-203 864)^f	80 906 541	223.8	224.2
2002	3243	156 674 (131 584-181 764)	81 173 400	193.0	193.8
2003	3014	155 791 (128 972-182 610)	81 425 816	191.3	192.3
2004	3022	156 890 (127 653-186 127)	81 754 354	191.9	193.6
2005	2829	140 953 (119 443-162 462)	82 005 260	171.9	173.7
2006	2574	133 297 (110 044-156 550)	82 324 418	161.9	163.6
2007	2633	132 837 (112 392-153 282)	82 749 431	160.5	162.0
2008	2786	136 149 (112 523-159 775)	83 118 264	163.8	165.3
2009	2976	144 606 (120 826-168 386)	83 280 391	173.6	174.9
2010	2877	143 329 (120 930-165 728)	83 267 556	172.1	173.2
2011	2948	150 372 (125 188-175 556)	82 830 017	181.5	182.4
2012	2852	146 459 (123 017-169 900)	82 487 297	177.6	178.1
2013	2631	133 133 (111 009-155 257)	82 252 861	161.9	162.3
2014	2627	135 255 (117 825-152 686)	82 116 071	164.7	165.1
2015	2493	118 114 (99 455-136 773)	82 096 458	143.9	144.1
2016	2535	122 360 (100 277-144 442)	82 127 667	149.0	149.3
2017	2645	118 800 (97 933-139 667)^f	82 153 212	144.6	144.9
2001-2017	48 166	2 406 109 (2 102 643-2 709 573)	NA	173.1	NA

Abbreviation: NA, not applicable.

^a Data source: National Electronic Injury Surveillance System–All Injury Program.¹⁸

^b Data source: Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System.¹⁷

^c Data source: US Census Bureau.¹⁹

^d Rates are per 100 000 persons aged 0-19.

^e Adjusted to the year 2000 US population.

^f A comparison of 95% CIs revealed a significant difference between the estimates for 2001 and 2017.

The crude rate of nonfatal dog bite injury per 100 000 persons was 194.3 among children aged 0-4, 220.2 among children aged 5-9, 168.7 among children and adolescents aged 10-14, and 109.6 among adolescents and young adults aged 15-19 (Table 2). The rate of nonfatal dog bite injury among adolescents and young adults aged 15-19 was significantly lower than the rate of nonfatal dog bite injury among other age groups.

Table 2.

Estimates of nonfatal dog bite injuries treated in hospital emergency departments, by age group, among children, adolescents, and young adults aged 0-19, United States, 2001-2017

Age Group, y	No. of Injuries Reported^a	National Estimate of Injuries, No.^b (95% CI)	Reference Population, No.^c	Crude Rate^d
0-4	13 886	657 378 (561 276-753 480)	338 395 727	194.3
5-9	15 598	751 546 (650 923-852 168)	341 323 037	220.2
10-14	11 937	598 757 (519 923-677 591)	354 923 387	168.7
15-19	6745	398 427 (345 255-451 600)^e	363 426 863	109.6

^a Data source: National Electronic Injury Surveillance System–All Injury Program.¹⁸

^b Data source: Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System.¹⁷

^c 2000 data. Data source: US Census Bureau.¹⁹

^d Per 100 000 persons in the corresponding age group.

^e Comparison of 95% CIs revealed a significant difference between the estimates for adolescents and young adults aged 15-19 compared with children and adolescents in the other 3 age groups.

During the study period, males were significantly more likely than females to have nonfatal dog bite injuries; crude rates of nonfatal dog bite injuries per 100 000 persons aged 1-19 were 191.5 among males and 151.6 among females. The estimate of total nonfatal dog bite injuries was 1 370 255 (95% CI, 1 196 784-1 543 728) among males aged 0-19 and 1 035 219 (95% CI, 902 102-1 168 338) among females, corresponding to an RR of 1.26 (95% CI, 1.26-1.26). Comparisons by sex among the 4 age groups showed that the differences between males and females were driven by boys aged 5-9 (RR = 1.30; 95% CI, 1.29-1.30) and aged 10-14 (RR = 1.50; 95% CI, 1.49-1.51) (Table 3).

Table 3.

Estimates of nonfatal dog bite injuries treated in hospital emergency departments, by sex and age group, among children, adolescents, and young adults aged 0-19, United States, 2001-2017

Sex^a	Age Group, y	No. of Injuries Reported^b	National Estimate of Injuries,^c No. (95% CI)	Reference Population^d	Crude Rate^e
Male	0-4	7606	361 305 (307 583-415 028)	172 939 502	208.9
	5-9	9090	432 199 (373 884-490 514)^f	174 413 280	247.8
	10-14	7336	365 674 (317 246-414 102)^g	181 519 438	201.5
	15-19	3592	211 077 (182 152-240 002)	186 557 892	113.1
Female	0-4	6274	295 619 (252 543-338 696)	165 456 225	178.7
	5-9	6504	319 167 (273 925-364 410)^f	166 909 757	191.2
	10-14	4601	233 083 (201 171-264 995)^g	173 403 949	134.4
	15-19	3153	187 350 (160 988-213 713)	176 868 971	105.9

^a Excludes persons with unknown sex (n = 10).

