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Animal Bites: Risk, Care & Reporting.

Human-Animal Interaction

The bond between humans and their animals has stood the test of time because it is mutually healing. For many, the pet is part of the family system--worthy of giving and receiving love. In the United States, humans and animals interact on a daily basis through contact with pets, farm animals, rodents, to occasional contact with wild animals. Therefore, it's not surprising that animal bites are indeed common. Domestic dogs are the most predominant mammal to bite humans accounting for 80-90% of total bites, followed by cats (5-15%) and the third most common are pet ferrets. An average of 4.5 million Americans are bitten by dogs each year with nearly 885,000 seeking medical care. In addition, there are annually about 400,000 cat bites with roughly 66,000 emergency department visits. Moreover, an estimated 27,000 plastic surgery repairs occur from dog bites each year.

Figure 1. The human-animal bond.

Animals often bite in response to being afraid, hurt or ill. Humans can also be injured unintentionally from pets when they break open skin while scratching or nipping during play. Most of these wounds are minor injuries and go unreported because patients self-administer first aid and often do not seek medical attention. Types of wounds from animal bites range from abrasions, lacerations, punctures, and additional injuries from mauling (avulsion, crush, fracture, dislocation, or amputation). Infection with bacteria can manifest as an acute, intense, localized inflammatory response. If left untreated, it can progress to severe sequelae, including sepsis. Latent sequelae from an animal bite can include disfigurement, functional disability, and mental health and infectious complications.

Various injuries occur from different mammalian bites. Dogs have strong jaws and blunt broad teeth that together cause injury by crushing and shearing resulting in significant soft tissue damage. Cats can both intensely bite and scratch resulting in fine puncture wounds that can entrap bacteria and mild-to-deep lacerations. A cat's teeth can efficiently inoculate pathogens into small joints, deep spaces, or tendon sheaths of the hand. These wounds appear initially benign but then develop hidden infection. A ferret's teeth are also small and sharp, and their style of attack is rapid fire bites. It is common to have to pry the ferret from their victim.

In addition to care for puncture wounds and lacerations, the major concern is infection. Bacteria in bite wounds reflects the oral flora of the biting animal, both their own normal flora and that of their food source including ingested prey. In a few cases, pathogenic bacteria can come from a victim's own skin or from the physical environment at the time of the injury. Dog bite wounds are polymicrobial, with a broad combination of aerobic and anaerobic microorganisms. The most common aerobic bacteria genera isolated in dog bite wounds are Pasteurella, Streptococcus, Staphylococcus and Neisseria, whereas the most common anaerobic bacteria include Fusobacterium, Porphyromonas, Prevoteiia, and Propionibacterium. Pure anaerobic bacterial growth is rare in dog bites and is almost always accompanied by aerobic organisms. Cat-bite wounds have similar microbiology for infections with additional concerns. Cats are the main reservoir of Bartonella henselae, the causative agent of cat scratch disease. Cat bites have also been associated with transmission of Francisella tularensis resulting in tularemia.

The most notorious infection transmitted through animal bites is rabies, which is usually always lethal without appropriate and timely postexposure treatment. Sadly, about 59,000 people die of rabies every year around the world, primarily from infected dog bites. Although rabies infection is rare, it occurs in the United States with only about 1 or 2 cases per year in people who fail to seek medical assistance, usually because they were unaware of their exposure.

According to the U.S. Centers for Disease Control (CDC), properly administered post-exposure prophylaxis has proven nearly 100% successful. Because of the severity of the disease, and the public health implications for transmission, laws are in place for the reporting of animal bites.

Vulnerable Populations

Children

The largest percentage of victims of dog bites are children. Boys are more likely to receive a dog bite than girls. The risk of injury to the head and neck is greater in children than in adults, adding to increased severity with a necessity for medical treatment, and higher death rates. Many children are emotionally traumatized by an animal bite and need timely professional mental health care.

