Animals are an integral part of the lives of many Americans. An estimated 39% of United States households include ≥ 1 dog, and 33% include ≥ 1 cat.1 Many occupations and certain hobbies also put individuals at increased risk of injury from animals. With numerous potential exposures, animal bites continue to be a major public health concern and a burden on the health-care system.2
In humans, consequences of animal bites include physical and emotional trauma, pain, infection, possible rabies exposure, and, rarely, death.3 Animal bites may also require emergency department visits, hospitalization, rabies PEP administration, and other costly health-care utilization.4–11 Dog bite injuries are associated with an estimated mean lifetime medical cost, including treatment and rehabilitation, of > $630 for an emergency department visit where the patient is released after treatment and > $18,000 for hospitalization.5,12 The aggregated annual cost of dog bite–related hospitalizations in the United States is approximately $53.9 million.5
Animal bite surveillance is an important public health function. Monitoring the burden of animal bites across a population and within various subpopulations informs targeted interventions. However, many animal bites are not reported to appropriate agencies.4,13–15 Like many states, North Carolina does not have a statewide system for reporting animal bites; however, emergency department visit data provide an alternative and, in some ways, superior means of examining the burden of animal bites.16,17
Prior studies5,9,11,18–20 have used the ICD-9-CM E-code, E906.0, to identify emergency department visits for dog bites. However, to our knowledge, no previous studies have used additional E-codes to identify emergency department visits for other animal bites together with a keyword search of emergency department visit chief complaints and triage notes to identify additional animal bite–related emergency department visits not assigned a bite-related E-code. The additional E-codes, chief complaints, and triage notes can provide more accurate bite incidence rates and, for the first time on a statewide level, emergency department visit incidence rates specific to bites from various animal species.
Public health officials are often interested in surveillance of rabies PEP use. However, in many states, rabies PEP administration is not reportable. Therefore, emergency department visit data may provide useful information regarding rabies PEP use.
The purpose of the study reported here was to use data from a statewide, population-based emergency department visit surveillance system to determine the incidence of animal bites among humans in North Carolina; to further assess these rates on the basis of age, sex, urbanicity, biting species, and month for selected species; and to describe patient and emergency department visit characteristics, including the use of rabies PEP.
Materials and Methods
The Institutional Review Boards of the University of North Carolina at Chapel Hill and the North Carolina Division of Public Health approved this study.
Dataset background and creation—The NC DETECT, the source of emergency department visit data for this study, is a statewide, population-based, syndromic surveillance system created by the North Carolina Division of Public Health in collaboration with the Carolina Center for Health Informatics in the Department of Emergency Medicine at the University of North Carolina at Chapel Hill.21 From 2008 to 2010, 108 to 113 of the 114 acute-care hospitals in North Carolina submitted emergency department visit data to NC DETECT. As of 2008, NC DETECT included information for > 99% of emergency department visits in North Carolina.
Emergency department visits made by North Carolina residents from January 1, 2008, through December 31, 2010, and included in NC DETECT were eligible for inclusion. North Carolina residency was determined on the basis of the patient's self-reported home county and ZIP code. Emergency department visits were included in the dataset only once. Eligible visits that met ≥ 1 of the following criteria were included: contained E-code E906.022 (dog bite) or E-code E906.1 (rat bite); contained E-code E906.3 (bite from other animal except arthropod) and was determined to be a mammalian or unidentified animal bite upon review of the chief complaint and triage note; contained E-code E906.5 (bite from unspecified animal) and was determined to be a mammalian or unidentified animal bite upon review of the chief complaint and triage note; or included a chief complaint or triage note that indicated a mammalian or unidentified animal bite, cat scratch, or bat scratch, but an animal bite E-code was not present. Emergency department visits with chief complaints or triage notes indicating cat or bat scratches were counted together with bites, as in previous research,23,24 because of the difficulty in distinguishing bites from scratches by these species.
The following types of visits were not included in the dataset: visits with chief complaints and triage notes indicating bat exposure but no bite or scratch; visits because of cat scratch fever (ie, disease caused by Bartonella henselae) without mention of a cat scratch or bite in the chief complaint or triage note and for which a bite E-code was not assigned; visits assigned a rabies-related E-code (V01.5 and V04.5) without an animal bite E-code, bite-related chief complaint, and bite-related triage note; and visits related to bites received from humans.