^b Data source: National Electronic Injury Surveillance System–All Injury Program.¹⁸

^c Data source: Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System.¹⁷

^d 2000 data. Data source: US Census Bureau.¹⁹

^e Per 100 000 persons in the corresponding age group.

^f Comparison of 95% CIs revealed a significant difference in estimates between boys and girls aged 5-9.

^g Comparison of 95% CIs revealed a significant difference in estimates between boys and girls aged 10-14.

Discussion

These data suggest that the number of nonfatal dog bite injuries among children, adolescents, and young adults aged 0-19 declined significantly from 2001 to 2017. The decline also represents a clinically important decrease of approximately 34% from 2001 to 2017. Although the annual estimated rates of nonfatal dog bite injuries to children, adolescents, and young adults are declining, these injuries are still common and costly: a dog bite injury resulted in an average cost of $18 200 per hospitalization and an annual aggregate cost of $53.9 million for adults and children, based on 2008 estimates.^16,21

The concentration of nonfatal dog bite injuries among children and adolescents aged 5-14 was found in other studies. A study using the same data source found that children aged 5-9 had the highest rate of nonfatal dog bite injuries (215.4 nonfatal dog bite injuries per 100 000 children aged 5-9) during 2005-2009.⁶ In another nationally representative data set of ED visits during 2008, children aged 5-9 had the highest rate (199.3 ED visits per 100 000 children aged 5-9) and children aged <5 had the second highest rate (175.0 per 100 000 children aged <5) of nonfatal dog bite injuries.¹⁶ Regional and local data also consistently show that children in the early school years and early adolescent years are disproportionately affected by nonfatal dog bite injuries.^{2,9,10,15,22,23} The reasons for the concentration of nonfatal dog bite injuries among children aged 5-14 are likely multifactorial. Data from other studies demonstrate that the scenarios contributing to dog bite injuries differ by age; children aged 5-9 are most frequently bitten by dogs they know, and children and adolescents aged 10-14 are most frequently bitten by unfamiliar dogs.²⁴ Young children may be less able than older children to pick up on dog behavioral cues that might otherwise warn older children or adults to leave the dog alone. The concentration of nonfatal dog bite injuries from unfamiliar dogs among adolescents is often the result of negative interactions with dogs.^24,25

Male children, adolescents, and young adults aged 0-19 are more likely than their female counterparts to sustain any injury, and nonfatal dog bite injuries are no exception.¹ Among children and adolescents aged 10-14, the risk of nonfatal dog bite injuries was 49% higher among boys than among girls. This finding suggests that the age- and sex-related differences are exacerbated during childhood and adolescence, which is consistent with findings on other injury types.¹² Although we hypothesized that we would find male–female differences in the rate of nonfatal dog bite injuries and RRs, we hypothesized that we would find a significant difference in the annual number of nonfatal dog bite injuries by sex only in the 10-14 age group. We did not expect to find sex-related differences among children aged 5-9. This finding, coupled with the persistent inverse relationship between age and nonfatal dog bite injury rate among persons aged 0-19, suggests that for children aged 0-4, immaturity in how they interact with dogs may be the predominant factor. However, by age 5, differences between girls and boys in their interactions with animals add another layer of complexity to interpretation of risk. One study combined data on ED visits for nonfatal dog bite injuries with clinical and historical patient data to demonstrate that the presence of externalizing behavioral disorders, such as attention deficit–hyperactivity disorder, was one of the comorbid chronic conditions associated with a greater risk of nonfatal dog bite injuries, but only among males. This finding suggests a complex interaction between sex and behaviors that contributes to the risk of nonfatal dog bite injuries.⁷

As with many patient safety initiatives, further reductions in dog bite injury will likely require a multipronged approach that may include regulatory and legislative efforts along with education in responsible pet ownership.²⁶ Our findings have direct applicability to an important additional recommended approach to limit dog bite injury: education of children and their parents on how to interact with dogs.²⁶ Studies have consistently demonstrated that most nonfatal dog bite injuries are caused by dogs the children know: up to 45% of the dogs involved in dog bite injuries live in the same home as the child victim.^{15,22,24,25,27} Educational interventions teaching proper behavior around dogs could reduce the number of fatal and nonfatal dog bite injuries.²⁶

