Discussion
This study highlights that COVID-19 public health measures were associated with an increase in the number of paediatric dog bite emergency department attendances, potentially due to children spending more time at home, with greater exposure to dogs. Additionally, the demographics of children at risk of dog bites have remained the same during this period. These results can be used to underpin the need for an evidence-based approach to dog bite injury prevention strategies targeted at children and their guardians during this pandemic and future ones.
Following 4 years of stable monthly patterns of dog bite attendance, there was a sharp increase in dog bites and attendance percentage between April and July 2020: an effective tripling in dog bite attendances and quadrupling in percentage of attendances. This is confirmed by a clear statistical association between the period of COVID-19 public health measures and a rise in dog bite attendances.
The national lockdown (March to May 2020)15 16 saw a rapid reduction in overall emergency attendance levels, which reached their lowest in April. It was expected that overall attendance levels would decline as patients and parents were fearful of hospital-acquired COVID-19 and were told not to seek medical aid unless absolutely necessary.1–3 However, children continued to attend Alder Hey for dog bites, with no clear decrease in attendance, despite overall attendance numbers dramatically decreasing (figure 1).
Dog bite numbers did not dramatically increase until May, over a month into the lockdown period. The initial stable level of dog bites during lockdown was unexpected given another study reported a rapid increase in dog bite attendance as soon as their lockdown began.20 During the initial period, life satisfaction and happiness in adults declined, with anxiety levels raised.28 Rates of self-harm and domestic violence also rose.29 30 These studies highlight that in some households the normal emotional palette had been disrupted, and this could feasibly include dogs, who are viewed as family members. Dogs’ routines also changed drastically during the first lockdown with 80% spending more time with children, and having less socialisation with other dogs and less exercise.31 Dog owners reported behavioural changes in their dogs and many reported a hesitancy to walk their dog due to COVID-19 infection risks.32 The observed time lag in attendances for bites may be due to a lag in household risk or a lag in attending hospitals.
Bite risk may not have increased immediately due to a range of reasons. It may have taken some time for dogs to exceed their tolerance threshold for behaviours directed towards them, and/or due to the accumulative effect of separate triggering experiences,33 particularly where there was greater activity occurring within homes during lockdown. Parental supervision of their children with dogs within the home is often limited,34 and this may have been further impacted during lockdown with parents having to juggle multiple conflicting demands on their time. In lockdown, there was also a fear of attending hospitals,35 so it is possible that less severe dog bite injuries were managed at home.
From May to July, the number of dog bite attendances increased faster than overall attendance number, leading to a higher percentage of attendances being due to dog bites. During this period, relaxation of public health restrictions and summer weather meant there was potentially more opportunity for children to be exposed to non-household dogs, providing another source of risk perhaps more absent previously. There may also have been increased exposure due to proliferation of dog adoptions and acquisition of ‘pandemic puppies’ as 2020 progressed.36 37 Further, according to UK Kennel Club research, many new puppies were bought on impulse with little research.38 Compounded by difficulty accessing professional advice due to ‘emergency only’ veterinary provision,39 and closure of training classes, many dogs acquired during 2020 may have had inadequate training and socialisation, which may result in a greater likelihood to biting.
August and September saw declining dog bite attendances and the percentage of attendances due to dog bites lowered, both measures returned to the normal range in September coincident with schools reopening,15 16 and likely resulted in children spending less time at home with dogs. In a study in Colorado, dog bite attendance numbers were not assessed beyond cessation of their lockdown,20 and it is possible that as public health measures eased, attendance rates would have returned to normal as our data have.
This study found that the sex and age profile of dog bite victims remained the same during the COVID-19 public health measures, in line with available international trauma data.1 3 Our data confirm dog bite seasonality,4 8 19 but to the best of our knowledge, this work is the first to describe sex differences related to dog bite seasonality, with dog bites to girls increasing during the summer, but not to boys; research is needed to understand why.
Limitations
The main limitation of these data is how representative they are of the wider UK population. Alder Hey Children’s Hospital is one of Europe’s largest paediatric hospitals, and the community it serves has one of the largest hospital admission rates for dog bites in the country.4 This research needs to be repeated at a national scale. For this audit, only case count and basic demographic information of the victims was captured. Further work exploring the association of COVID-19 public health measures with severity and anatomical location of the bites, and the context of the bite, is critically important if we are to understand why dog bites increased. The variable ‘COVID-19 Public Health Measures’ encompasses a complex range of measures varying in timing and likely impact. It is likely that multiple confounding and interacting factors led to the increase in dog bite attendance rates. It was felt that the pragmatic decision to choose a broad definition was justified. All our hypotheses as to why dog bites rose are speculative, and more research is needed.