Recheck visits by a patient to the same emergency department or an emergency department in the same health-care system could be identified through a masked identification number, but recheck visits to a different emergency department or an emergency department outside the health-care system could not be identified. Visits to an emergency department in the same health-care system were considered the equivalent of visits to the same emergency department.
Dataset for incident animal bite–related emergency department visit analysis—Each patient's first animal bite–related emergency department visit in calendar time was considered an incident visit, with the exception of recheck visits that occurred in January 2008 (n = 11; these were included in total animal bite-related visits but excluded from the incident visit dataset). A recheck visit was defined as one that occurred ≤ 30 days from an incident visit. The first visit to occur > 30 days after the most recent incident visit was considered another incident visit.
On the basis of E-codes, chief complaints, and triage notes, each visit was individually coded according to the biting animal species. Bites from wildlife included a bat bite or scratch or a bite from one of the following animals: raccoon, squirrel, chipmunk, fox, opossum, beaver, groundhog or woodchuck, prairie dog, mole, skunk, bear, coyote, wolf, otter, or hedgehog.
Data analysis—Incidence rates of animal bite–related emergency department visits were calculated with person-time denominators from the US Census Bureau 2008–2010 Intercensal Population Estimates for North Carolina.25 Incidence rates and 95% CIs were calculated over the 3-year period and within yearly and monthly intervals for the entire state and by sex, age group, rural or urban residence, and biting animal species, with age adjustment to the US Census Bureau 2008 Intercensal Population Estimates for North Carolina by 5-year age groups. Rate differences and 95% CIs were calculated with a statistical spreadsheet.a Rural versus urban residence, determined on the basis of self-reported county of residence, was classified as a dichotomous variable in which 85 of the 100 North Carolina counties were categorized as rural and 15 were categorized as urban.26
For cross-sectional analysis, frequencies and percentages of incident animal bite–related emergency department visit and patient characteristics were assessed. Animal bite injuries were examined on the basis of ICD-9-CM diagnosis code group.22 Incident visits during which rabies PEP was administered were identified with the ICD-9-CM procedure code V04.5.
Results
Overview of animal bite–related emergency department visits—From 2008 through 2010, 38,479 patients in North Carolina made 42,614 animal bite–related emergency department visits, or approximately 0.3% of the > 14 million emergency department visits in the state. These visits were summarized as follows: E-code E906.0 (dog bite; n = 26,353), E-code E906.1 (rat bite; 213), E-code E906.3 (bite from other animal except arthropod) with subsequent classification as a mammalian or unidentified animal bite upon review of the chief complaint and triage note (5,606), E-code E906.5 (bite from unspecified animal) with subsequent classification as a mammalian or unidentified animal bite upon review of the chief complaint and triage note (771), or visits for which the chief complaint or triage note indicated a mammalian or unidentified animal bite, cat scratch, or bat scratch, but an animal bite E-code was not present (9,671). In total, 3,313 of 38,479 (8.6%) patients made animal bite–related recheck visits to the same emergency department. Of these patients, 2,724 (82.2%) made 2, 421 (12.7%) made 3, and 168 (5.1%) made ≥ 4 recheck visits.
Of 38,971 incident animal bite–related emergency department visits during the study period, 25,054 (64.3%) were coded for dog bite, 211 (0.5%) for rat bite, 5,129 (13.2%) for bite from another animal (except arthropod), and 722 (1.9%) for bite from an unspecified animal. The remaining 7,855 (20.2%) incident visits had animal bite indicated in the chief complaint or triage note but did not have a corresponding E-code. Of these 7,855 visits, most involved a dog bite (n = 4,315), cat bite or scratch (1,801), or unidentified animal bite (1,381).
Incidence rate of animal bite– related emergency department visits—The statewide incidence rate of animal bite–related emergency department visits remained approximately constant over the study period: 135/100,000 person-years (95% CI, 132/100,000 person-years to 137/100,000 person-years) in 2008 and 141/100,000 person-years (95% CI, 139/100,000 person-years to 144/100,000 person-years) in 2010. Although differences among groups were not evaluated statistically, incidence rates were highest for children < 10 years of age, after which the rate declined with age overall (Table 1). The incidence rates for males and females were similar.
