Trend Analysis of Animal Bite Cases: A Retrospective Study at Anti-Rabies Clinic of a Tertiary Care Hospital of Kashmir

Background: Rabies which is 100 fetal but preventable is caused by bite of rabid animals particularly dogs. Animal bites cases are major public health problem in India and also in the UT of Jammu & Kashmir. Objective(s): To study the trend and seasonal Variation of animal bite cases attending the Anti Rabies clinic (from 2009 to 2022), run by Department of Community Medicine, Government Medical College Srinagar at SMHS Hospital. Material(s) and Method(s): The retrospective Cross sectional study conducted at Anti-Rabies Clinic of SMHS Hospital, a tertiary care associated Hospital of Government Medical College Srinagar. Data was collected from the record of Animal bite register at Anti rabies clinic after proper permission from the incharge of the clinic. Data was entered and analyzed on Excel soft ware. Result(s): More than 70,000 number of animal bites cases were reported at the Anti-Rabies clinic from the year 2009 to 2022. there has been a rise of cases from the year 2009 to 2018 with a slight decrease in the year 2019-20. About 97% of all animal bites were dog bites. Majority of the cases (>60%) were category of three (3) exposure. One year analysis for seasonal variation shows that incidence was more in March and May-June. Conclusion(s): the present study showed that animal bites cases were rising with little decrease in the year 2019-20 as may be due to lesser animal human interaction due to Covid-19 restrictions. Keeping in view the present trend it is expected that the Animal bite cases will show rising trend in coming years. Multidisciplinary approach is advocated to control the increasing trend.

Impact of COVID-19 pandemic on burden of dog bite cases at a Tertiary Care Hospital in Kashmir

Background: Dog bite is a public health problem in Kashmir incurring huge cost of treatment. Objective(s): To see the impact of COVID-19 pandemic on the burden of dog bite cases and the profile of patients, comparing with that of the years before the three peak waves of COVID-19 and after that at Shri Maharaja Hari Singh Hospital. Methodology: This is a retrospective record review of the dog bite cases in the year 2018 to 2022 in Anti Rabies Clinic, SMHS Hospital Srinagar. The target population of the study were people living in Srinagar city. Proportion of dog bite according to demographic and clinical variables were calculated. Univariate and multivariate analysis were done to look for risk factors responsible for dog bite in COVID infection waves compared to pre and post pandemic times. Results and Conclusion(s): The dog bite cases in the prepandemic time period and during the three waves of COVID 19 infection were recorded at 3.3% and 2.4% respectively. There was male predominance and highest incidence of the dog bite was in age group of 20-59 years. The commonest site of bite were lower limbs and stray dog bites were highest risk exposure. Less dog bite cases reported in 2020, 2021 which may be due to the impact of pandemic. Majority of the cases were stray dog bites and high incidence of dog bites can be a major concern for health, social and economic wellbeing of the nation which needs urgent intervention.

Compliance rate of anti-rabies vaccination in patients presenting with an animal bite

Introduction: To prevent rabies in animal bite victims, complete postexposure prophylaxis (PEP) with an anti-rabies vaccination (ARV) is essential. This study was done to determine the compliance rate of ARV in patients with animal bites who presented to the emergency department (ED) during the COVID-19 pandemic. Materials and Methods: This was a prospective observational study done on patients presenting to the ED with a history of animal bites over 1 year (May 2020-June 2021). Categorical variables were presented as percentages, and quantitative variables were summarized using mean and standard deviation (SD). Results: A total of 122 animal bite (World Health Organization [WHO] Category II and III) victims presented to the ED during the study. The mean age of the cohort was 38.12 (SD: 16.4) years with a male (n = 67: 54.9%) preponderance. Based on the physiological stability, a majority were triaged as priority III (n = 119;97.5%). Most patients presented with dog bites (n = 88;72.1%), followed by cat (n = 14;11.5%) and rat bites (n = 13;10.7%). Two-thirds were unprovoked (n = 82;67.2%) and were caused by stray animals (n = 62;50.8%). More than half (n = 65;53.3%) of the bites were WHO Category III bites. All Category II and III patients had received the first dose of ARV at our center and category III patients received immunoglobulin local injection as well. Noncompliance to ARV was seen in almost a quarter (n = 32;26.2%) of patients of which forgotten dates (n = 11;34.4%) were the most common cause. There was no significant statistical variable to determine the cause of noncompliance. Conclusion: Unprovoked bites by stray dogs were the cause of a majority of the animal bites. Compliance with PEP remains low at two-thirds of the total. The most common cause of noncompliance to ARV was due to forgotten dates. The following core competencies are addressed in this article: Medical knowledge, Systems-based practice, Practice-based learning and improvement. © 2022 The authors.

