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37

Introduction

Incidents due to lesions caused by animals, aboveall those due to dog bites, represent an importantpublic health problem, with costs both in humanand health care terms because o the consequencesassociated with post-traumatic stress and trauma odierent levels o severity in the various countries othe world. Understanding o the phenomenon, ando the actors connected to these episodes, is therst step to prevent and limit these events.

Since 2009, in north east Italy and the countriesbordering it, rabies has re-emerged with a signicanteconomic impact on account o the measures thathave to be taken to prevent the inection romspreading. The study o morbidity deriving romlesions caused by animals, in particular dogs, andthe analysis o the site distribution o the events, cancontribute to the assessment o the risks connectedwith lesions caused by animals and to the planningo targeted interventions or prevention.

Given the absence o investigations into thephenomenon o animal lesions caused by animals

in the Province o Bolzano, in 2010 a studywas undertaken or the whole territory o theAutonomous Province o Bolzano (APB).

Materials and Methods

Type o investigation

An observational (cross-sectional) retrospectivestudy o the data or medical- veterinary surveillancewas carried out in the APB in 2010 in an areaincluding the our Health Districts o the Alto AdigePublic Health Service, corresponding to the territoryo the APB.

Data collection

As a source o data, the standardised reportquestionnaires compiled by the hospital emergencydepartments (HEDs) and the doctors o the provincewere used. These contain data or age, the sex o thepersons injured, the site and context o the eventand the type o animal involved.

In addition, other standardised questionnaires werecollected and analysed concerning the assessmento the dogs responsible or the bites by the veterinaryocers o the Veterinary Service o the Public Health

Service.To assess the context, the veterinary ocersused a standardised method or quantiying the

Veterinaria Italiana 2013, 49 (1), 37-50

Keywords

Bites,Cat,Dog,Dog aggression,Epidemiological survey,Lesions,Risk actors,Veterinary public health.

Summary

Lesions caused by animals, in particular by dogs, are a health issue to which public opinionoten reacts sensitively. To eectively manage and prevent these events, it is thereoreessential to evaluate the public health impact o this phenomenon and to identiy the mainconnected risk actors. The aim o the present survey in the Autonomous Province o Bolzanowas to collect various epidemiological variables helpul in understanding the problem atlocal level. The incidence and impact on Health Services o human lesions by several animalspecies or the year 2010 is presented, as well as a more detailed analysis o dog bites, giving aprole o the victims and o the animals involved. Dierent actors (geographical, contextual,seasonal and relational) that can be associated with episodes where dogs react aggressivelyto humans are illustrated. On the basis o the collected data, recommendations are given toprevent risk situations.

1 Alto Adige Public Health Service Veterinary Service, District o Bolzano,

via Laura Conti, 4 - 39100 Bolzano, Italy

[email protected] Regional Centre o Veterinary Epidemiology Giovanni Vincenzi

Istituto Zooproflattico Sperimentale delle Venezie, Viale dellUniversit, 10 - 35020 Legnaro, Padua, Italy

Giulia Morosetti1, Marica Toson2 & Christian Pier1

Lesions caused by animals in theAutonomous Province o South Tyrol in 2010:

Fact-fnding or prevention

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38 Veterinaria Italiana 2013, 49 (1), 37-50

greatest risk. A prole was given o the typicalcharacteristics o the victim, o the dog involved,and the context o the case.

The rates calculated are rough or specic rates ocumulative incidence, calculated as the number onew cases involving residents o the Alto Adige in 2010out o the number o inhabitants at the beginning othe year under consideration (healthy population atrisk). To measure the strength o association betweendichotomous variables, the odds ratio was calculatedwith an exact relative condence interval o 95%,while the Chi-square test was used to evaluate thesignicance o the association.

To make a comparison between the age distributiono the persons injured by dogs and those injured

by cats, the non-parametric Wilcoxon-Mann-Whitney test was used to compare the medians otwo independent samples. To establish the degreeo agreement between victim and master aboutthe real context o the bite, Cohens K-test wasconducted. To assess the trend or annual incidence,Cuzicks non-parametric test or trends on orderedgroups (1985) was used. For some percentages,the relative condence intervals (exact condenceintervals or binomial variables) was calculated,with the hypothesis that the cases observed are arepresentative sample o a more generic population.

Finally, or some quantitative variables, a ew indiceso synthesis were given, such as average, median,minimum, maximum and standard deviation (SD).

temperament and psychological balance o the dog,as well as the skill o its owner in managing it, with a

pre-established points scheme that made it possibleto place the cases in nine categories o possible dog-manager combinations (see also Table I ).

The data or the resident human population wasobtained rom the last survey, ASTAT 2009 (2). Dataor visits to the Public Health Service were kindlyprovided by the provincial epidemiological authority.