Animal bite–related emergency department visit incidence rates in North Carolina by patient age group, patient sex, and biting animal species according to NC DETECT data from 2008 through 2010.
| Variable | No. of emergency department visits for animal bite | Person-years | Incidence rate per 100,000 person-years (95% CI) |
|---|---|---|---|
| Patient age group (y) | |||
| 0–4 | 3,827 | 1,897,515 | 201.7 (195.3–208.1) |
| 5–9 | 4,405 | 1,888,142 | 233.3 (226.4–240.2) |
| 10–14 | 3,338 | 1,873,179 | 178.2 (172.2–184.2) |
| 15–19 | 2,504 | 1,977,678 | 126.6 (121.7–131.6) |
| 20–24 | 2,849 | 1,956,315 | 145.6 (140.3–151.0) |
| 25–29 | 2,776 | 1,859,107 | 149.3 (143.8–154.9) |
| 30–34 | 2,442 | 1,853,649 | 131.7 (126.5–137.0) |
| 35–39 | 2,411 | 2,004,414 | 120.3 (115.5–125.1) |
| 40–44 | 2,470 | 2,002,900 | 123.3 (118.5–128.2) |
| 45–49 | 2,700 | 2,083,789 | 129.6 (124.7–134.5) |
| 50–54 | 2,387 | 1,979,368 | 120.6 (115.8–125.4) |
| 55–59 | 1,915 | 1,773,231 | 108.0 (103.2–112.8) |
| 60–64 | 1,503 | 1,553,499 | 96.8 (91.9–101.6) |
| 65–69 | 1,143 | 1,166,162 | 98.0 (92.3–103.7) |
| 70–74 | 812 | 867,916 | 93.6 (87.1–100.0) |
| 75–79 | 642 | 663,229 | 96.8 (89.3–104.3) |
| > 79 | 842 | 920,480 | 91.5 (85.3–97.7) |
| Not reported | 5 | — | — |
| Total | 38,971 | — | — |
| Patient sex | |||
| Male | 19,382 | 13,802,570 | 140.4 (138.4–142.4) |
| Female | 19,583 | 14,518,003 | 134.9 (133.0–136.8) |
| Not reported | 6 | — | — |
| Total | 38,971 | — | — |
| Biting animal | |||
| Dog | 29,586 | 28,320,573 | 104.5 (103.3–105.7) |
| Cat | 5,314 | 28,320,573 | 18.8 (18.3–19.3) |
| Wildlife* | 698 | 28,320,573 | 2.5 (2.3–2.6) |
| Equid | 110 | 28,320,573 | 0.39 (0.32–0.46) |
| Swine or small ruminant (sheep or goat) | 32 | 28,320,573 | 0.11 (0.07–0.15) |
| Other small animals and rodents† | 433 | 28,320,573 | 1.5 (1.4–1.7) |
| Other animals‡ | 2,805 | 28,320,573 | 9.9 (9.5–10.3) |
| Total§ | 38,978 | — | — |
Cat or bat scratches were counted together with bites because of the difficulty in distinguishing bites from scratches by these species.
Includes bat, raccoon, squirrel, chipmunk, fox, opossum, and other wildlife species.
Includes rat, mouse, rabbit, hamster, guinea pig, gerbil, ferret, and other rodent.
Includes unidentified animal, nonhuman primate, and other animal.
Total is > 38,971 because some patients were evaluated for animal bites from multiple species.
— = Not applicable.
The incidence of dog bite–related emergency department visits was 104.5/100,000 person-years, whereas that for other mammalian species ranged from 0.11/100,000 person-years to 18.8/100,000 person-years (Table 1). The pattern of dog bite–related visit incidence versus age group mirrored that for all bites, with the highest incidence in children 5 to 9 years of age (200.9/100,000 person-years [95% CI, 194.5/100,000 person-years to 207.3/100,000 person-years]; Figure 1). The incidence of dog bite–related visits for males and females was 115/100,000 person-years and 95/100,000 person-years, respectively, yielding a rate difference of 20/100,000 person-years (95% CI, 17/100,000 person-years to 22/100,000 person-years).
Incidence rates for animal bite–related emergency department visits among humans in North Carolina by patient age group and biting animal species (dog [dashed line], cat [dotted line], or other mammal [solid line]). Values were calculated on the basis of NC DETECT data from 2008 through 2010. Vertical lines represent 95% CIs.
