An Update on Fatalities Due to Venomous and Nonvenomous Animals in the United States (2008–2015)

Animal and human bites: Navigating evaluation and care

ABSTRACT

Patients who have experienced animal or human bites may present for care in a number of settings with a variety of injuries requiring different approaches to treatment and management. Because animal and human bites range in severity and can result in a host of sequelae, their evaluation and management can be complex. In caring for patients with an animal or human bite, NPs must consider the many factors relevant to such an injury.

All the Better to Taste You With, My Dear: ED Management of Mammalian Bites

Mammal bites account for over 5 million visits to Emergency Departments (EDs) annually. Nurse Practitioners (NPs) need to stay abreast of current guidelines, changes to antibiotic regimens that are now most effective, and understand in what circumstances collaboration with other specialists is indicated. It is not enough to care for the wound, itself, but rather understand in what presentations additional care may be needed despite the fact that there is no clear evidence at the time of evaluation of the need for advanced care. Additionally, NPs should understand what resources are available within their community for wound care that may exceed the scope and ability of the facility in which they practice. Health departments may need to be utilized in the care of ED patients who present with wounds that are suspicious for rabies. Finally understanding what constitutes a high, medium, and low risk bite will aide NPs in delivering optimal care within the communities they serve while also minimizing patient morbidity.

The domestication of SARS-CoV-2 into a seasonal infection by viral variants

Introduction

The COVID-19 pandemic was caused by the zoonotic betacoronavirus SARS-CoV-2. SARS-CoV-2 variants have emerged due to adaptation in humans, shifting SARS-CoV-2 towards an endemic seasonal virus. We have termed this process 'virus domestication'.

Methods

We analyzed aggregate COVID-19 data from a publicly funded healthcare system in Canada from March 7, 2020 to November 21, 2022. We graphed surrogate calculations of COVID-19 disease severity and SARS-CoV-2 variant plaque sizes in tissue culture.

Results and Discussion

Mutations in SARS-CoV-2 adapt the virus to better infect humans and evade the host immune response, resulting in the emergence of variants with altered pathogenicity. We observed a decrease in COVID-19 disease severity surrogates after the arrival of the Delta variant, coinciding with significantly smaller plaque sizes. Overall, we suggest that SARS-CoV-2 has become more infectious and less virulent through viral domestication. Our findings highlight the importance of SARS-CoV-2 vaccination and help inform public policy on the highest probability outcomes during viral pandemics.

Characterization of the Hemolytic Activity of Mastoparan Family Peptides from Wasp Venoms

Biologically active peptides have attracted increasing attention in research on the development of new drugs. Mastoparans, a group of wasp venom linear cationic α-helical peptides, have a variety of biological effects, including mast cell degranulation, activation of protein G, and antimicrobial and anticancer activities. However, the potential hemolytic activity of cationic α-helical peptides greatly limits the clinical applications of mastoparans. Here, we systematically and comprehensively studied the hemolytic activity of mastoparans based on our wasp venom mastoparan family peptide library. The results showed that among 55 mastoparans, 18 had strong hemolytic activity (EC50 ≤ 100 μM), 14 had modest hemolytic activity (100 μM < EC50 ≤ 400 μM) and 23 had little hemolytic activity (EC50 > 400 μM), suggesting functional variation in the molecular diversity of mastoparan family peptides from wasp venom. Based on these data, structure-function relationships were further explored, and, hydrophobicity, but not net charge and amphiphilicity, was found to play a critical role in the hemolytic activity of mastoparans. Combining the reported antimicrobial activity with the present hemolytic activity data, we found that four mastoparan peptides, Parapolybia-MP, Mastoparan-like peptide 12b, Dominulin A and Dominulin B, have promise for applications because of their high antimicrobial activity (MIC ≤ 10 μM) and low hemolytic activity (EC50 ≥ 400 μM). Our research not only identified new leads for the antimicrobial application of mastoparans but also provided a large chemical space to support the molecular design and optimization of mastoparan family peptides with low hemolytic activity regardless of net charge or amphiphilicity.