Defnition o case

All the episodes reported by the HEDs and by thedoctors o the province concerning visits by aperson or lesions caused by animals, regardless othe nature o the lesion (traumas, bites, scratches,bruises, etc.), between the 1st o January 2010and the 31st o December 2010 in the APB wereconsidered to be cases.

Statistical analysis

A picture o the phenomenon o lesions causedby animals was given or the province by meanso a descriptive analysis, and the data or theannual incidence o lesions caused by animals,

including those or dogs, was obtained. The site-time distribution o the events was analysed anddescribed to assess the areas and population at

Table I. Relative requency o attacking dog/owner type according to assessment o veterinary ocer.

TypeNumber of

assessments% of cases

1. Balanced dog. Ma naged corre ct ly: the reac tion o the dog i s un dersta nda ble and can be justifed by the context 127 55.0

2. Balanced dog: Management could be better, the owner needs to improve his/her skills 20 8.7

3. Balanced dog, however the owner is not able to manage the dog correctly 1 0.44. The owner is able to manage the dog, but the animal is scared/anxious/reactive 31 13.4

5. The owner needs to improve his/her skills and the dog is scared/anxious/reactive 40 17.3

6. The owner has no control over the dog and the animal is scared/anxious/reactive 3 1.3

7. Aggressive dog, however the owner has good control 0 0.0

8. Aggressive dog, the owner needs to improve his/her skills and management 5 2.2

9. Aggressive dog. The owner has no control over the animal. Retraining class is suggested. 4 1.7

Total 231 100.0

Table II. Distribution o total number o lesions according to animal species.

Animalspecies

Number oflesions

% oflesions

Lower lim95% C.I.

Upper lim95% C.I.

Dogs 390 84.8 81.1 87.9

Cats 52 11.3 8.6 14.6

Other animals 18* 3.9 2.4 6.3

Total 460 100.0

*Three snake bites and one bat bite among the lesions caused by other animals.

Table III. Distribution o total number o lesions according to residence

in South Tyrol.

Residence of injured person Number of lesions % of lesions

Resident in South Tyrol 397 86.3

Non-resident 63 13.7

Total 460 100.0

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39Veterinaria Italiana 2013, 49 (1), 37-50

Table VII it can be seen that animal lesions account

or a minimal number o visits to the Public Health

Service hospitals in the Health Districts o Merano,

Bressanone and Brunico compared to other causes

o visit, with the exclusion o the Bolzano Health

District, or which data are not available.

Periods o greatest impact

The peak o visits or medical treatment or lesions

caused by animals was ound to be in the summer

months (Figure 1).

Prognosis and severity o lesion

The prognosis was reported in 252 cases out o 460

visits (54.8%), with an average duration o recovery

o 7.9 days (SD 5.2646, Min 1 - Max 56, Median 7).In only eight out o 460 cases (1.74%) was hospital

admission necessary. O these, 5 were due to lesions

caused by dogs and three or viper bites.

Dogs were the animals most commonly involved

in severe lesion cases; unortunately, a detailed

description o the lesion was only occasionally

reported, making in-depth analysis impossible.

Sotware used

EPI Ino 3.5.1; Stata 9; Microsot Word, Excel; ESRIArcMap.

ResultsTables II to IV summarise the situation or thephenomenon o lesions caused by animals in theProvince o Bolzano. Dog lesions predominate overthose caused by other animal species, and mainlyinvolve residents.

Visits or medical treatment

Almost hal o the cases were treated by the BolzanoHealth District (Figure 1). The highest number o dogs

in the APB (n= 14,048, 41% o the dogs registered inthe provincial dog register) is also registered in thisdistrict.

The requency o visits or medical treatment orlesions caused by animals is described in Tables Vand VI. There were 398 visits to the HEDs (81.5%),while in 62 cases (13.5 %) the patient went to thegeneral practitioner surgeries o the province.

In the Merano Health District there was the highestproportion o visits to general practitioner surgeriescompared to HEDs, ollowed by Brunico, whilealmost all the reports o lesions caused by animalsin Bolzano and Bressanone come rom their HEDs.

With regard to the importance o lesions caused byanimals compared to other causes o accident, in

BZ

49%

ME

20%

BX

17%

BRU

14%

Figure 1. Distribution o animal lesion cases according to Health District.

Table IV. Distribution o number o lesions to residents by animal species.

Animal speciesNumber of

lesions% of

lesionsIncidence/100,000

residents (a)

Dogs 337 84.9 66.9

Cats 47 11.8 9.9

Other animals 13 3.3 2.6

Total 397 100.0 78(a) Incidence calculated on population resident in South Tyrol in 2010 =

503,399 inhabitants

Table V. Distribution by Health District and type o medical care visit.

