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The
small
explanatory
power
of
the
remaining
health
sector
variables
employed
in
this
analysis
challenges
the
common
belief
that
inpatient
services
are
widely
sub-
stituted
for
home
care
and
the
validity
of
various
need
estimation
formulas.
In
other
words,
restricting
the
sup-
ply
of
hospital
and
nursing
home
beds
and
keeping
occupancy
rates
high
may
have
little
effect
on
the
use
of
home
health
services,
and
substantial
work
to
develop
valid
and
reliable
measures
of
the
need
for
home
health
services
apparently
is
needed.
The
practical
contribution
of
community-level
utiliza-
tion
research
is
the
insight
that
it
provides
into
likely
responses
of
the
health
care
delivery
system
to
factors
that
affect
the
supply
and
use
of
health
resources.
On
one
hand,
the
relatively
strong
explanatory
power
of
geo-
graphic
division
suggests
the
effect
of
cultural
factors
that
underlie
different
patterns
of
health
care
delivery
among
regions;
if
not
immutable,
the
influence
of
those
factors
probably
could
be
reduced
only
after
lengthy
and
costly
efforts
at
community
education.
On
the
other
hand,
the
finding
that
medical
necessity
accounts
for
only
an
eighth
of
the
explained
variance
indicates
a
large
discretionary
element
in
the
use
of
Medicare
home
health
benefits,
and
it
suggests
that
many
determinants
of
use
are
susceptible
to
community
intervention,
particularly
the
availability
of
services.
Further,
the
lack
of
associa-
tion
between
the
employment
of
home
health
nurses
and
varying
degrees
of
urbanization
suggests
that
the
unequal
availability
of
home
health
services
to
Medicare
benefici-
aries,
for
the
most
part,
is
not
related
to
the
availability
of
nurses
for
employment.
In
short,
it
appears
likely
that
the
use
of
home
health
services
could
be
promoted
by
com-
munity
initiatives
aimed
at
development
of
service
capac-
ity,
coordination
of
services,
agency
regulation,
and
so
forth.
This
analysis
provides
evidence
of
the
potential
of
general
community
characteristics
in
explicating
the
use
of
health
services.
Useful
insight
is
gained
by
consider-
ing
problems
of
medical
care
organization
within
the
broader
context
of
community
research
by
social
scien-
tists.
That
75
percent of
the
variance
in
the
use
of
Medi-
care
home
health
benefits
is
unexplained
underscores
just
how
much
remains
to
be
learned
regarding
various
modes
of
health
care
delivery.
Aspects
of
home
care
that
remain
to
be
explored
fully
by
community-level
research
include
need,
availability,
accessibility,
quality,
accept-
ability,
continuity,
and
costs.
Understanding
how
these
aspects
work
in
combination
to
determine
the
use
of
services
holds
forth
the
promise
of
successful
strategies
to
intervene
in
the
production
and
consumption
of
home
health
services.
References
..................................
1.
Callahan,
W.:
Medicare:
utilization
of
home
health
services,
1975.
Research
and
Statistics
Note
No.
2.
Health
Care
Financing
Administration,
Baltimore,
June
1978.
2.
Hammond,
J.:
Applied
research
in
home
health
services.
Community
level
utilization
analysis,
vol.
3.
DHEW
Pub-
lication
No.
(OPEL
79-3).
Health
Services
Administration,
Rockville,
MD,
July
1979.
3.
Rushing,
W.
A.:
Community,
physicians,
and
inequality.
Lexington
Books,
Lexington,
MA,
1975.
4.
Sharkansky,
I.:
Regionalism,
economic
status,
and
the
pub-
lic
policies
of
American
States.
In
Public
policy
analysis
in
political
science,
edited
by
I.
Sharkansky.
Markham,
Inc.,
Chicago,
1970,
pp.
186-206.
5.
Andersen,
R.,
and
Newman,
J.