Clinical Manifestations and Risk Factors Associated with 14 Deaths following Swarm Wasp Stings in a Chinese Tertiary Grade A General Hospital: A Retrospective Database Analysis Study

INTRODUCTION

The objective was to evaluate the poisoning severity score (PSS) as an early prognostic predictor in patients with wasp stings and identify associated clinical characteristics and risk factors for mortality.

METHODS

A total of 363 patients with wasp stings at Suining Central Hospital between January 2016 and December 2018 were enrolled. Within the first 24 h of admission, the poisoning severity score (PSS) and the Chinese expert consensus on standardized diagnosis and treatment of wasp stings (CECC) were utilized for severity classification, and their correlation was examined. Patients were then divided into survival and death groups based on discharge status. Logistic regression analysis was employed to analyze factors influencing patients' outcomes.

RESULTS

The mortality of wasp sting patients was 3.9%. The PSS and CECC were found to correlate for severity classification. Additionally, female gender, age, number of stings, and PSS were identified as independent risk factors for mortality in wasp sting patients. Combining these four factors yielded an AUC of 0.962 for predicting death.

CONCLUSIONS

PSS aids in early severity classification of wasp stings. Female gender, age, number of stings, and PSS were independent mortality risk factors in these patients.

Dog-related deaths registered in England and Wales from 2001 to 2021

OBJECTIVE

This study aimed to describe the incidence and demographics of fatal dog bites or strikes, as defined in English and Welsh mortality data (2001-2021).

STUDY DESIGN

A descriptive analysis of the Office for National Statistics registered deaths data set.

METHODS

Individuals whose cause of death was defined as 'bitten or struck by a dog' were identified. The average annual number of dog-related deaths and trends in incidence were calculated. Age and sex demographics of victims were described.

RESULTS

In total, there were 69 registered deaths, a mean of 3.3 (95% confidence interval 0.3-6.3) dog-related deaths per year, and a mean annual incidence of 0.59 (95% confidence interval 0.06-1.11) deaths per 10 million population. There was no year-on-year change in incidence. Of victims, 59% were male, 10% were <5 years, and 30% were ≥75 years.

CONCLUSIONS

Dog-related deaths are rare in England and Wales and have not increased between 2001 and 2021. Further contextual information about the incidents is needed to be able to develop public health strategies and interventions.

Impact of Envenomation With Snake Venoms on Rabbit Carcass Decomposition and Differential Adult Dipteran Succession Patterns

The current study investigates the postmortem successional patterns of necrophagous dipteran insects and the rabbit carcass decomposition rate upon envenomation with snake venom. In total, 15 rabbits, Oryctolagus cuniculus domesticus L. (Lagomorpha, Leporidae), were divided into 3 groups (5 rabbits each; n = 5); the first and second groups were injected with lethal doses of venoms from the Egyptian cobra, Naja haje L. (Squamata, Elapidae), and the horned viper, Cerastes cerastes L. (Squamata, viperidae), respectively. The third group (control) was injected with 0.85% physiological saline and euthanized with CO2. The carcass decomposition stages: fresh, bloating, decay, and dry were recorded and monitored. Data revealed that envenomation shortened the decomposition process by 3 d, 20% shorter than the control. The overall succession pattern of fly species revealed a lower abundance during the fresh stage, which peaked during the decay stage, and declined to the minimum number in the dry stage at the end of the 15-d experimental duration. A total of 2,488 individual flies, belonging to 21 species of 10 families, were collected from all experimental carcasses. The Calliphoridae, Muscidae, and Sarcophagidae were the most abundant and diverse families, whereas the other seven families were rare and least abundant. Although C. cerastes venom was significantly less lethal than N. haje, it showed a faster carcass decomposition process and a higher impact on fly abundance. These data showed that envenomation impacts insect succession and carcass decomposition, which should be taken into account when using insects in forensic investigations since envenomation with snake venoms is one of the leading causes of death worldwide.