Health DistrictNumber of visits to Hospital

Emergency Dept (HED)Number of visits to

General PractitionerTotal % of visits

% visits to District HED on totalnumber of visits to HED

Bolzano 211 15 226 49.1 53.0

Bressanone 71 8 79 17.2 17.8

Merano 65 25 90 19.6 16.3

Brunico 51 14 65 14.1 12.9

Total 398 62 460 100.0 100.0

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On average, the injured person was 39.7 years old,but there were cases o both very young childrenand very old people (SD 22.5350, Min 1-Max 88,Median 41, Mode 9).

Figure 3 shows that the age group most requentlyinjured by dogs was children rom 5 to 9 years old,with a slightly greater prevalence o emales.

Figure 4 shows the rate o incidence o dog lesionsor 2010. The age group with the highest percentageo individuals injured by animals is that o ages 5 to 9with an incidence rate o 129.6 cases per 100,000inhabitants.

For cats, most cases concern age groups over 22.The age o persons injured by dogs is signicantlydierent rom that o persons injured by cats (theWilcoxon-Mann-Whitney non-parametric test orcomparison between medians, median = 41 vs 50.5,P = 0.0015). Further aggregation o the age groupsgives the distribution o cases shown in Table IX.

It can be seen that although the total number olesions or minors is less than or adults, incidence inthe ormer remains the highest.

Characteristics o the injured person

As shown in Table VIII, there is not a greatdierence between the percentage o male andemale persons injured. I, however, the specieso the animal involved and the sex o the victim isconsidered, a signicant relationship with the sexo the person injured is revealed (Table I). Taking

the actor o sex into consideration, the odds obeing injured by a dog or men was ound to be1.87 (exact 95% C.I. 1.08 - 3.32, 2 = 5.57, P = 0.018).Women were shown to be twice as likely than mento be injured by a cat (n = 35 vs. n = 17, OR = 2.12,exact 95% C.I. 1.11 - 4.17, 2 = 6.01, P = 0.0142); inmost cases the victims were adult women.

The most serious cases o dog bites involved women.In ve cases, all due to dog bites (1.4%), hospitaladmission was necessary. In 4 o these the personadmitted to hospital was a woman. The age o all thewomen injured and admitted to hospital was above

60, while the man admitted was 26.In 24 cases (6.2%), the person injured resided outsidethe province.

0

10

20

30

40

50

60

70

January

February

March

April

May

June

July

August

September

October

November

December

Num

berofcases

Month

Figure 2. Seasonal pattern o animal lesions in South Tyrol(n=460).

Table VI. Distribution o visits to Hospital Emergency Departments byHealth District.

HealthDistrict

Number ofvisits to HED

% of visitsto HED (a)

Lower lim95% C.I.

Upper lim95% C.I.

Bolzano 211 93.4 89.3 96.2

Bressanone 71 89.9 81.0 95.5Merano 65 72.2 61.8 81.1

Brunico 51 78.5 66.5 87.7

Totale 398 81.5

(a) This percentage is calculated on the total number o medical care vi sits o eachhealth district.

Table VII. Distribution by reason or visit to Hospital EmergencyDepartments, Bolzano Health District excluded.

Reason for access Number %

Animal lesions 187 0.12%

Road accident 2,056 1.30%

Injury at workplace 6,936 4.50%

Domestic accident 11,691 7.50%

Violence by other person 551 0.40%

Sel- harm, attempted suicide 45 0.00%

Sports accident 11,152 7.20%

Skiing accident 2,897 1.90%

Injury at school 1,347 0.90%

Other type o accident 12,886 8.30%

Other symptoms 106,156 68.20%

Total 155,717 100,00%

Table VIII. Distribution o lesions according to gender o victim.

Gender Number oflesions

% oflesions

Lower lim95% C.I.

Upper lim95% C.I.

Male 224 48.7 44.1 53.4

Female 236 51.3 46.6 55.9

Total 460 100.0

Table IX. Distribution o number o lesions according to gender o victimand animal species.

Gender Dog Other species Total

Male 199 25 224

Female 191 45 236

Total 390 70 460


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the number o dogs in the relative district is similar,while in the Health District o Merano it is almosthal.

Geographical distribution

Figure 6 shows that the urban zones, in particularBolzano and its environs, have the greatestrequency o cases. In only 18 (4.6%) cases did thedogs owner reside outside the province.

Relationship o the injured person to the dogIn Table X it can be seen that in 41.7% o dog bitecases the dog was known by the victim and was

Analyses o cases o dog lesions

In 2010, 390 cases o lesions caused by dogs werereported in the APB, with an incidence o 66.9 per100,000 inhabitants. It was possible to establishthe trend over time only or the Health District oBolzano (Figure 5), in which a diminishing trendin annual incidence in the last 15 years can beobserved (number o cases o lesions out o themean population or the relative year). Cuzicks non-parametric test or trend on ordered groups (1985)shows a signicant decline in annual incidence over

time (z = -3.49, P > |z| = 0.000).In three Health Districts (Bolzano, Bressanone andBrunico) the proportion o biting dogs compared to

0

2

4

6

8

10

12

14

16

18

20

0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-745-9 15-19 25-29 35-39 45-49 55-59 65-69 75-79 80 and

over

Numberoflesioncases

Age class

Male Female

Figure 3. Absolute requency o dog lesions according to age group and gender o injured person (n=390).