Chronic Conditions including Persons with Diabetes

Patients with chronic conditions that may affect the immune system, such as alcohol or drug dependency, asplenia, rheumatoid arthritis and diabetes mellitus, have a higher risk for developing infections from animal bites. Patients with peripheral circulatory disorders, such as diabetic peripheral neuropathy, are particularly vulnerable because the scratch or bite may go unnoticed or ignored leading to delayed presentations for care and complications.

Pets

Transmission of rabies and other infections from one infected animal to another animal can occur from bites, scratches and bodily fluid exchange (e.g. saliva) between the animals. According to the CDC "Any animal bitten or scratched by either a wild, carnivorous mammal or a bat that is not available for testing should be regarded as having been exposed to rabies."

International Travelers

According to the World Health Organization, dog bites account for more than 50% of animal-related injuries in people who are travelling. The second most common bite injury to tourists is from monkeys!

Nursing Care

General Medical Care

First aid for an animal bite includes controlling the bleeding, cleansing, covering and elevating the wound. Also, identifying and having access to the animal incase quarantine and testing is indicated. Medical care for the victim is recommended. If the presenting patient is unstable, priority is to maintain airway, breathing, and circulation by managing any profuse bleeding from a wound or amputation. General nursing care of most animal bite wounds begins with emotional support to the victim, obtaining a detailed account of the incident, description of the wound, proper localized care of the wound, followed by possible administration of a tetanus toxoid booster, and discharge education for any prophylaxis antibiotics and signs of developing infection. The bite wound should be washed vigorously and irrigated with water, normal saline, or dilute povidone-iodine solution for adequate cleaning to reduce inoculation of the oral flora from the biting animal (check your agency's protocol). Medical examination will determine if debridement or closure/suturing of the wound is indicated. Closure should only be considered in wounds that are well cleansed. Bite wounds with a delay in presentation of over 8-12 hours, or in immunocompromised victims, generally are left open or have a delayed closure. Examination is also indicated for neurological injuries that could lead to functional disability and disfigurement. Diagnostic X-rays often indicated for patients with bone or joint involvement. Moreover, gram stain and wound cultures are not indicated for every bite; however, cultures are helpful in diagnosing and treating infection during follow-up care. Inpatient admission is rare (<10%), however, usually half of patients will require closure of an animal-bite laceration.

Wounds of the Hand & Forearm

Overall, the hands are the most common injury site for victims of animal bites, especially non-dog and cat bites. Because the hands are hosts to many bacteria they are at high risk for developing a postbite infection. About 50% of hand bites from dogs become infected, whereas up to 80% of hand cat bites develop infections.

Wounds of the Head & Face

The most prevalent site >50% of dog bites occur on the head and neck. Facial wounds have a low risk of infection even when closed primarily due to their increased blood supply.

Emotional Supportive Care

Animal bites affect patients physically and emotionally. It is common for them to have anxiety, fears and even nightmares after an animal attack. Research has found that most children display emotional signs and symptoms (acute stress reaction, depression, anxiety) within days following a significant mutilating injury. Like other traumas, parents may not recognize the emotional distress signs in their children. Therefore, it is imperative to include assessment and if necessary referral for mental health counseling for victims of animal bites, regardless of their age.

Animal Bites in Nevada

In Nevada, (NRS 441A.120) the definition of "animal bite" means breaking of the skin by the teeth of an animal. Between 2015-2017, there were 4,554 reported animal bites from rabies-susceptible animals in Nevada excluding Clark County (data were unavailable).

The most reported number of animal bites came from healthcare practitioners in Washoe County and Carson City, with the lowest number reported from the rural Nevada counties of Lincoln, Mineral and Storey.

Bats are the primary reservoir for rabies in Nevada. Data from testing bats in Washoe County during 1998-2012 found that 12-18% of the bats were positive for rabies. Infected bats may not show any signs of rabies, so infection can only be confirmed in a laboratory.

Rabid bats may act erratic due to disorientation and difficulty flying. Nationally, the CDC reports that the number of rabid bats is increasing.