Correlation between early changes of serum lipids and clinical severity in patients with wasp stings

BACKGROUND

Wasp stings are a serious problem worldwide, and patients in severe cases may experience multi-organ failure. However, the mechanism of hypolipidemia in patients with wasp stings is unknown.

OBJECTIVE

To investigate the relationship between early changes in lipid levels and clinical severity and the possible underlying mechanisms.

METHODS

A retrospective analysis of 212 patients (mild: 77; moderate: 50; severe: 85) with wasp stings was conducted. Clinical data, including lipid test results within 24 h of admission, were analysed. A total of 1060 healthy age- and gender-matched controls were used.

RESULTS

Patients with wasp stings had lower lipid levels than healthy controls (P<0.01). Lipid levels decreased with disease severity, except for triglycerides (P<0.05). The number of stings, degree of organ failure, need for mechanical ventilation and extracorporeal blood purification, and mortality were higher in the severe group than in the mild and moderate groups (P<0.01). A decrease in lipid levels was accompanied by an increase in inflammatory indicators. In the severe group, a reduction in lipid levels was associated with ventilator application and blood purification, independent of survival status.

CONCLUSIONS

Patients with wasp stings experience a reduction in lipid levels, which is related to the severity of clinical manifestations. Early lipid levels may serve as a simple indicator for the severity of wasp stings, and targeting lipid metabolism may be a novel treatment.

Mohave Rattlesnake (Crotalus scutulatus) Identification Revisited

Crotalus scutulatus (Mohave rattlesnake) is a clinically significant pit viper broadly distributed across much of the arid southwestern United States and mainland Mexico. Identification of C scutulatus is a concern among emergency medical service and emergency department personnel owing to its reputation for severe envenomations and difficulty in visually differentiating between C scutulatus and other species, primarily Crotalus atrox (western diamond-backed rattlesnake). We contrast distinctive characteristics of C scutulatus, C atrox, and 3 other sympatric species: Crotalus molossus, Crotalus ornatus, and Crotalus viridis (western and eastern black-tailed rattlesnakes and prairie rattlesnake, respectively). Greenish coloration eliminates C atrox but does not confirm C scutulatus. Obvious coarse and fine speckling of the dorsal pattern and a pale postocular stripe intersecting the mouth characterize C atrox. Dorsal speckling is insignificant or absent in the other species, whereas the pale postocular stripe passes above the mouth in C scutulatus and C viridis and is absent in C molossus and C ornatus. Tails boldly ringed with alternating black and white or contrasting shades of gray are shared by C atrox and C scutulatus, respectively, but a lack of boldly ringed tails characterizes the other species. The proximal rattle segment is yellow and black, or entirely yellow, in C scutulatus but black in the others. The most reliable visual identifications are based on evaluations of multiple traits, all of which are variable to some extent. Traits such as tail ring width and the size and number of crown scales have frequently been overemphasized in the past.

What We Know about Sting-Related Deaths? Human Fatalities Caused by Hornet, Wasp and Bee Stings in Europe (1994-2016)

Simple Summary

Information about fatalities due to stinging insects is scarce. Hymenopteran-related deaths (n = 1691) in 32 European countries based on official registers over a 23-year period (1994–2016) are described. Male adults (25–64 years) were the most common group to be fatally injured and almost half of the fatalities were recorded at “unspecified places”. Fatalities per million inhabitants per year ranged from 0 to 2.24 with an average of 0.26. Geographic, environmental, and ecological factors influence the frequency of stings, and its subsequent reaction. It is necessary to produce and interpret knowledge using diverse sources and in an interdisciplinary way. As part of the One Health philosophy, people and hornets, wasps and bees, as well as the environment that they share are closely connected.