36,7

129,6

66,8 68,1

95,4

64,5

50,6

34,5

70,677,2

68,1

88,2

49,9

68,1 70,6

50,9 53,0

0,0

20,0

40,0

60,0

80,0

100,0

120,0

140,0

0-4 5-9 10-14 15-19 20-24 25-29 30-34 34-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80 andover

Incidence

Age class

Figure 4. Age specic incidence o dog lesions (per 100,000 inhbts.). Resident cases (n=337).


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In 5 cases (1.4%) admission to hospital wasnecessary ater a dog bite. The breeds involved were:1 Rottweiler, 1 Collie, 2 mongrels and 1 o unknownbreed. In 4 o these 5 cases the sex o the dog wasknown and was male.

The average age o the dogs in the cases or which

the age was reported (n = 256) was 4.9 years(SD 3.396; Min 0 - Max 19; Median 4).

owned by the person bitten or had regular contactwith the injured person.

Characteristics o the dog

There were 32,236 dogs (Males = 17,462,

Females = 14,774) in the register at the beginningo the study. In the cases in which the dogs sexwas known (n = 292, 74.8%), signiicantly moremale dogs than emale dogs were involved: 215males (73.6%; 95% C.I. 68.2%-78.6%), 77 emales(26.4%; 95% C.I. 21.4%-31.8%). There was strongevidence o an association between the male sexo the dog and the greater possibility o a lesionto the person (OR 2.38, 95% C.I. 1.82-3.12, 2 MH44.95, P65) 57 14.6 55 61.2

Adults 247 63.3 206 65.7

Minors (

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to the categorisations o dog breeds established by

the ENCI (Italian Kennel Club), with the addition o

the group o mongrels (including unknown breeds)

and that o pit bulls.

Numerically the cases caused by mongrels (39.9%)

and sheepdogs (27.7%) were more requent(Figure 7). However, when the number o bite cases

are compared with the number o dogs o the same

breed recorded in the provincial dog register, the

breeds with the highest rate o risk are ound to be

the dachshunds and once again the sheepdogs,

ollowed by the pit bulls (Figure 8).

Type o breeds involved

In 328 cases the breed o the dog involved wasreported. The dogs that bit were grouped according

0 5 10 15 20 25 30 35 40 45

Greyhounds

Small Companion dogs

Hounds

Terriers

Spaniels/Retrievers

Pointers/Gun dogs

Primitive, Nordic Type

Mongrels, Non ENCI Breeds

Pinscher-Schnauzer-Mastis

Pitbulls

Sheepdogs

Dachshund

DogBreedGroups

% on total number of lesion cases

Figure 7. Relative requency o lesion cases according to dog breed group.

Greyhounds

Small Companion dogs

Hounds

Terriers

Spaniels/Retrievers

Pointers/Gun dogs

Primitive, Nordic Type

Mongrels, Non ENCI Breeds

Pinscher-Schnauzer-Mastis

Pitbulls

Sheepdogs

Dachshund

DogBreed

Groups

0 0,2 0,4 0,6 0,8 1 1,2 1,4 1,6 1,8 2

Risk Index

(% lesion caused by the breed group/% presence of the breed group

in the total dog population)

Figure 8. Lesion risk index o the diferent dog breed groups.

Table XI. Relationship between attacking dog and injured person.

Relationshipwith dog

Numberof cases

%Lower lim95% C.I.

Upper lim95% C.I.

Owner 24 9.9% 6.5% 14.4%

Regular contacts 77 31.8% 26.0% 38.1%

Unknown 141 58.3% 51.8% 64.5%

Total 242 100.0%


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generally slightly injured, while playing with the dog.In various cases the dog had reacted against beingdisturbed while being handled or had accidentlyinjured the person in charge o it while he/she wastrying to separate it rom another dog during a ght.An unknown person was more oten injured in the

context o the dog deending its territory, its owner,or the owners home or possessions. Frequentlycases were reported o an attack on persons walkingor running past or in reaction to an attempt by astranger to approach the dog.

Context o lesions to minors

With minors (

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a local level. The main aim was to prepare strategiesor the prevention o damage to persons and toproduce recommendations or better managemento animals kept as companion pets in the contexto the possible risk o transmission o rabies, whosepresence among wild animals had re-emerged in

the province since the end o 2009.With regard to the completeness o the data collected,it is possible that cases o less severe lesions treatedat home or by the general practitioner, less usedto notiying the veterinary authorities accordingto xed procedures, have escaped inclusion. Therewere also some cases involving non-resident personsor animals in which it was not possible to ollowup the animal. It also seems plausible that minorcases involving ones own dog or one belonging toriends or relations do not get reported to the HealthService. Also according to Fedele et al. (14) not all

cases o visits or medical treatment o dog lesionsare reported and very slight lesions are treated athome; according to Kahn et al. (18) and Schalamonet al. (27), ewer than 50% o dog bites are reported.