Record Keeping of External Calls to the Maxillofacial Department

Introduction/Aims: External telephone calls to the Northampton Maxillofacial department are often from Kettering General Hospital, GPs, GDPs, or patients. There was no system as to where or how to record details taken from external telephone calls. Therefore, not all calls were being noted. A proforma sheet was created to provide staff with a place to document call details. Compliance of record keeping was recorded. The aim of this clinical audit quality improvement project is to improve and measure the compliance of record keeping of external telephone calls to the Maxillofacial department. Material(s) and Method(s): The gold standard of record keeping is 100% compliance as per GDC Principle 4. A proforma sheet was created and a charting system meant calls were logged. Completed proformas were scanned onto the department's desktop. Audit cycles were conducted over one month. The first cycle was conducted from 20th December 2021 until the 20th January 2022. Intervention was then carried out, including discussion of results at a staff meeting, training on record keeping and one to one supportive feedback to colleagues on their record keeping of external calls. After this, a second cycle was conducted from the 1st March 2022 until the 31st March 2022. Results/Statistics: In cycle 1, 29 external calls were taken, with 19 documented. Record keeping compliance of external calls was 66%. The gold standard was not achieved. 32% of calls were from patients/relatives of patients, 31% of calls were from Kettering General, 21% from GPs and 16% from GDPs. 43% were regarding facial swellings and 22% were trauma related. The remaining calls which each had a weighting of 5%, were regarding: dog bites, orthodontics, osteotomies, biopsies, parotidectomies, trigeminal neuralgia and oral antral fistulas. 12 patients were advised to attend the A&E department, 3 patients were admitted for emergency surgical treatment, and 5 were booked for a review at a trauma clinic. In cycle 2, there was significant improvement, as record keeping compliance of external calls was 85%. 20 external telephone calls were noted, with 17 recorded using the proforma sheets. 16% of calls were regarding facial swellings, 21% were trauma related, 26% had post-extraction concerns, 5% had COVID-19 queries, 16% had delayed healing, 11% involved uncontrollable bleeding and the final 5% called for antibiotic advice. 9 patients were advised to attend the A&E department, 1 patient was admitted for emergency surgical treatment, and 7 were booked on to a trauma clinic. Conclusions/Clinical Relevance: The audit raises awareness for ethical record keeping, patient safety and legal implications. It highlights areas for teaching, such as management of facial swellings. As the gold standard was not achieved, the aim is to re-audit after more intervention, to improve compliance of good record keeping to 100%. The Maxillofacial department at Kettering General are also looking to implement the proformas and audit. This demonstrates the project can be generalised to more hospitals. Copyright © 2022

Lethal Waterhouse-Friderichsen syndrome caused by Capnocytophaga canimorsus in an asplenic patient.