Abstract

Epidemiology of Hymenopteran-related deaths in Europe, based on official registers from WHO Mortality Database (Cause Code of Death: X23), are presented. Over a 23-year period (1994–2016), a total of 1691 fatalities were recorded, mostly occurring in Western (42.8%) and Eastern (31.9%) Europe. The victims tended to concentrate in: Germany (n = 327; 1998–2015), France (n = 211; 2000–2014) and Romania (n = 149; 1999–2016). The majority of deaths occurred in males (78.1%) between 25–64 years (66.7%), and in an “unspecified place” (44.2%). The highest X23MR (mortality rate) were recorded in countries from Eastern Europe (0.35) followed by Western (0.28), Northern (0.23) and Southern Europe (0.2). The countries with the highest and lowest mean X23MR were Estonia (0.61), Austria (0.6) and Slovenia (0.55); and Ireland (0.05), United Kingdom (0.06) and the Netherlands (0.06), respectively. The X23 gender ratio (X23GR; male/female) of mortality varied from a minimum of 1.4 for Norway to a maximum of 20 for Slovenia. Country-by-country data show that the incidence of insect-sting mortality is low and more epidemiological data at the regional level is needed to improve our understanding of this incidence. With the expansion of non-native Hymenopteran species across Europe, allergists should be aware that their community’s exposures are continually changing

An unsolved case in a culturally diverse community in Italy

The number of foreign citizens resident in Italy is approximately 5 million, making them the 8.7% of the resident population of the country. However, over the past 20 years, foreign citizens accounted for 24% of the total number of defendants involved in homicides, especially associated with robbery, disputes and assaults, generally connected to prostitution. Investigations of cases in the context of culturally diverse or minority communities can be particularly complex. This is due to the education, the cultural background and the cohesiveness of the community, alongside a negative view of law enforcement. These factors determine a relatively low resolution rate of these violent crimes in these communities.

The investigation of the suspicious death of an Indian citizen living in Italy is presented in this paper. The body was discovered in a cattle shed, and despite the initial assumption of an accidental death, the cranial lesions were not consistent with the view that the death was caused by a kick by a cow. The results of a multidisciplinary analysis, including imaging, pathology, toxicology and veterinary forensics, were directed towards a homicide, with the manner of death ultimately filed as undetermined. During the course of the investigation, the collaboration between law enforcement and the community was thwart with difficulty, and as a consequence this case is currently unsolved. In order for law enforcement to continue to play a constructive and supportive role, it is imperative that every country invest in civil education of local population and of any ethnic groups, minorities and culturally diverse people.

Macroscopic hematuria in wasp sting patients: a retrospective study

BACKGROUND

Macroscopic hematuria after wasp sting has been reported in Asia to occur before acute kidney injury (AKI), and is often used by clinicians as a sign indicating the need for intensive care and blood purification therapy. However, there is no study on the clinical characteristics and prognosis of this symptom.

METHODS

The clinical data of 363 patients with wasp sting admitted to Suining Central Hospital from January 2016 to December 2018 were retrospectively analyzed. At admission, the poisoning severity score (PSS) was used as the criterion for severity classification. According to the presence of macroscopic hematuria, the patients were divided into macroscopic hematuria and non-macroscopic hematuria group.

RESULTS

Of the 363 wasp sting patients, 219 were male and 144 were female, with a mean age of 55.9 ± 16.3 years. Fifty-one (14%) had macroscopic hematuria, 39 (10.7%) had AKI, 105 (28.9%) had rhabdomyolysis, 61 (16.8%) had hemolysis, 45 (12.4%) went on to received hemodialysis, and 14 (3.9%) died. The incidence of AKI in macroscopic hematuria group was 70.6%, and oliguric renal failure accounted for 72.2%. Patients with macroscopic hematuria had significantly higher PSS (2.2 ± 0.5 vs. 1.1 ± 0.3, p < .001).

CONCLUSION

Macroscopic hematuria can be regarded as a surrogate marker of deteriorating clinical outcome following wasp stings. In wasp sting patients with symptoms of macroscopic hematuria or serum LDH higher than 463.5 u/L upon admission, the risk of AKI increases significantly, therefore hemodialysis should be considered. The PSS is helpful in early assessment of the severity of wasp sting patients.

