Pattern and outcome of dog bite injuries among children in Ado-Ekiti, Southwest Nigeria

Introduction Dog bites in humans are a major public health problem. Globally, millions of people are bitten by dogs but most of the fatal cases occur in children. There is paucity of data on dog bite related diseases among Nigerian children. Objectives: to determine the pattern of dog bite injuries and associated health problems among children seen at Ekiti State University Teaching Hospital. Methods This is a retrospective study on the clinical data of patients managed for dog bite related injuries between January 2010 and June 2014. Results In all, 84 cases of dog bite injuries were managed constituting 0.89% of the total consultations; six (7.1%) had rabies. Most of the victims were aged 6-12 years (60.7%) and majority (71.4%) was boys. Eighty two percent of the victims presented within 24hrs of the injury. Thirty-six (43%) had WHO grade 3 dog bite injury at presentation and the lower limb was the commonest (57.1%) bite site. Use of herbal preparation was the most common pre-hospital treatment 60%. Although 92.9% received anti-rabies vaccine, only 64.3% of them completed the vaccination schedule. The case fatality rate for dog bite was 7.14%. The six that died all presented late, had no post exposure prophylaxis and died within 24 hours of admission. Conclusion There is need for public enlightenment on dangers associated with dog bites and also for the government to defray the high cost of post exposure prophylaxis treatment for children.


Introduction
Dog bite remains a major public health and clinical problem causing palpable fear and anxiety in the patients, the relatives and the attending health care worker not only for the associated morbidity but for the risk of contracting rabies which if not adequately prevented or passes unrecognized almost always result in fatal outcome [1][2][3]. Dogs are the major reservoir and vector of the rabies virus in Nigeria [4]. Dog bites and rabies are a major public health issue globally and this is not unconnected with the well known fact that rabies is usually fatal once the clinical symptoms develop [5]. Dog bites are the main causes of these preventable traumatic injuries especially in the Paediatric population [6].
Globally, millions of people are bitten by dogs; reports in the USA estimated about 4.5 million dog bites per year and this resulted in 368,265 emergency department visits in 2001 [7]. It was reported that, forty-two percent of dog bite victims are children below fourteen years of age and the injury rate was reported to be highest for children between 5 and 9 years of age with the rate decreasing with increasing age [7]. The injury rate was also reported to be higher among the boys than girls [7].
Dog bites cause a crushing-type wound because of their rounded teeth and strong jaws. Dog bites can result in varying degrees of injuries but fatal injuries occur mostly in children. Victims suffer from psychological and emotional trauma in addition to the physical injuries sustained from the bites [6]. Stray and unvaccinated dogs abound on the streets in Nigeria and other developing countries thereby putting children particularly at risk of either provoked or unprovoked attack by these dogs. Many of these dogs are dogs initially kept as pets, for security purpose, for hunting and also for consumption in some cultures; many of them are later abandoned by the owners. Almost all of them have never had rabies vaccination thus putting victims at risk of rabies [1,2].
The most feared complication of dog bites is rabies although not all bites result in rabies [8]. It is however essential to assess for and pre-empt the possibility of rabies in every victim of dog bites in Nigeria and most developing countries because of the preponderance of unvaccinated dogs [8]. Rabies is an acute viral disease of the central nervous system that remains largely untreatable. Rabies (meaning madnesss in Latin) is caused by rabies virus of the family Rhabdoviridae and the genus Lyssavirus [9]. The rabies virus affects all warm-blooded animals including man and the outcome is usually fatal [10]. It causes an acute encephalomyelitis and it is typically transmitted from the saliva of a rabid animal via a bite, scratch or mucous membrane exposure [5]. Dogs and cats are the major reservoirs and vectors of rabies transmission especially in Africa and Asia whereas in the Americas, bats are more important in transmitting the disease [11]. Rabies is almost always fatal if postexposure prophylaxis (PEP) is not administered before the development of symptoms [5]. Globally, about 55,000 human deaths occur annually and over 98 percent of these mortalities are caused by canine rabies [12]. Over 50% of these mortalities occur in children less than 15 years of age [13]. Africa accounts for approximately 24,200 deaths [14]. The only way of preventing rabies is through the administration of pre-exposure immunization to individuals at risk, administration of PEP with or without human rabies immune globulin (HRIG) and control of rabies in animal population [15]. Human diploid cell vaccine in combination with rabies immune globulin when administered promptly to rabies-   (Table 2). Thirty-six (43.0%) of the victims presented with grade 3 WHO wound severity grading as shown in Figure 1.
Treatments received in the hospital ranged from washing the bite site with soap and water, to suturing of lacerations and wound dressing, analgesics, tetanus prophylaxis, anti-rabies vaccination (ARV), intravenous fluids and diazepam administration as well as antibiotics administration as shown in Table 3. The treatment administered is determined by the severity or grade of the injury.
Patients with higher grades of injury significantly received more hospital treatments (P=0.001) ( Table 3). Human rabies immune globulin was not administered on any of the patients.