On the other hand, a actor contributing to thecompleteness o the reports in this survey may havebeen the reappearance o wild animal rabies in theprovince since 2009 and the campaign launchedbetween 2009-2010 to inorm the population aboutthe severity o the disease and the measures orvaccination and control. These may have inducedpersons with animal lesions to seek medical

treatment, even in minor cases.

Impact on the Health Service agencies

Apart rom a small number o serious cases, lesionscaused by animals rarely make hospital admissionnecessary (27). In the APB the rate o hospitalisationwas less than in other studies. Shelton (28) ound ahospitalisation rate ater a visit to the HED in Florida(USA) o 4.7%, while in this survey admission wasonly necessary or 1.74% o patients who visited theHealth Service because o lesions caused by animals.

Naturally the dierences may also be due to thedierent possibilities or access to treatment in thetwo territories studied.

Moreover, i only the cases concerning dogs areconsidered, requency o admission is even rarer(1.3%). Although biting is one o the normal ormso a dogs behaviour, lesions are not always causedby a bite. In most episodes, people visited theHealth Service or scratches or bruises (1, 6, 10, 23,26, 27, 31) and this was observed also in this study.In various cases the dog had simply played with theperson in a rather unrestrained way without biting,

causing haematomas or supercial grazes.It was not possible to analyse the type or severityo the lesions/traumas because o the sporadic

(Kappa = 0.816) and in the case in which the dogplayed (Kappa = 0.568) or was receiving ood(Kappa = 0.603). Little agreement is ound in othercontexts, in which the injured person reported acertain type o interaction (or example, handling,stroking) with the dog, while the dog owner gave a

dierent interpretation o what happened.

Veterinary aspects

Veterinary assessment o the dog responsible

or biting

The dog remained unknown/unascertainableby the veterinary ocer in 105 o the 390 cases(26.9%), (Figure 10).

For 231 cases, the veterinary ocers assessment was

available with the distribution shown in Table XIII.73 (31.6%) o the episodes could be attributed topoor management o the dog by its owner.

Anti-rabies vaccination

The dogs vaccination status was known in 64.1% othe lesion cases (n= 250). In 16 o these cases (6.4%)the dogs did not have a valid vaccination or had notbeen vaccinated.

DiscussionThis survey reers to the whole o 2010 and is part oa series o activities started by the Veterinary Serviceo the APB to better understand the phenomenono lesions rom animals, in particular rom dogs, at

27,4

39

16,2

21,8

0

5

10

15

20

25

30

35

40

45

BZ ME BX BR

Frequency

ofca

ses

Health District

Bolzano (BZ), Merano (ME), Bressanone (BX), Brunico (BR)

Figure 10. Proportion o cases where attacking dog remained unknownor untraceable in each health district.


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Health Service, unpublished). This corresponds to aman/dog ratio o 15.6:1.

The incidence o lesions or 2010 was 78.9 per 100,000inhabitants (urban and rural context combined),slightly higher than that ound by Ostanello et al.(22) in the urban context o Bologna, which was 58.4

per 100,000 inhabitants, with a man/dog ratio o19:1, but much lower than that observed by Matter(19) in Switzerland in 1996, in urban and rural areas,o 192.5 per 100,000 inhabitants, with a man/dogratio o 16:1, similar to the APB. The incidence olesions caused by cats in this survey was also muchlower than that ound in Switzerland by Matter (19)o 9.9 as opposed to 77.7 per 100,000 inhabitants.

Risk actors

There are limitations in the design o the study

on account o the lack o checks to establish theassociation between bites and various actors.However, or some variables a more detailed analysiswas possible and some results were ound to be inline with the ndings o other studies.

Age and sex o the injured person

With regard to the age o the person injured by a dog,the victims most requently involved are childrenunder the age o 10. This datum is conrmed invarious studies (14, 19, 27). According to Ostanello

et al. (22), the age group most aected, that is,children between the ages o 0 and 9, is also the oneat greatest risk rom bites to the ace.

In the APB, in severe cases o lesions caused by dogsand in injuries caused by cats, those most requentlyinvolved are elderly patients. Many authors agree onthe act that the victims who suer severe injuriesare most oten children and women, above allelderly women (1, 6, 10, 23, 26, 30).

The average age o those injured by a dog is lowerthan that o those injured by a cat both in this study

(39 vs. 49 years o age [ANOVA, P=0.001]) and in thato Ostanello et al. (22). These authors report that theage group with the highest incidence o dog lesionswas ages 20-29, while or cat lesions it was 60-69.Shelton (28) noted that injuries caused by cats wereconsiderably more requent in adult women andminors under the age o 20.