The assessment of the efficacy of STRs panels recommended by the ISAG for canine pedigrees analysis for forensic casework

Canine DNA is widely used in forensic investigations, particularly in dog attacks cases on humans. Nowadays, STR markers are employed worldwide in forensic laboratories to test human and animal genotypes. In the study we analysed the effectiveness of panel – 18 STR as previously recommended by ISAG and the same panel with three additional markers – 21 STR, which has been recommended by ISAG as the core panel for dog identification since 2016. We calculated the PD, PID for these sets of panels and estimated RMP based on the DNA profile obtained during an investigation of a woman bitten by a dog. The high combined CPD value for 18 and 21 STRs showed values close to 1.0. The CPID value for theses panels was 5.2 × 10−10 to 6.4 × 10−14. Statistical analysis estimated the random DNA match, in the case of the woman bitten by a dog, with a probability of 4.3×1019 and 2.8×1022, using 18 and 21 STR panels respectively, and that the canine DNA profile from the crime scene originated from the suspected dog and not from another random dog. Our results show that both STR panels can be used effectively for individual identification and forensic casework.

Social and environmental factors influencing contemporary cases of wolf aggression towards people in Poland

Understanding factors and mechanisms causing large carnivore aggression towards people is crucial for their conservation in modern human-dominated landscapes. We present detailed descriptions of wolf attacks on people in early summer 2018 in two areas of Poland, analysis of behaviour, fitness and origin of individuals responsible for the attacks and management actions undertaken by local communities as well as governmental bodies and non-governmental organisations. We show that attacks were caused by yearling wolves (13-month-old male and 14-month-old female) originating from local packs, which appeared near households several months prior to incidents. Both individuals were positively food-conditioned and showed increasing habituation caused by irresponsible behaviour of people such as long-lasting intentional feeding or illegal keeping. Post mortem necropsy revealed obesity and serious abnormality of spleen (polysplenia) in the problem female wolf that negatively impacted her fitness and was the most likely reason for her presence near households and feeding on leftovers. Despite prolonged observations of these wolves very close to human settlements (less than 30 m), no mitigation actions were undertaken until the attacks, after which both individuals were killed. We provide several recommendations to avoid aggressive human-carnivore encounters.

Wilderness Medicine

With more families spending time outdoors or embarking on wilderness adventures, pediatricians may be tasked with providing appropriate counseling to parents and children. Although the breadth of wilderness medicine can be extensive, this article will focus on preventive measures, common injuries, and injury treatment options in an outdoor environment. [Pediatr Ann. 2021;50(6):e234-e239.].

Tourniquet Use in Animal Attacks: An Analysis of News Media Reports

Background

Animal attacks pose a significant public health problem in the United States. Non-venomous animals are the leading cause of mortality in these attacks, and extremity injuries leading to hemorrhage are a common pattern. The Stop the Bleed campaign advocates for public training in bleeding control tactics and public access to bleeding control kits. Controlling life-threatening bleeding, as promoted by the Stop the Bleed campaign, may be a method to reduce preventable death in these attacks.

Methodology

We searched the Nexus Uni database, which compiles international news media articles, to collect newspaper articles in the United States between 2010 and 2019 that referenced animal attacks on humans in which a tourniquet was applied. We screened articles to assess for inclusion criteria and isolated a single report for each attack.

Results

A total of 50 individual attacks met the inclusion criteria and were included for data collection. Overall, 92% (n = 46) of the victims survived the attacks, and the average victim age was 33. California was the most common location of the attacks (n = 12, 24%), sharks caused the most attacks (n = 26, 52%), and victims most often sustained isolated extremity injuries (n = 24, 48% for arm and n = 24, 48% for leg). Laypeople applied the most tourniquets (n = 29, 58%), and appliers most frequently used improvised tourniquets (n = 30, 60%).