Citation: Journal of the American Veterinary Medical Association 244, 5; 10.2460/javma.244.5.597
Emergency department visits related to cat bites and scratches were the next most common, with an overall incidence rate of 18.8/100,000 person-years (Table 1). The incidence was 32.0/100,000 person-years (95% CI, 28.4/100,000 person-years to 35.7/100,000 person-years) among adults > 79 years of age and 25.6/100,000 person-years (95% CI, 21.8/100,000 person-years to 29.5/100,000 person-years) among those 75 to 79 years of age (Figure 1). The incidence of cat bite or scratch–related visits for females was 26/100,000 person-years, and that for males was 12/100,000 person-years, with a rate difference of 14/100,000 person-years (95% CI, 13/100,000 person-years to 15/100,000 person-years).
The incidence of emergency department visits for dog bites, cat bites or scratches, and bites from other animals (including those categorized as wildlife, equids, swine or small ruminants, other small animals and rodents, or other) generally followed a seasonal pattern, with an apparent increase in the spring and summer and decrease through the fall and winter (Figure 2). This pattern was especially prominent for dog bite–related visits.
Incidence rates for animal bite–related emergency department visits among humans in North Carolina by month and year of occurrence and biting animal species. See Figure 1 for key.
Citation: Journal of the American Veterinary Medical Association 244, 5; 10.2460/javma.244.5.597
The age-adjusted incidence of animal bite–related emergency department visits in rural counties was 141.2/100,000 person-years, compared with 122.4/100,000 person-years in urban counties (Table 2).
Age-adjusted incidence rates and rate differences for animal bite–related emergency department visits in North Carolina by residence setting according to NC DETECT data from 2008 through 2010.
| Residence setting | No. of emergency department visits for animal bite | Person-years | Age-adjusted incidence rate* per 100,000 person-years (95% CI) | Age-adjusted rate difference per 100,000 person-years (95% CI) |
|---|---|---|---|---|
| Urban | 17,620 | 14,268,735 | 122.4 (120.6–124.2) | — |
| Rural | 19,553 | 14,051,838 | 141.2 (139.2–143.1) | 18.8 (16.1–21.5) |
Residence setting type was determined on the basis of the self-reported county of residence of the patient. Analysis excludes 1,798 of 38,971 incident visits for which age or county were not reported.
Age-adjusted incidence rate was standardized to the 2008 US Census Intercensal Population Estimate for North Carolina by the following age groups (in years): 0 to 4, 5 to 9, 10 to 14, 15 to 19, 20 to 24, 25 to 29, 30 to 34, 35 to 39, 40 to 44, 45 to 49, 50 to 54, 55 to 59, 60 to 64, 65 to 70, 70 to 74, 75 to 79, and > 79.
— = Not applicable (referent category).
Cross-sectional evaluation of incident animal bite–related emergency department visits—Among North Carolina residents with an incident animal bite– related emergency department visit from 2008 to 2010, the median age was 29 years (range, 0 to 99 years; mean, 32; SD, 22). Of 38,971 incident visits, 11,570 (29.7%) were made by children ≤ 14 years old (Table 1). Similar numbers of incident animal bite–related visits were made by males and females. Patients from rural counties made 19,555 (50.2%) of these visits, while 17,623 (45.2%) were made by patients from urban counties and 1,793 (4.6%) did not specify a county.
In 35,297 (90.6%) incident animal bite emergency department visits, the patient was discharged, whereas in 1,091 (2.8%), the patient was hospitalized. Of 1,091 hospitalizations, 628 (57.6%) were associated with dog bites, 307 (28.1%) with cat bites or scratches, and 156 (14.3%) with other animal bites. Other visits ended with patients leaving against or without medical advice (882 [2.3%]), transfer to another facility (293 [0.8%]), unknown disposition (124 [0.3%]), other outcome, including death (102 [0.3%]), or observation (25 [0.1%]); 1,157 (3.0%) incident visits had disposition information missing. Fewer than 10 patients were reported to have died. However, identifying information was not available for death certificate verification.
Rabies PEP was administered during 1,664 of 38,971 (4.3%) incident animal bite–related emergency department visits. Among the 698 emergency department visits for a wildlife bite, rabies PEP was administered at 234 (33.5%) visits. Rabies PEP was administered at 379 of 5,314 (7.1%) cat bite or scratch-related visits and at 839 of 29,586 (2.8%) dog bite–related ED visits.