E:
Societal
and
individual
determinants
of
medical
care
utilization
in
the
United
States.
Milbank
Mem
Fund
Q
51:
95-124,
winter
1973.
Severe
Attacks
by
Dogs:
Characteristics
of
the
Dogs,
the
Victims,
and
the
Attack
Settings
JOHN
C.
WRIGHT,
PhD
This
research
was
conducted
while
the
author
was
an
assistant
professor
in
the
Department
of
Psychology,
Clemson
University,
Clemson,
S.C.,
and
was
supported
by
a
grant
from
that
university's
Research
Grant
Committee.
Tearsheet
requests
to
John
C.
Wright,
PhD,
Associate
Professor,
Department
of
Psychology,
Mercer
University,
Macon,
Ga.
31207.
Synopsis
....................................
Sixteen
incidents
involving
dog
bites
fitting
the
de-
scription
"severe"
were
identified
among
5,711
dog
bite
incidents
reported
to
health
departments
in
five
South
Carolina
counties
(population
750,912
in
1980)
between
July
1,
1979,
and
June
30,
1982.
A
"severe"
attack
was
defined
as
one
in
which
the
dog
"repeatedly
bit
or
vigorously
shook
its
victim,
and
the
victim
or
the
person
intervening
had
extreme
difficulty
terminating
the
at-
tack."
Information
from
health
department
records
was
clar-
ified
by
interviews
with
anintal
control
officers,
health
January-February
1985,
Vol.
100,
No.
1
55
and
police
officials,
and
persons
with
firsthand
knowl-
edge
of
the
events.
Investigation
disclosed
that
the
dogs
involved
in
the
16
severe
attacks
were
reproductively
intact
males.
The
me-
dian
age
of
the
dogs
was
3
years.
A
majority
of
the
attacks
were
by
American
Staffordshire
terriers,
St.
Ber-
nards,
and
cocker
spaniels.
Ten
of
the
dogs
had
been
aggressive
toward
people
or
other
dogs
before
the
inci-
dent
that
was
investigated.
Ten
of
the
16
victims
of
severe
attacks
were
10
years
of
age
or
younger;
the
median
age
of
all
16
victims
was
8
years.
Twelve
of
the
victims
either
were
members
of
the
family
that
owned
the
attacking
dog
or
had
had
contact
with
the
dog
before
the
attack.
Eleven
of
the
victims
were
bitten
on
the
head,
neck,
or
shoulders.
REPORTS
OF
OBSERVED
ATTACKS
by
dogs
that
resulted
in
human
fatalities
indicate
that
(a)
the
typical
dog
mak-
ing
such
an
attack
repeatedly
bites
or
vigorously
shakes
its
victim
until
the
victim
no
longer
moves
(1),
and
(b)
human
intervention
is
frequently
less
effective
in
stop-
ping
this
type
of
event
than
in
stopping
less
severe
attacks
(1-3).
In
the
most
comprehensive
study
of
fatal
attacks
to
date,
Pinckney
and
Kennedy
(2)
cited
74
cases
that
occurred
from
March
1966
through
June
1980.
The
data
In
88
percent
of
the
cases,
the
attacks
took
place
in
the
owner's
yard
or
home,
or
in
the
adjoining
yard.
In
10
of
the
16
incidents,
members
of
the
victims'
families
wit-
nessed
the
attacks.
The
characteristics
of
these
attacks,
only
one
of
which
proved
fatal,
were
similar
in
many
respects
to
those
that
have been
reported
for
other
dog
bite
incidents
that
resulted
in
fatalities.
On
the
basis
of
this
study,
the
author
estimates
that
a
risk
of
2
fatalities
per
1,000
reported
dog
bites
may
exist
nationwide.
Suggestions
made
for
the
prevention
of
severe
attacks
focus
on
chang-
ing
the
behavior
of
both
potential
canine
attackers
and
potential
victims.
were
collected
from
accounts
of
fatal
dog
bites
published
in
newspapers
throughout
the
United
States
and
included
the
11
cases
cited
by
Winkler
(3).