Conclusions

While mortality in this series was low, there are hundreds of fatalities from non-venomous animal attacks each year. Equipping and training the at-risk public to stop bleeding may save additional lives. Future Stop the Bleed efforts should improve access to public hemorrhage control equipment and expand educational outreach to people engaged in high-risk activities with animals.

Animal-Encounter Fatalities, United States, 1999-2016: Cause of Death and Misreporting

OBJECTIVES

Errors and misreporting on death certificates are common, along with potential inaccuracies in cause-of-death coding. We characterized and compared fatalities by animal-encounter mentions reported as underlying cause of death (UCD) with animal-encounter mentions reported as multiple cause of death (MCD) to determine factors associated with misreporting UCD.

METHODS

We analyzed fatality data from 1999-2016 from the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research by UCD and MCD animal-encounter mentions (International Classification of Diseases, 10th Revision codes W53-59, X20-27 and X29, T63.0-63.6, T63.8-63.9, and T78.2-78.4). We examined differences in reporting by age, sex, race, autopsy (yes, no, unknown), allergic reactions, and toxicities.

RESULTS

The number of animal-encounter mentions by UCD was 3638 (202 average per year) and by MCD was 4280 (238 average per year), a difference of 18% (n = 642; 36 average per year) by MCD analysis. The number of nonvenomous animal-encounter mentions increased 20% (from 2138 UCD to 2567 MCD), and the number of venomous animal-encounter mentions increased 14% (from 1500 UCD to 1713 MCD). Decedents aged ≥65 had the highest additional number of animal-encounter mentions among all age groups, primarily encounters with other reptiles (n = 113), other mammals (n = 71), and dogs (n = 42). Of 642 MCD additional animal-encounter mentions, heart disease (n = 211, 33%) and infections (n = 146, 23%) represented more than half of the UCD. Of 553 dog-encounter fatalities, 165 (30%) were among children aged ≤4.

CONCLUSIONS

Animal-encounter fatalities, analyzed by UCD alone, may be underreported. An initiating animal injury, complicated by comorbidities and fatality, may obscure the causal chain, resulting in misreporting UCD. Ongoing training for medical certifiers is recommended, highlighting accurate identification of UCD and contributing causes in the causal chain of death.

Using Surveillance of Animal Bite Patients to Decipher Potential Risks of Rabies Exposure From Domestic Animals and Wildlife in Brazil

Direct contact with domestic animals and wildlife is linked to zoonotic spillover risk. Patients presenting with animal-bite injuries provide a potentially valuable source of surveillance data on rabies viruses that are transmitted primarily by animal bites. Here, we used passive surveillance data of bite patients to identify areas with high potential risk of rabies transmission to humans across Brazil, a highly diverse and populous country, where rabies circulates in a range of species. We analyzed one decade of bite patient data from the national health information system (SINAN) comprising over 500,000 patients attending public health facilities after being bitten by a domestic or wild animal. Our analyses show that, between 2008 and 2016, patients were mostly bitten by domestic dogs (average annual dog bite patients: 502,043 [436,391-544,564], annual incidence per state: 258 dog bites/100,000 persons) and cats (76,512 [56,588-97,580] cat bites, 41 cat bites/100,000/year), but bites from bats (4,172 [3,351-5,365] bat bites, 2.3/100,000/year), primates (3,320 [3,013-3,710] primate bites, 2.0/100,000/year), herbivores (1,908 [1,492-2,298] herbivore bites, 0.9/100,000/year) and foxes (883 [609-1,086] fox bites, 0.6/100,000/year) were also considerable. Incidence of bites due to dogs and herbivores remained relatively stable over the last decade. In contrast bites by cats and bats increased while bites by primates and foxes decreased. Bites by wild animals occurred in all states but were more frequent in the North and Northeast of Brazil, with over 3-fold differences in incidence between states across all animal groups. Most bites reported from domestic animals and wildlife occurred in urban settings (71%), except for bites from foxes, which were higher in rural settings (57%). Based upon the Ministry of Health guidelines, only half of patients received the correct Post-Exposure Prophylaxis following a bite by a suspect rabid animal. We identified areas and species of high-risk for potential zoonotic transmission of rabies in Brazil and reveal that, despite increasing human encroachment into natural ecosystems, only patients reporting bites by bats increased. Our study calls for future research to identity the socio-ecological factors underlying bites and the preventive measures needed to reduce their incidence and potential risk of rabies transmission.