It is possible that the source o data infuences thedatum or the relative age o the victim. In act, it islikely that children are taken to the doctor in all caseswhile adults are more inclined to treat themselves athome in minor cases.

In this survey, keeping in mind the conoundingeect o age, there seems to be an associationbetween the sex o the person and the animal

compilation o the medical diagnoses on the reportorm. However, in the ew serious cases that occurredor which documentation was complete, the patientneeded long, complex treatment: in the 5 cases odog attacks with severe consequences, averagehospitalisation was 28 days.

The cost o medical treatment due to dog bitesshould not be underestimated. In addition to thedanger associated with rabies, these traumas arerequently a source o inection (9). Furthermore, ina great number o cases, as well as treatment, thepatient was given a prophylaxis against rabies andtetanus.

The indirect costs connected to these kinds oincident must also be considered. They concerntime o work, or o school in the case o minors(on average eight days). The costs deriving rompsychological trauma caused by reaction to the dogcannot be estimated.

Proportion o animal lesions in visits to

hospital emergency departments

From the data collected, it emerges that between0.15 and 0.3% o visits to the HEDs o Bolzano,Merano, Bressanone and Brunico were or lesionscaused by animals. Similar data or visits to HEDs wasnoted by Ostanello et al. (22) in the city o Bologna(0.21%) and by Matter (20) or the pediatric hospitalin Lucerne (0.36%).

The hospital o Bolzano receives the largest numbero cases o lesions rom animals, which in percentageterms make up 0.25% o the total number o visits tothe HED.

As also observed in Piedmont by Fedele et al.(14), most cases were reported to the veterinaryauthorities o the HEDs and only a small proportiono the visits concerned general practitioners or thePublic Health and Hygiene Services, although, asmentioned above, it is possible that not all the visitsto the services o the province were reported.

In comparison with other causes o visits due toaccidents to the Public Health Service, animallesions are among the least requent reasons whencompared to other types o accident (e.g. sportsaccidents, domestic accidents). Unortunatelydetailed inormation o this type is lacking or theDistrict o Bolzano, to which almost hal the reportedcases belong.

Incidence o lesions

The population o the APB is 503,399 inhabitants

(ASTAT 2010). At the beginning o 2010, in the APB32,236 dogs were registered in the dog registry (2010Annual Report o the Veterinary Service o the Public


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There are indications that some breeds tend tobe more dangerous on account o their geneticcharacteristics or because o the type o attack(11, 21, 29), in particular the sheepdog group(16): Alsatians, maremma sheepdogs and Belgiansheepdogs (7).

In the APB, mongrels are the most numerous typeo dog, so it is not surprising that they are the doggroup by ar the most requently involved in caseso lesions to persons. However, when the requencyo attacks by the various groups o dogs wascompared with the size o that group in the dogregister, other groups o breeds, not the mongrels,were ound to be o greater importance. Thesecertainly included some groups already consideredaggressive by public opinion, such as sheep dogsand the pinscher-schnauzer-masti group, but alsobreeds not generally considered dangerous, such as

dachshunds. When only the requency and not theseverity o the lesion are considered, in this surveythe latter group occupies rst place as an index orisk rom biting.

With regard to dachshunds, it is not surprising thatthe high risk index o 1.8 ound in this survey is similarto that ound by Cattarossi & Martuzzi (7) who putthe dachshund category, with a risk index o 1.47,in sixth place in their classication. In act, as theseauthors note, until a ew generations ago this breed,in common also with terriers, was used to hunt intotheir lair combative prey that the dog had to attack

and possibly kill without human intervention. Theyare thereore dogs that, as Notari & Goodwin (21)observe, are o medium-high aggressiveness, highreactivity and so potentially more inclined to bitethan other breeds.

In the APB, dachshunds are more popular andnumerous than terriers. Perhaps or this reason, theterrier group, although including highly reactivebreeds comparable to the dachshunds, were oundto be less requently involved in the cases o lesionsreported.

These data support the correctness o the decisionto abolish the regulations whose provisions includeda list o so-called dangerous dogs. Although insome breeds selective breeding may have aimedto produce individual dogs with strong reactivity,sense o territory, possessiveness, tenacity o biteand a general tendency to react to stimuli withoensive-deensive attacks (20), the concept o thedangerousness o breeds will certainly continue tobe the subject o extensive debate, as the variablesto be taken into account are not only the geneticand behavioural characteristics o the dog but manyother actors, including the individual characteristics

o each dog-manager pair. As De Keuster et al. (12)also underlined, the tendency to bite dependsnot just on genetics, but also on various actors

responsible or biting: compared to the emale sex,men appear at greater risk rom lesions caused bydogs, while women are at greater risk rom lesionscaused by cats. This observation is in line with thendings o Ostanello et al. (22), who describe cleardierences among the victims o lesions caused

by animals: a greater number o male patients areinjured by dogs, while injuries caused by cats morerequently concern women patients. Shelton (28), onthe other hand, noted a generally higher requencyo lesions among women, with an incidence per100,000 inhabitants o visits to the Public HealthService or bites o 103.6 or women compared to85.5 or men.