BACKGROUND: Capnocytophaga canimorsus, a Gram-negative rod, belongs to the Flavobacteriaceae family and colonizes the oropharynx of dogs and cats. Infections with C. canimorsus are rare and can induce a systemic infection with a severe course of the disease. So far, only five case reports of C. canimorsus infections associated with Waterhouse-Friderichsen Syndrome (WFS) have been reported with only two of the patients having a history of splenectomy. CASE PRESENTATION: Here, we report a fatal case of WFS due to C. canimorsus bacteremia and mycetal superinfection in a 61-year-old female asplenic patient. Despite extensive therapy including mechanical ventilation, antibiotic coverage with meropenem, systemic corticosteroids medication, vasopressor therapy, continuous renal replacement therapy, therapeutic plasma exchange, multiple transfusions of blood products and implantation of a veno-arterial extracorporeal membrane oxygenation the patient died 10 days after a dog bite. The autopsy showed bilateral hemorrhagic necrosis of the adrenal cortex and septic embolism to heart, kidneys, and liver. Diagnosis of C. canimorsus was prolonged due to the fastidious growth of the bacteria. CONCLUSIONS: The occurrence of a severe sepsis after dog bite should always urge the attending physician to consider C. canimorsus as the disease-causing pathogen. A therapeutic regimen covering C. canimorsus such as aminopenicillins or carbapenems should be chosen. However, despite maximum therapy, the prognosis of C. canimorsus-induced septic shock remains very poor. Asplenic or otherwise immunocompromised patients are at higher risk for a severe course of disease and should avoid exposure to dogs and cats and consider antibiotic prophylaxis after animal bite.

COVID-19 pandemic and lockdown increase the frequency and severity of periorbital dog bite injuries in children.

Objective: To determine whether the COVID-19 pandemic and lockdown increase the risk of head, neck, and face (HNF) dog bite injuries in children. Methods: Using a retrospective cohort study design, the investigators enrolled a sample of children presenting with HNF dog bite injuries during 22 weeks before and 22 weeks during the COVID-19 pandemic in a German level 1 trauma center. The predictor variables were COVID-19 pandemic and lockdown. The outcome variables were grouped into demographic, anatomic, injury-related, and therapeutic. Appropriate statistics were computed, and statistical significance was set at P ≤ .05. Results: The sample included 36 subjects (19.4% girls; 97.2% Caucasians; 50% isolated periorbital injuries; 61.1% during the lockdown; 16.7% after the lockdown) with an average age of 8 ± 3.3 years. Compared to the pre-COVID-19 period, pediatric HNF dog bite injuries increased ca. 5.5- and 1.5-fold during and after the lockdown, respectively. The COVID-19 pandemic was significantly associated with severe household injury from a pet dog, number of inpatients and treatments in the operating room, and prolonged hospitalization. Isolated periorbital injury was common during the COVID-19 pandemic (P = 0.04; relative risk [RR], 4.86; 95% confidence interval [95% CI], 0.76 to 31.12), especially during the lockdown (P = 0.02; RR, 4.36; 95% CI, 0.72 to 26.6). Conclusion: During the COVID-19 pandemic, especially during the lockdown, there is an increasing tendency of frequency and severity of domestic HNF dog injuries in children, and periorbital region is the most injury-prone.

The impact of COVID-19 pandemic on rabies post-exposure prophylaxis services in Asia.

Human rabies is a preventable disease through post-exposure prophylaxis (PEP) in rabies endemic countries where enzootic cycle of dog rabies occurs. The COVID­19 pandemic has induced an unprecedented challenge for under-funded and already stretched health­care systems particularly in low- and middle-income countries, which are unfortunately bearing a huge burden of human rabies. An analysis of hospital-based PEP data in India, Nepal, Sri Lanka, and Thailand, focus group discussion and key informant interview have been carried out to better understand the impact of Covid-19 pandemic in human rabies prophylaxis. It is necessary to better prepare for human rabies prophylaxis in future pandemics based on lesson learnt from current pandemic. The PEP should be categorized as an emergency medical service, and it should be part of the hospital medical emergency. Mass dog vaccination against rabies should be accelerated to reduce the risk of potential bite of roaming dogs and pet dogs in communities. It is a wise decision to invest in cost-effective preparedness, i.e., mass dog vaccination rather than costly response, i.e., human rabies prophylaxis.