National Estimates of Noncanine Bite and Sting Injuries Treated in US Hospital Emergency Departments, 2011-2015

OBJECTIVES

Injuries resulting from contact with animals are a significant public health concern. This study quantifies and updates nonfatal bite and sting injuries by noncanine sources using the most recent data available (2011-2015) from the National Electronic Injury Surveillance System-All Injury Program with the purpose of using these updates to better understand public health consequences and prevention techniques. Increased rates of bites and stings can be expected in this study's time frame, possibly caused by the increasing human population expanding into animal territories, as well as changes in animal geographic distribution and pet ownership.

METHODS

The National Electronic Injury Surveillance System-All Injury Program is an ongoing nationally representative surveillance system used to monitor all types and causes of injuries treated in US hospital emergency departments (EDs). Cases were coded by trained hospital coders using information from medical records on animal sources of bite and sting injuries being treated. Data from 2011-2015 were weighted to produce national annualized estimates, percentages, and rates based on the US population.

RESULTS

An estimated 1.17 million people visited EDs for noncanine bite and sting injuries annually. This translates to a rate of 371.3/100,000 people. Insects accounted for 71.0% of noncanine bite and sting injuries, followed by arachnids (19.2%) and mammals (7.8%). The estimated annual total lifetime medical and work cost of unintentional noncanine injuries was $5,755,581,000.

CONCLUSIONS

Various sources of bite and sting injuries had an outsized effect on injury rates and identify potential areas of focus for education and prevention programs to reduce the burden of these injuries on health and healthcare costs. The study describes the diversity of animal exposures based on a national sample of EDs. Noncanine bite and sting injuries significantly affect public health and healthcare resources. Priorities can be focused on animal sources with the most impact on bite and sting injury rates, healthcare costs, and disease burden.

Nonfatal horse-related injuries treated in emergency departments in the United States, 1990-2017

BACKGROUND

Horse-related injuries can cause severe morbidity and mortality. The objective of this study is to investigate the epidemiological features of horse-related injuries treated in emergency departments (EDs) in the United States.

METHODS

A retrospective analysis of horse-related injuries from 1990 through 2017 was conducted utilizing the National Electronic Injury Surveillance System (NEISS). Cases were identified using the NEISS code 1239 (Horseback Riding: Activity, Apparel, or Equipment). Analyses performed included calculation of national injury estimates, relative risks (RRs) with 95% confidence intervals (CIs), and linear regression.

RESULTS

From 1990 through 2017, an estimated 1,836,536 (95% CI: 1,494,788-2,178,284) individuals presented to United States EDs with horse-related injuries. The annual injury rate decreased by 30.8% from 1990 to 1996, increased by 33.0% from 1996 to 2000, and then decreased by 46.0% from 2000 to 2017. Among older adults >60 years of age, the annual injury rate increased by 139.6% during the study period. The number of concussion and closed head injury diagnoses increased by 337.2% from 1990 to 2009. The most common mounted mechanism of injury was a fall or being thrown (73.9%), while the most common unmounted mechanism was being kicked (42.1%). Mounted injuries were more likely to lead to hospitalization than unmounted injuries (RR, 2.10, 95% CI: 1.59-2.77).

CONCLUSIONS

Despite the recent decline in horse-related injuries, these injuries are still common. Clinicians should be aware of the spectrum of ED presentations of horse-related injuries. Prevention efforts focused on older adults and concussions and closed head injuries warrant special attention.