Although
36
of
the
74
attacks
were
not
observed,
in
75
percent
of
the
witnessed
cases
someone
tried
to
intervene;
in
67
percent
of
these
cases,
the
person
intervening
had
difficulty
stopping
the
attack.
The
typical
fatal
attack,
then,
is
characterized
by
re-
peated
and
uninhibited
biting,
and
the
dog
is
relatively
unresponsive
to
attempts
to
terminate
the
attack.
Other
Characteristics
of
severe
attacks
by
dogs
Dog
Previous
Ca
s
eeAge
aggression
Obedience
Rabies
number
Breed
Sex
(years)
against-2
trained
vaccination
1
.American
Staffordshire
terrier'
M
3.50
FM,AQ,ST,D
No
No
2
..............
Rottweiler
M
1.50
No
Yes
Yes
3
.St.
Bernard
M
0.67
No
No
Yes
4
.Siberian
husky
M
2.00
?
No
Yes
5
.Cocker
spaniel
M
0.67
AQ
No
No
6
.St.
Bernard-German
shepherd
mixed-breed
M
5.00
AQ,ST
No
Yes
7
.St.
Bernard
M
3.00
ST
No
Yes
8
.American
Staffordshire
terrier
M
2.50
AQ,ST,D
Yes
Yes
9
.American
bulldog'
M
3.00
AQ,D
No
Yes
10
.American
Staffordshire
terrier
M
2.50
?
No
No
11..Cockapoo...
Cockapoo
M
4.50
ST
No
Yes
12
.American
Staffordshire
terrier'
M
5.00
No
No
Yes
13
.St.
Bernard
M
3.50
D
No
Yes
14
.American
Staffordshire
terrier'
M
10.50
D
No
Yes
15
.Irish
setter
M
2.00
No
No
No
16
.Cocker
spaniel
M
2.50
AQ,ST,D
Yes
Yes
1
Afthough
the
owner
would
not
admit
that
the
dog
was
used
in
pit
fighting,
the
investigating
animal
control
officer
reported
evidence
to
the
contrary
(for
example,
lesions
and
scars
about
the
head
and
extremiies).
2
FM
=
family
member;
AO
=
acquaintance;
ST
=
stranger;
D
=
dog.
56
Public
Heath
Reports
dog
attacks
fitting
this
behavioral
description
may
belong
in
the
same
category
as
fatal
dog
bites,
whether
the
attack
results
in
the
victim's
death or
not.
Such
"severe"
attacks
were
the
focus
of
this
investigation.
This
study
was
done
(a)
to
estimate
the
proportion
of
severe
attacks
among
total
reported
dog
bites
and
(b)
to
determine
the
characteristics
of
the
dog,
victim,
and
setting
associated
with
severe
dog
bite
events.
Methods
Severe
attacks
were
identified
among
records
of
5,711
dog
bite
incidents
that
were
reported
to
five
county
health
departments
(population,
750,912
in
1980)
in
the
Pied-
mont
area
of
South
Carolina
between
July
1,
1979,
and
June
30,
1982.
A
"severe"
attack
was
defined
as
one
in
which
the
dog
"repeatedly
bit
or
vigorously
shook
its
victim,
and
the
victim
or
the
person
intervening
had
extreme
difficulty
terminating
the
attack."
Information
gathered
during
interviews
with
animal
control
officers,
health
and
police
officials,
and
persons
with
firsthand
knowledge
of
specific
dog
bite
events
helped
to
identify
those
attacks
that
qualified
as
"se-
vere."
The
amount
of
physical
damage
resulting
from
the
bite
was
not
a
discriminating
variable.
For
example,
an
8-year-old
boy's
ear
was
severed
by
the
boy's
pet
Dober-
man
while
the
two
were
wrestling
in
the
front
yard
of
their
home.