These results could depend on the act that in theAPB, the cat is usually kept as a companion animalby adult women and elderly women. The control andmanagement o dogs, on the other hand, is oten

delegated to male members o the amily, especially inthe case o dogs, which are more dicult to look ater.

Seasonality

As ound by other authors (14, 22, 28), the requencyo lesions peaks in summer when in the APB thereis more tourism and more outdoor recreationalactivity, and during which dogs are probably takenout more requently and or longer periods, witha greater chance o interacting with people andanimals.

Geography

In the 7,400 km2 territory o the APB, the greatestconcentration o cases o lesion occurs in the largepopulation centres (the communes o Bolzano,Appiano, Renon, Merano, Bressanone, Brunico andVipiteno). The problem is thereore primarily one opublic urban medical-veterinary health care.

The provincial capital Bolzano, a densely inhabitedurban area with 104,029 inhabitants and 4,550 dogs,is the commune with the greatest requency o lesions

caused by dogs (19% o the total) and a man/dog ratioo 23:1. It is probable that in urban environments,where the probability o man-dog interactions ismore requent and the areas o cohabitation smaller,people may run a greater risk o being injured byanimals than in a rural environment (22).

Typology o dog

In the APB the stray dog phenomenon is absent andwe consider the data or the typology o the dogpopulation registered in the present-day provincial

electronic dog registry system to be sucientlycomplete and representative o the local dogpopulation.


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Context

Interpretation o the context in which the dogsreaction occurred varies according to whether it isreported by the person who was the victim o theattack or the dogs manager. The dogs owner andthe injured person oten do not agree on how theevent happened. The closest agreement is in caseso lesions due to the intervention o a person toseparate two dogs ghting each other, where itis clear what happened. In many other cases thatwould seem to be the result o wrong or decientinterpretation o possible warning signals romthe dog, descriptions oten do not match: theinjured person states that he/she wanted to strokethe dog while the dogs manager believes theperson disturbed the dog. In particular, the signso aggressiveness o a rightened dog may be lessvisible and not interpreted correctly by the owner.

This is even more likely i the person is a stranger tothe dog (3).

Moreover, the context o the event would seem todier according to whether the person is amiliarwith or unknown to the dog. In the ormer case,there is a prevalence o cases o lesion during playor as a result o the dogs reaction to being handled(e.g. grooming o its coat), while in the latter case themost requent cases o attack regard actions takento deend its territory or attacks by an unattendeddog on persons walking or running past.

As well as the dierences connected with the dogsamiliarity with the injured person, the question othe latters age plays an important role. In variousstudies, and likewise in this survey, children areclearly ound to be at greater risk than adults.Although or Gershman et al. (16) most bites seem tobe inficted on people who are strangers to the dogsamily, or Schalamon et al. (27) most attacks by dogson children are by dogs known to them (73%), butnot living with them, caused by the child disturbingthe dog. According to De Keuster (12), 86% obites to children occur as a result o an interactioninitiated by the children. Various authors have notedthat children are bitten by a dog they know eitherduring play or when the dog is disturbed (1, 6, 10,23, 26, 27, 30).

Children and adolescents must thereore be taughtto correctly interpret particular signs, posturesand sounds o the animal, and to adopt sae ormso behaviour to avoid negative interactions. Thisshould be done under the constant supervision oan adult, with the main objective o guaranteeingthe wellbeing o both dog and child.

In Australia, programmes in schools teaching

children how to behave saely with dogs havesignicantly increased the adoption o protectiveorms o behaviour by the children involved in

connected to socialisation, education, physical andpsychological health, the behaviour o the victimand, according to the authors o this survey, alsothat o the owner. Lesions rom dogs must thereorealways be considered in the human socio-culturalcontext in which they occur.

Sex and age o the dog

Other variables that must certainly be taken intoconsideration in assessing the risk o biting are theanimals sex and age. Beaver (3) emphasises that non-neutered male dogs are involved considerably morerequently in problems arising rom aggressiveness,comprising more than hal o all cases described. Thisis also conrmed by Gershman et al. (16). Moreover,the dogs involved are generally young adults (4, 5).

In this survey, male adult dogs o about our years o

age are involved considerably more oten in cases olesions to persons than emale dogs.

Hence the importance o paying particular attentionto the socialisation and education o this categoryduring the period o its development, in particularduring puberty (6-18 months), especially in the caseo large dogs and/or dogs with high levels o arousal.It is precisely during adolescence that male dogsmay challenge the hierarchy within the amily-pack,adopt orms o behaviour or the deence o territory,and indulge in playul activity with strong physicalinteraction and competition with other males (3).