A Better Way to Manage Paediatric Maxillofacial Trauma;A Retrospective Study Examining the Presentation of Maxillofacial Soft Tissue Injuries and Management over 3-year period at a Regional Children's Hospital

Introduction: Maxillofacial treatment is evolving with changing paediatric lifestyles and clinical limitations, including COVID-19. The aim of this study is to assess trends in the presentation of maxillofacial soft tissue injuries and subsequent management within a regional paediatric hospital. Methods: Retrospective study over a 3-year period (from 2019-2021 between January and April). Inclusion of all paediatric patients seen on the emergency department by OMFS team. Results: Between 2019 and 2021, the total number of patients dropped by over half. The average age dropped from 5.9 in 2019 to 3.8 in 2021. Males were more commonly seen. Extraoral injuries increased by 21%. Intraoral injuries reduced by 8%. Less complicated communicating injuries and associated dental trauma were seen in 2021. Lip lacerations accounted for most injuries. In 2020, there was 21% reduction in conservative management of injuries. Wound closure under LA increased by 12% in 2020. There has been an overall increase in wound closure under GA by 5% between 2019 and 2020. Falls accounted for most injuries, however, there has been an increase in dog bite injuries by 5% in 2021. Conclusions: The average age has dropped between 2019-2021 and hence treatment options remain limited. Age, cooperation, and severity of injury are important factors. The number of overall lacerations has decreased but a greater proportion required formal closure under general anaesthesia. It is vital OMFS surgeons are aware of the changes in presentation and current trends in management. This will help to better equip surgical teams for the changing landscape of paediatric maxillofacial trauma.

Phenotypic and Genomic Analysis of Novel, Fastidious, Gram-negative Bacilli Isolated from Clinical Wound Specimens

Background. Animal bites are considered the thirteenth leading cause of nonfatal ED visits. Epidemiology studies have shown a rise in dog bites during the COVID-19 pandemic in the U.S. In Oct. 2020, we received a facultatively anaerobic, non-hemolytic Gram-negative rod (OL1) from a dog bite wound for identification. 16S rRNA gene sequencing showed OL1 was 95.9% identical to Ottowia pentelensis in the family Comamonadaceae. Our historical sequence database revealed 8 additional isolates (OL2-OL9) from hand wounds/abscesses (including 3 dog bites) since 2012 that had > 99.8% identity with OL1. Most other Ottowia sp. have been isolated from industrial and food sources, with no reports from patient samples. As these clinical isolates likely represent a novel Ottowia species, we aimed to characterize them using both phenotypic and genomic approaches. Methods. The OL isolates were tested in API 20 NE panels (8 conventional and 12 assimilation tests) for 4 d. Paired-end genomic DNA libraries (Nextera DNA Flex Library Prep, Illumina) were sequenced as 150 nt reads by Illumina NovaSeq. De novo assembly, annotation, functional prediction, and phylogenetic analyses were performed with Geneious, PATRIC, and web-prediction databases. Strain comparison was done with StrainTypeMer. Results. All 9 OL isolates were negative for indole, urea, arginine, esculin, PNPG, glucose fermentation and carbohydrate assimilation tests. Potassium gluconate assimilation and gelatin hydrolysis were positive for 5 and 4 isolates, respectively. StrainTypeMer showed the isolates from different patients were not closely related, but 2 from the same patient were indistinguishable. The estimated genome size was ~3.1 Mbp, with 66.1% G/C, and ~3523 coding genes. Potential virulence factors (BrkB and MviM), multidrug efflux systems (MdtABC-TolC and Bcr/CflA), and 1-2 intact prophages were identified. Genomic phylogenetic analysis with RAxML showed the OL isolates clustered separately from all known Ottowia spp. Conclusion. These OL isolates are fastidious, Gram-negative bacilli from clinical wound specimens, and are associated with dog bites. Genomic and 16S rRNA gene sequence analysis suggests these isolates constitute a novel species within the family Comamonadaceae.