Immunotherapy and biologicals for the treatment of allergy to Hymenoptera stings

Introduction: Venom immunotherapy (VIT) is an effective treatment for Hymenoptera venom allergy. The occurrence of severe reactions (SRs) to VIT, although infrequent, hampers the achievement of tolerance to insect stings. Risk factors for such reactions include allergy to honeybee venom, concomitant mast cell disorders, and the build-up phase of VIT. A role for omalizumab has come forward in recent years. Areas covered: This article reviews the available literature on the efficacy of omalizumab in preventing SRs and allowing the attainment of VIT maintenance doses. Pre- and co-treatments with omalizumab were evaluated, with positive overall results. Adding omalizumab to VIT in patients with SRs generally results in tolerance to VIT, thus restoring its precious preventive value. Expert opinion: VIT is effective for patients with Hymenoptera venom allergy and is recommended to prevent further (possibly fatal) reactions to stings. Omalizumab has shown efficacy in protecting patients from VIT-related SRs, particularly in those at high risk of SRs because of mast cell disorders and/or honeybee venom allergy. Notwithstanding, the accepted dose and time course of omalizumab for achieving tolerability and ensuring safety during VIT are not yet defined. In the future, other biologicals may play a role in preventing SRs during VIT.

EAACI position paper: Comparing insect hypersensitivity induced by bite, sting, inhalation or ingestion in human beings and animals

Adverse reactions to insects occur in both human and veterinary patients. Systematic comparison may lead to improved recommendations for prevention and treatment in all species. In this position paper, we summarize the current knowledge on insect allergy induced via stings, bites, inhalation or ingestion, and compare reactions in companion animals to those in people. With few exceptions, the situation in human insect allergy is better documented than in animals. We focus on a review of recent literature and give overviews of the epidemiology and clinical signs. We discuss allergen sources and allergenic molecules to the extent described, and aspects of diagnosis, prophylaxis, management and therapy.

Mortality, hospital admission, and healthcare cost due to injury from venomous and non-venomous animal encounters in the USA: 5-year analysis of the National Emergency Department Sample

Background

Injuries due to encounters with animals can be serious, but are often discussed anecdotally or only for isolated types of encounters. We sought to characterize animal-related injuries presenting to US emergency departments (ED) to determine the impact of these types of injuries.

Methods

All ED encounters with diagnosis codes corresponding to animal-related injury were identified using ICD-9-CM codes from the 2010 2014 National Emergency Department Sample (NEDS). Outcomes assessed included inpatient admission, mortality, and healthcare cost. Survey methodology was applied to univariate and multivariate analyses. Weighted numbers are presented.

Results

There were 6 457 534 ED visits resulting from animal-related injuries identified. Bites from non-venomous arthropods (n=2 648 880; 41%), dog bites (n=1 658 295; 26%) and envenomation from hornets, wasps or bees (n=812 357; 13%) constitute the majority of encounters. There were 210 516 patients (3%) admitted as inpatients. Inpatient admission was most common for those suffering from venomous snakes or lizard bites (24%, n=10 332). Death was infrequent occurring in 1162 patients (0.02% of all ED presentations). The greatest number of deaths was due to bites from non-venomous arthropods (24% of deaths, n=278) whereas rat bites proved the most lethal (6.5 deaths per 10 000 bites). Among persons aged 85 years or greater, odds of hospital admission for any animal-related injury was 6.42 (95% CI 5.57 to 7.40) and the OR for death was 27.71 (95% CI 10.38 to 73.99). Female sex was associated with improved survival (OR 0.55, 95% CI 0.41 to 0.73) and lower rates of hospital admission (OR 0.77, 95% CI 0.75 to 0.79). The total healthcare cost for these animal encounters during the observed time period was $5.96 billion (95% CI $5.43 to $6.50 billion).

Conclusion

The morbidity, mortality, and healthcare cost due to animal encounters in the USA is considerable. Often overlooked, this particular mechanism of injury warrants further public health prevention efforts.

Level of Evidence

Level IV.