Discussion
This study showed that dog bite related injuries are not a common presentation both in the children emergency unit as well as the outpatient department of our hospital as it constituted about 0.89% of the total consultation over the study period. This figure is however higher than 0.31% and 0.24% reported by Schalamon et al [18] and Kahn et al [19] in their studies respectively. This prevalence is however less than 1.5% documented by Dwyer et al [6] at a pediatric trauma unit in South Africa. For the families that lost their wards to dog bite related injuries, it was a 100% loss hence, dog bites still remains a major public health issue in most developing countries because these deaths can be prevented. The high vulnerability of children to dog bite injury as shown by previous studies conducted locally and internationally [1,7,20,21], has been attributed to children's inability to defend themselves, their small stature and also to the fact that they may provoke the attack in the first instance [1]. Whereas adults are able to stand up to the dogs and defend themselves in most cases, there were many reported cases of unprovoked attacks in this study further highlighting the need to protect children from undue attacks by dogs in the study area. It might be important to come up with prevention programs for children since they are the most vulnerable group as evidenced by this study. Prevention programs such as teaching children how to respond to, behave around and interact with dogs; a randomized controlled trial of a school based intervention in Australia This study revealed that children between the ages of 6 and 12 years are more commonly bitten by dogs and also showed male preponderance (71.4%) among the victims which is similar to findings in previous studies [1,20] and this is not unconnected with the natural behaviour of boys who are more adventurous and daring than their female counterparts, they are also likely to yell, play with or grab the dogs if possible, which put them at risk of being bitten.

The most common site of bites in this study was the lower limb which is similar to what was documented by Abubakar et al [1] in
Jos and Iyalohme et al [5] in Ekpoma, Edo state. Similar to these studies [1,5], head and neck injuries were uncommon in our study.
Majority of the bites were from stray dogs whose owners were known to the victims. This is a common practice in our environment Injections can be given into anterolateral thigh for children [24].
Only a little above 50% of the dog bite victims in this study completed the PEP regimen which is slightly lower than the 60.5% documented by Abubakar et al [1] in Jos. This is probably not globulin. This may also be due to the fact that the attending physicians did not prescribe it alongside the human diploid cell vaccine or that the care givers couldn't afford it because of the exorbitant cost or probably because it was not available.
Eighty-two percent of the victims in this study presented within 24 hours of injury which is commendable but this is slightly lower than 87.7% reported by Abubakar et al [1] in Jos. Most of our patients had inappropriate home remedies administered before presentation in the hospital and this could have delayed hospital presentation in some of them thus putting the victims at risk of developing complications or even a false sense of assurance when in the real sense the problem was yet to fully evolve. Hence, public enlightenment campaign would be of help in encouraging early presentation as well as informing the public on the right thing to do if they encounter such victims. The six deaths recorded in this study, were from the lower social class, they did not receive PEP with ARV and also presented late with features of rabies and all of them died within 24 hours of presentation. These observations not only underscore the importance of timely PEP in preventing rabies following dog bite injury, but also highlight the unholy alliances between poverty, ignorance, and inadequate access to quality health care in preventing avoidable deaths. The parents of the affected children might have acted out of ignorance or lack of financial power to be able to access care and purchase the human diploid vaccine to complete the PEP regimen among other treatments. There is therefore the need for more aggressive health education of the public and also for the provision of subsidy on the vaccine including the human rabies immune globulin as well as other cares for children with dog bite injury. This will make health care affordable at our health facilities and help to prevent avoidable deaths. One major way of alleviating this burden is the rapid implementation of the newly passed National Health Bill in Nigeria.
The bill gives financial leverage to Nigerians on health care costs among other benefits [26].

Conclusion
In conclusion, this study revealed that dog bite related injuries and          Chi-square value = 84.000 & P-value = 0.001; NB: ARV-Anti Rabies Vaccine