Among those with an incident animal bite emergency department visit, the highest frequencies of ICD-9-CM diagnosis codes for skin or subcutaneous tissue infections were in adults 35 to 69 years of age (Table 3). These differences were not evaluated statistically. Skin or subcutaneous tissue infection was diagnosed in 796 of 29,586 (2.7%) dog bite–related visits and 898 of 5,314 (16.9%) cat bite or scratch–related visits, resulting in a prevalence difference of 14.2% (95% CI, 13% to 15%). Wounds to the head, neck, or face were recorded in 6,304 animal bite– related visits, 1,931 (30.6%) of which were made by 0 to 4 year olds and 1,456 (23.1%) of which were made by 5 to 9 year olds. Of the 6,304 visits for head, neck, or face wounds, 5,961 (94.6%) were associated with dog bites, 163 (2.6%) with cat bites or scratches, and 180 (2.9%) with other animal bites. Of 54 animal bite–related emergency department visits that included a diagnosis of skull fracture, 19 (35.2%) were made by 0- to 4-year-old children, and 53 (98.1%) involved dog bites.
Animal bite injuries diagnosed during 38,971 incident animal bite–related emergency department visits according to NC DETECT data from 2008 through 2010.
| Patient age group (y) | Infection of skin, subcutaneous tissue, or both* | Wounds to head, face, or neck† | Wounds to upper limbs‡ | Wounds to hands§ | Wounds to lower limbs‖ | Skull fracture¶# |
|---|---|---|---|---|---|---|
| 0–4 | 73 (3.6) | 1,931 (30.6) | 588 (4.1) | 357 (3.7) | 171 (2.8) | 19 (35.2) |
| 5–9 | 55 (2.7) | 1,456 (23.1) | 1,016 (7.1) | 472 (4.9) | 612 (10.1) | < 10 (< 18.5) |
| 10–14 | 56 (2.7) | 675 (10.7) | 917 (6.4) | 498 (5.1) | 732 (12.1) | < 10 (< 18.5) |
| 15–19 | 53 (2.6) | 318 (5.0) | 848 (5.9) | 548 (5.7) | 495 (8.2) | < 10 (< 18.5) |
| 20–24 | 117 (5.7) | 307 (4.9) | 1,175 (8.2) | 817 (8.4) | 488 (8.1) | < 10 (< 18.5) |
| 25–29 | 105 (5.1) | 282 (4.5) | 1,119 (7.8) | 802 (8.3) | 495 (8.2) | < 10 (< 18.5) |
| 30–34 | 116 (5.7) | 193 (3.1) | 1,079 (7.5) | 722 (7.4) | 416 (6.9) | < 10 (< 18.5) |
| 35–39 | 162 (7.9) | 204 (3.2) | 1,038 (7.2) | 699 (7.2) | 410 (6.8) | < 10 (< 18.5) |
| 40–44 | 158 (7.7) | 211 (3.3) | 1,086 (7.5) | 752 (7.8) | 430 (7.1) | < 10 (< 18.5) |
| 45–49 | 215 (10.5) | 237 (3.8) | 1,183 (8.2) | 830 (8.6) | 442 (7.3) | < 10 (< 18.5) |
| 50–54 | 186 (9.1) | 166 (2.6) | 1,039 (7.2) | 738 (7.6) | 395 (6.5) | < 10 (< 18.5) |
| 55–59 | 161 (7.9) | 127 (2.0) | 920 (6.4) | 676 (7.0) | 284 (4.7) | < 10 (< 18.5) |
| 60–64 | 145 (7.1) | 73 (1.2) | 723 (5.0) | 536 (5.5) | 230 (3.8) | 0 (0) |
| 65–69 | 141 (6.9) | 53 (0.8) | 555 (3.9) | 415 (4.3) | 145 (2.4) | < 10 (< 18.5) |
| 70–74 | 95 (4.6) | 40 (0.6) | 395 (2.7) | 303 (3.1) | 112 (1.8) | 0 (0) |
| 75–79 | 74 (3.6) | 14 (0.2) | 344 (2.4) | 248 (2.6) | 78 (1.3) | 0 (0) |
| > 79 | 136 (6.6) | 17 (0.3) | 379 (2.6) | 282 (2.9) | 123 (2.0) | 0 (0) |
| Total | 2,048 | 6,304 | 14,404 | 9,695 | 6,058 | 54 |
Injuries were grouped on the basis of ICD-9-CM diagnosis codes; data are reported as number (%). Some patients had multiple injury types, and some visits did not include codes that allowed injury classification.
Includes codes 681 (cellulitis and abscess of finger and toe), 682 (other cellulitis and abscess), 684 (impetigo), and 686 (other local infections of skin and subcutaneous tissue).
Includes codes 870 (open wound of ocular adnexa), 871 (eyeball), 872 (ear), 873 (head), and 874 (neck).