Retrospective review of dog bites in pediatric patients

Purpose of Study Dog bites have historically been a common cause of pediatric emergency department (ED) visits. In June 2020 in the Journal of Pediatrics, 'Dog Bites in Children Surge during Coronavirus Disease-2019: A Case for Enhanced Protection' discussed an almost three-fold increase in dog bites treated in the ED since the beginning of the COVID-19 pandemic at an urban Children's Hospital in the Midwest. This study aimed to describe the epidemiology of dog bite ED visits and to evaluate changes in dog bite visits over 2019 (pre-COVID) and 2020 (during COVID). This study addressed two objectives: 1) To describe the epidemiology of dog bite related ED visits and admissions;2) To evaluate changes in the rate of dog bite ED visits during pre- Covid and during Covid. Methods Used This study reviewed 2 years (2019 and 2020) of dog bite visit data from the 'Children's Injury Database' (CID), our injury surveillance system of ED attended injuries. Descriptive statistical and epidemiologic analyses were conducted using Epi Info 7 (CDC). Statistical comparisons and analyses of continuous and categorical data were performed. Differences in proportions and T Test of means were reported with corresponding 95% Confidence Intervals (CI's). Summary of Results During the 2 year period, 522 dog bite cases were treated representing 1.7% of all injury visits. Gender analyses indicated a higher proportion of males vs females (53.6% vs 46.4%), respectively, overlap of exact CI's of proportions were observed. A higher proportion of white patients vs nonwhites among dog bite cases was observed (62.8% vs 37.2%), respectively, (no overlap of exact confidence intervals of proportions). This difference was also significant when comparing race proportions of dog bite visits to all other injury visits (62.8% vs 48.7%), respectively, difference of 14.1%, 95% CI (9.8, 18.2). Mean patient age was 6.1 yrs. Outcome metrics included patient disposition (3 categories): Admitted 57 (10.9%), Discharged 458 (87.7%), Other 7 (1.4%). Admitted patients were younger (statistically) 4.9 yrs vs 6.3 yrs, age difference -1.4 yrs 95% CI diff (-0.3, -2.5). Total length of stay for Admitted = 117 days (mean 2.1 days) and for Discharged mean hrs in the ED 3.7 (s.d. 8.7). Total charges were $2.6 million (mean = $4902, median $2043). The leading anatomic sites injured were head, face, and neck, all ages, (61.1%), but accounted for 79.8% for ages under 6 yrs. An increase in the rate of dog bite visits was detected during 2020 vs 2019, (20.4 per 1,000 injury visits vs 14.6 per 1,000 visits, rate difference = 5.8, 95% CI (3.4, 9.6). Conclusions The pandemic of COVID-19 with a national shel- #538 Figure 1 Overall CMV testing among failed hearing ter in place order was associated with more dog bite visits in the ED. 2020 had 20% fewer total injury visits than 2019, yet 10.5% higher number of dog bite visits. Dog bites are a significant cause of injury in children and result in costly visits seen in the ED. These data will support parental education on preventing dog bite injuries in children.

Paediatric dog-bites: Are 'pandemic puppies' a cause for concern?

Introduction: There has been a substantial increase in dog ownership during the COVID-19 pandemic, in part due to national lockdowns prompting many to seek canine companionship. Published studies from the US have associated this with increased paediatric presentations with dog-bites to the emergency department (ED). However, this has yet to be elucidated in the UK. Method: All attendances to ED and referrals to our regional paediatric plastic surgery service with paediatric dog-bites between 23/03/2020 and 01/06/2020 (UK national lockdown) were compared with the same period in 2019 (control). The location of bites and total ED attendances were also collected. Chi-squared test was used to determine statistical significance, p≤0.05 taken as significant. Results: Fewer overall paediatric attendances to ED were noted between the lockdown period compared to control (4429 vs 9620). Similarly, fewer children presented with dog-bites during lockdown compared to control (25 vs 45). Proportionally, this data represents 5.6 bites per 1,000 ED attendances during lockdown vs 4.7 during the control period (p=0.44). Facial bites were more common during lockdown accounting for 60% vs 47% in the control period (p=0.28). Conclusions: Despite reports of increased dog ownership, our findings do not demonstrate significantly more paediatric dog-bite presentations. Although not statistically significant, more facial bites were noted during lockdown. We speculate this may be due to parents presenting with self-perceived more 'serious' injuries. Thorough research and careful consideration are essential prior to bringing a new dog into a home with young children.