Recent studies demonstrated that brief educational interventions can improve knowledge of safe behavior around dogs and the ability of children to interpret a dog’s behavior.^28

-31 A nonrandomized, quasi-experimental study conducted in 2011 demonstrated that a video-based educational intervention could improve the knowledge of dog bite injury prevention among 120 children aged 5-9 visiting an ED (for all causes), from 58% passing a preintervention assessment to 90% passing a postintervention assessment, based on how the children performed in a simulated dog encounter.²⁸ A randomized controlled trial published in 2015 involving 70 children aged 3-5 demonstrated that a brief video intervention focused on comparing friendly dog activities with aggressive or fearful dog activities resulted in both improvement in knowledge and improvement in recognizing problematic dog behaviors in the intervention group but not in the control group, who watched an unrelated video.²⁹ A randomized trial conducted in 2013-2014 evaluating an educational intervention using mobile technology found that training parents and children in proper behavior around dogs improved child knowledge of safe behaviors and safety skills in field testing with live dogs.³² The pattern of educational interventions improving short-term knowledge of dog bite injury prevention and behaviors has been examined in other studies; however, few studies have evaluated, much less demonstrated, changes in dog bite injury frequency.³³

Taken together with other published data on age- and sex-related differences in dog bite injuries, our study suggests that any educational interventions designed to improve behavior around dogs or reduce the risk of dog bite injuries should be tailored to the age group and the sex of the target population. However, it is unclear how well the short-term knowledge and behavioral improvement demonstrated by these interventions will translate to reductions in dog bite injuries. Close parental supervision, including when young children are around dogs, is inversely associated with child injury.³⁴ Because of the risks of dog bite injuries to infants and young children, both CDC and the American Veterinary Medical Association recommend parental education on safety around dogs along with child education and that parents always directly supervise interactions with dogs for infants and young children.^35,36

Limitations

This study had several limitations. First, the estimates of rates provided by the WISQARS data likely underestimate the true rate of nonfatal dog bite injuries in the United States because the cases come only from persons who were treated in EDs. Children who were treated for dog bite injuries by health care providers other than EDs or who did not seek medical care were not represented in these data. Because many minor nonfatal dog bite injuries are unreported, these data likely represent underestimates of the true frequency of nonfatal dog bite injuries.³⁷ The data presented were also limited because they are estimates, using data drawn from a nationally representative group of EDs participating in surveillance and then applying those estimates to the overall population. Therefore, some of the observed year-to-year differences in the rates reported may be in part due to changes in the local environments of the surveillance sites or fluctuations in the surveillance processes themselves, resulting in magnified changes when applied to the entire US population. However, the national representativeness of the selected surveillance sites was meant to provide robust national estimates.

Second, the significance of the observed change from 2001 to 2017 was driven by substantially higher estimates of nonfatal dog bite injuries during calendar year 2001 than during other years. In fact, the 95% CIs for all other years (eg, 2002-2017) overlapped, raising the question of whether 2001 represented an anomalous year in nonfatal dog bite injuries or in how surveillance of nonfatal dog bite injuries was conducted in 2001. Without data from 2000 or earlier, it was not possible to evaluate whether data estimates from 2001 were anomalous or accurate. Other large year-to-year fluctuations in the estimated rate of nonfatal dog bite injuries treated in EDs were evident, such as the decrease of 20 nonfatal dog bite injuries per 100 000 persons aged 0-19 from 2004 to 2005. However, the drop of 30 nonfatal dog bite injuries per 100 000 persons aged 0-19 from 2001 to 2002 was the largest year-to-year difference noted in these data.

Finally, data on clinical person-level details, the circumstances of the injuries, and the degree of injury sustained were not available in WISQARS. Without knowing the circumstances of the injuries, particularly whether the injuries were random or provoked, we were not able to determine why boys and girls in the middle age groups had different rates of estimated nonfatal dog bite injuries. Although single-site studies using medical record review have provided insight on contributing factors, documentation of injury event settings, child or dog behavior precipitating the injury, dog breeds involved, dog ownership, and location of the interaction are often incomplete, even in research centers that have repeatedly studied the issue.²²

Conclusions

Nonfatal dog bite injuries treated in EDs in the United States among children, adolescents, and young adults aged 0-19 declined 34% from 2001 to 2017. Males aged 0-19, particularly male children and adolescents aged 5-14, are significantly more likely than their female counterparts to be treated in the ED for nonfatal dog bite injuries. Regulatory changes along with age-appropriate and sex-specific educational programs may further reduce the risk of nonfatal dog bite injury.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

William T. Basco Jr, MD

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