Place

Another infuential actor is the place in which theevent occurs. Over hal the events took place inpublic places. Various events occurred near or insideowners homes, but not inside the victims homes.It was noticed that dogs behave aggressively muchmore oten in the homes o their own amilies,in their gardens or yards, or in the immediateneighbourhood (1, 6, 10, 23, 26, 27, 30). For DeKeuster (12), a small number o cases (9%) occur in

public parks; most o these incidents occur becausethe dog was not adequately controlled (51%) orwandered unattended near its own home (31%),whereas more than hal o dog bites happenedwhile it was accompanied on walks along streetsand roads and 30% on the private property o theamily where the dog lives.

This means various cases o lesion could be avoidedby taking into account the territorial and deensivebehaviour o the dog, making sure it cannot cross theboundaries o its owners property, and preventingit entering areas people pass through or that give

access to public places, or else by ensuring that thedog is adequately supervised in areas in which it islet o the lead.


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to be o primary importance to consult expertswhen choosing the breed and type o dog. Thischoice should be suited to the amily context and tothe puppys style o lie and socialisation.

Many lesions occur because o the owners poormanagement o the dog or because the dog iskept in conditions that cause it rustration or evenmake it eel unwell. It is necessary to study ways oinorming/educating that enable owners to managetheir dogs correctly.

It would also seem important to inorm the publicabout illegal practices and the risks o buyingpuppies rom unscrupulous sellers. These animalscan develop behavioural pathologies, oten seriousones, deriving rom adoption too early and rominsucient intra- and interspecic socialisation intheir period o development.

It is necessary to underline the importance opromoting high quality dog breeding, with asuitable choice o breeding partners, not only rom aphysical-morphological point o view, but also romone o balance o character.

In addition, the need must be stressed or adequatetraining or health care workers and those workingin the dog training sector, and or opportunitiesor the exchange o experiences acquired in thiseld, with an integrated multidisciplinary approachto guarantee the fow o inormation, suitabletreatment with prophylactic human and animal

vaccination in the case o lesions, and the adoptiono techniques or the assessment o dog behaviour.

In organising the presence o sta or accidentand HEDs and or veterinary controls on animalsresponsible or bites, the seasonal nature o thephenomenon, typically associated with summer,should be kept in mind.

In areas in which wild animal rabies is present, itis necessary to stress the importance o raisingawareness among the population about going tothe doctor and o ensuring the active availability o

anti-rabies and anti-tetanus vaccinations.

Acknowledgements

This study would not have been possible withoutthe active collaboration in the recording andcommunication o the cases occurring in the APBo the doctors and nursing sta o the HEDs, o theprovincial general practitioners, and o the veterinaryocials and technical sta o the our centres o theveterinary services o the Public Health Service. Theauthors would like to thank all o the above. They

would also like to thank the Provincial Institute oStatistics (ASTAT) and the provincial epidemiologicalobservatory or the data they have kindly provided.

preventive activities compared to groups nottargeted by such activities (30). The decision tobring a dog into the amily must also be careullyconsidered and must not be made just to satisy theincessant requests o the children. In any case, thepotential benets connected with the presence o a

dog on the psycho-emotional development o thechild must be set against its possible costs, includingthe risk o lesions. Schalamon et al. (27) suggest, orexample, waiting until school age is reached beoreadmitting a dog into the amily.

Assessment o the dangerousness o dogs

In a territory where wild animal rabies is present, theobservation o dogs is clearly o primary importanceor keeping this pathology under surveillance.However, in uture, veterinary assessment must

increasingly take into account aspects that arenot strictly clinical but are connected with thebehavioural equilibrium o the dog and the way it ismanaged by the person in charge o it.

In 2010, or the rst time an assessment orm or useby veterinary ocers was introduced in the APB. Tocreate a data-collection tool that was simple to usein day-to-day activities, it was necessary to strikea compromise between the need to simpliy theprocedure as much as possible and at the same timeto objectively collect inormation that was useulor assessing the animal responsible or biting.

Although there are still many diculties in makinga satisactory assessment o behavior and context,data seem to indicate that most lesions occur not somuch because o the dogs behavioural problems butbecause o deciencies in the training/managemento the animal by its owner.

Conclusions

On the basis o the results obtained by this surveyand in order to prevent, as ar as possible, cases olesions to people by animals, in particular dogs,

the ollowing recommendations are considerednecessary:

Surveillance o the phenomenon is essential and thefow o inormation between doctor and veterinaryocer must be improved and coordinated.

Particular attention must be given to makinginteractions between children and dogs sae. Itseems essential or the latter to be taught by adults,themselves well-inormed, to respect the spaceand needs o the dog and o companion animals ingeneral.

Given how easy it is or some dog breeds, originallyselected or utilitarian purposes, to succeed inbecoming popular and widespread, it would seem


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