Canine-to-Human Transmission of Mycoplasma canis in the Central Nervous System.

Dog bites remain a common occurrence in our society, particularly in toddlers and small children under the age of 2. Injuries to the head and face, more common in younger children, can often lead to significant morbidity. Additionally, there continues to be considerable clinical equipoise for standardized post-dog bite injury management. Here, we present the only reported pediatric case in the literature of Mycoplasma canis-associated central nervous system (CNS) infection in an 11-month-old infant who sustained a dog bite to the calvarium. The prevalence of dog bites during the SARS-CoV-2 pandemic had interestingly tripled in number after stay-at-home orders in 1 particular pediatric emergency department in Colorado. This observation paired with advances in microbiological identification like MALDI-TOF (matrix-assisted laser desorption/ionization time-of-flight mass spectrometer) may lead to the identification of future cases of uniquely canine pathogens that play a role in human infection.

Consequences of COVID-19 Lockdown on Children and Their Pets: Dangerous Increase of Dog Bites among the Paediatric Population.

BACKGROUND: The SARS-CoV-2 pandemic has not only put our national health systems to the test, but it also notably hit the economy, the society and the psychology of the people. Our pets have been subjected to the pandemic related stress too. The aim of the study was to evaluate whether the stress induced on domestic dogs resulted in an increase of dog bites in the paediatric population. METHODS: A retrospective study was conducted on all patients admitted to our paediatric emergency department for dog bite from January 2014 and December 2020. We compared the total mean dog bites of the years 2014-2019 and the mean number per single month with the respective 2020 data. The bites were divided between bites from family dogs and bites from stranger dogs. Continuous data were analysed using single sample t test while categorical values with chi-squared test, considering statistically significant a p value < 0.05. RESULTS: From January 2014 to December 2019, we recorded a mean of 41 ± 5.9 dog bites (range: 30-46) of which a mean 13 ± 2.6 (range: 10-17) were due to family dogs (32%) and a mean of 28 ± 2.4 (range: 25-31) were due to stranger dogs (68%); the male-to-female ratio was 3:2 and 43% of the injuries concerned the head and face, 26% the lower limbs, 25% the upper limbs, 3% the genitalia and 3% the torso. From January 2020 to December 2020, 30 children were admitted for dog bites: 22 were from family dogs (73%) and 8 from stranger dogs (27%); the male-to-female ratio was 14:11 and 72% of the injuries concerned the head and face, 16% the upper limbs, 8% the lower limbs and 4% the torso. The 2020 data's higher number of family dog bites compared with the mean of those in the 2014-2019 period was statistically significant (p < 0.01) such as the 2020 data's lower number of stranger dog bites when compared with the mean number of stranger dog bites in the 2014-2019 period (p < 0.01). Between 2014 and 2019, a mean of 9 ± 2 (range: 6-12) of the wounds needed to be sutured (22%), while 32 ± 3 (range: 28-35) wounds were discharged after application of Steri Strips (78%). On the other hand, in 2020, 21 wounds needed to be sutured (70%), and 9 received just Steri Strips application (41%). The frequency distribution of the treatments required (stitches vs. Steri Strips) between the 2014 to 2019 period and the 2020 period was statistically significant (p < 0.0001). CONCLUSIONS: The number of family dog bites in children increased in 2020, especially during the lockdown period. Paediatricians should pay a lot of attention now more than ever to educate parents on the importance of always supervising children who are playing with dogs.