Reporting is our Duty

Despite current Nevada law and the public health impact of animal bites these injuries are underreported. In Nevada, by law, all animal-to-human bites from a rabies-susceptible animal must be reported. In Nevada Administrative Code 441A.225 "report of animal rabies or an animal bite by a rabies-susceptible animal must be made to the health authority or to the rabies control authority, if designated by the health authority, within 24 hours after identifying the case. The report must be made by telephone if it is made during the regular business hours of the health authority or rabies control authority, as applicable, or using the after-hours reporting system if the report is made at any other time." NAC 441A.155 defines a rabies-susceptible animal as "any mammal, including, but not limited to, a bat, cat, dog, cow, horse, ferret, cougar, coyote, fox, skunk and raccoon, and any wild or exotic carnivorous mammal."

Nurses can play a key role in assuring that animal bites are reported to public health authorities and follow county-specific protocols that may also include notifying animal-control authorities. We can't know the extent of the problem if it is not reported and tracked. Nurses can advocate for animal-bite victims and the public at large.

References & Resources

Clark County Animal Control: http://www.clarkcountynv.gov/administrativeservices/animal-control/Pages/faq.aspx

Southern Nevada Health District: http://www.southernnevadahealthdistrict. org/health-topics/rabies.php

EPI News from Washoe County: https://www.washoecounty.us/health/files/ ephp/epi-news/2013/vol-33-no-15-08-02-13-animal-bite-reporting-andrabies-post-exposure-prophylaxis.pdf

W.H.O. Animal Bites: http://www.who.int/news-room/fact-sheets/detail/ animal-bites

U.S. Centers for Disease Control: https://www.cdc.gov/rabies/index.html

Lyu C, Jewell M, Kuo T, et al. Burden of Bites by Dogs and Other Animals in Los Angeles County, California, 2009-2011. Public Health Reports [serial online]. November 2016;131(6):800-808.

Golinko M, Arslanian B, Williams J. Characteristics of 1616 Consecutive Dog Bite Injuries at a Single Institution. Clinical Pediatrics [serial online]. April 2017; 56(4):316-325.

Rasmussen D, Landon A, Powell J, Brown G. Evaluating and treating mammalian bites. JAAPA: Journal of The American Academy of Physician Assistants (Lippincott Williams & Wilkins) [serial online]. March 2017; 30(3):32-36.

Abrahamian FM, Goldstein EJ. Microbiology of Animal Bite Wound Infections. Clinical Microbiology Reviews Apr 2011, 24 (2) 231-246.

Howell RD, Sapienza A. The management of domestic animal bites to the hand. Bulletin of the NYU Hospital for Joint Diseases. 73.2 (Apr. 2015): p156.

Report the Bite

* Who was bit. (Name, address, phone number)

* Where they were bit. (Body location of the bite & location were bite occurred (park, yard, etc.)

* Description of the biting animal.

* Other important details.

Check with your local Health Authority or Animal Control for a specific form to complete.

5 Tips to Avoid a Dog Bite

"I can be your best friend, but sometimes when I'm angry or scared I might bite!"

1. Don't disturb me or frighten me, particularly when I am eating, with my toys, tied up, in a car, with my puppies, ill or asleep.

2. Keep away from me when I am angry or scared.

3. Don't move if I approach you when I am not on a leash. Stand still.

4. Approach me slowly and quietly. Ask my owner if you can pet me.

5. If I bite you--act quickly. If you fall over, curl up, protect and stay still. Wash the wound with soap & water and seek medical care.

Reference: Adapted from WHO's prevent dog bites resources

By Bernadette M. Longo, PhD, RN, FAAN & Dustin Boothe, MPH

Bernadette M. Longo, Ph.D., RN, APHN-BC, CNL, FAAN

Chair of NNA's Environmental Health Committee

Emerita Professor at the Orvis School of Nursing, UNR

Dustin Boothe, MPH, REHS

Division Manager and Epidemiologist

Carson City Health and Human Services
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Title Annotation:NNA Environmental Health Committee
Author:Longo, Bernadette M.; Boothe, Dustin
Publication:Nevada RNformation
Date:Nov 1, 2018
Words:2121
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