Includes codes 880 to 887 (open wound of upper limb).
Includes codes 882 (open wound of hand except fingers alone), 883 (open wound of fingers), 885 (traumatic amputation of thumb), and 886 (traumatic amputation of other fingers).
Includes codes 890 to 897 (open wound of lower limb).
Includes codes 800 to 804 (skull fracture).
To maintain confidentiality, cells with values > 0 and < 10 are not enumerated.
Discussion
In the present study, animal bite–related visits accounted for 42,614 of > 14 million (approx 0.3%) emergency department visits in North Carolina throughout the 3-year study period, a similar but slightly higher proportion than the 7,035 of 4,382,051 (0.2%) emergency department visits in North Carolina related to cardiac arrest in 2009.21 In other studies,5,12 investigators found that from 2008 through 2010, dog bite injuries were associated with an estimated mean lifetime medical cost > $630 for an emergency department visit followed by patient discharge and > $18,000 for hospitalization.
By the age of 10, a child in North Carolina had a 1 in 50 risk of dog bite injury requiring an emergency department visit. This finding may be related to the physical stature of children and their behavior around dogs4 as well as the health-care–seeking behavior of guardians. Although differences among groups were not evaluated statistically, rates of incident animal bite– related emergency department visits were highest for children ≤ 14 years old, ranging from 178.2/100,000 person-years to 233.3/100,000 person-years, whereas rates of 91.5/100,000 person-years to 149.3/100,000 person-years were found for other age groups.
To our knowledge, the present study was the first to examine the statewide incidence of cat bite or scratch–related emergency department visits. A North Carolinian had a 1 in 60 lifetime risk of cat bite or scratch injury resulting in an emergency department visit. Although individuals > 79 years old had the lowest animal bite incidence in this study overall, the highest incidence of cat bite– or scratch–related emergency department visits was found for this same age group. Although ownership of or exposure to cats was not investigated, these factors may have contributed to this result, together with increased skin fragility and decreased motor skills in the elderly.27 It is also possible that individuals > 79 years of age may have been more likely to seek emergency department care for cat bites and scratches than were members of other age groups.
Rabies PEP was administered during 1,664 of 38,971 (4.3%) incident animal bite–related emergency department visits in North Carolina during the study period. Further studies are warranted to determine whether emergency department data for rabies PEP may potentially be useful for surveillance purposes in states where rabies PEP use is not reportable.
The present study had several limitations. The study included data from North Carolina only; however, North Carolina is the 10th largest state on the basis of population and contains an approximately equal distribution of rural and urban populations. Therefore, these findings may be applicable to similar states and to the nation. Additionally, the rates presented were population based and did not rely on complex sampling methods for estimation. Because only 3 years of emergency department visit data were evaluated, it was difficult to assess changes over time. Finally, medical record review was not performed to verify E-coding, chief complaints, or triage notes.
Animal bites, specifically dog and cat bites, are typically monitored and prevention efforts undertaken at state and local levels. The present study showed that statewide emergency department syndromic surveillance data can be used for other public health initiatives without creating an additional burden for data providers. Monitoring species-specific bite incidence across the state and in various subpopulations may provide valuable insight for public health veterinarians, and findings may be used to renew support and target efforts for animal bite prevention.
Our results suggested that dog bite prevention efforts in North Carolina should be directed at children ≤ 14 years of age, particularly during the spring months. Targeted interventions could be made in schools and day cares.28 Dissemination of bite prevention education materials at the point of sale of animals should be encouraged, specifically for animals adopted from shelters and humane societies or purchased from breeders or pet stores.28 Education on avoidance of cat bites and scratches is also important, particularly among elderly persons, for whom targeted interventions could be made through church groups, senior citizen centers, or meals-on-wheels programs.28 Bite prevention materials could also be disseminated by primary care veterinarians at pet wellness examinations.
ABBREVIATIONS
| CI | Confidence interval |
| E-code | External-cause-of-injury code |
| ICD-9-CM | International Classification of Diseases, 9th Revision, Clinical Modification |
| NC | DETECT North Carolina Disease Event Tracking and Epidemiologic Collection Tool |
| PEP | Postexposure prophylaxis |
EpiSheet: Spreadsheets for the Analysis of Epidemiologic Data, Rothman KJ, Boston, Mass. Available at: krothman.hostbyet2.com/Episheet.xls. Accessed Mar 19, 2013.
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