The
dog
bit
the
boy's
ear
at
the
same
time
the
boy
pulled
away
from
the
dog,
and
the
injury
resulted.
No
further
attack
was
elicited.
The
boy
incurred
"se-
vere"
physical
damage;
however,
because
the
incident
did
not
have
the
characteristics
of
a
severe
attack
as
defined,
it
was
not
classified
as
severe
for
the
purposes
of
this
study.
Results
Dogs.
Of
the
5,711
dog
bite
incidents
reported
to
the
five
South
Carolina
health
departments
during
the
3-year
period
of
this
study,
16
attacks
were
classified
as
severe.
The
16
dogs
involved
were
reproductively
intact
males
(median
age,
3
years;
age
range,
.67
to
10.5
years).
Five
attacks
were
by
American
Staffordshire
or
Staffordshire
bull
terriers;
three
by
St.
Bemards
and
one
by
a
St.
Bernard-German
shepherd
mixed-breed;
two
by
cocker
spaniels
and
one
by
a
cocker
spaniel-poodle
mixed-breed
(cockapoo).
The
remaining
four
attacks
were
by
a
bulldog,
an
Irish
setter,
a
rottweiler,
and
a
Siberian
husky.
No
attempt
was
made
to
determine
American
Kennel
Club
registration.
All
16
dogs
reportedly
were
kept
as
pets
or
watch
dogs
or
both
(none
were
strays);
however,
there
was
evidence
that
the
bulldog
and
three
of
the
Staffordshire
terriers
were
used
for
"pit"
fighting
(table).
In
general,
the
dogs
seemed
well
cared
for;
only
four
had
not
been
vaccinated
for
rabies,
and
three
had
been
obedience
trained.
Reports
from
dog
owners and
animal
control
officers
indicated
that
10
of
the
dogs
had
a
history
of
aggression
toward
people
or
other
dogs
before
the
severe-bite
episode
(table).
Victims.
The
10
male
and 6
female
victims
of
severe
attacks
ranged
in
age
from
2/2
to
72
years
(median
age,
8
Characteristics
of
severe
attacks
by
dogs
(continued)
Victim
Setting
Family
Other
victim
Attack
Age
Relabonship
Bite
Dragged
Location
member
dogs
Dog
interaction
warning
Sex
(years)
to
dog2
locaton3
to
ground
of
attack
present
present
chained
with
dog
by
dog
F
4.0
FM
H,U
Yes
In
yard
Yes
No
Yes
Yes
No
F
8.0
AQ
H
Yes
In
new
home
No No
No No
No
M
4.0
AQ
H
Yes
In
yard
Yes
No
No
Yes
No
F
8.0
ST
H
Yes
In
new
home
No No
No
Yes
No
M
2.5
AQ
H
Yes
In
yard
Yes
No
Yes Yes
Yes
M
30.0
AQ
L
Yes
In
yard
Yes
No
No4
No
Yes
M
3.5
AQ
H
Yes
In
yard
Yes
No No
No
No
F
25.0
AQ
L,T
Yes
In
yard
Yes
No
No4
No
Yes
M
72.0
ST
H,U,L,T
Yes
Adjoining
road
No
No
No4
No
Yes
M
3.0
FM
H
Yes
In
yard,
road
No
Yes
Yes
?
No
F
66.0
ST
L
No
Adjoining
road
Yes
No
No
No
Yes
M
10.0
FM
T
No
In
yard
Yes
No
Yes
No
No
F
42.0
ST
H,U,L,T
Yes
4
houses
away
No
Yes5
No
Yes
No
M
4.0
FM
H,T
Yes
In
yard
Yes
No
Yes
Yes
No
M
47.0
FM
U
No
In
yard
No No
No
Yes
Yes
M
3.0
AQ
H,T
Yes
In
yard
Yes
No
No No
Yes
3
H
=
head,
neck,
shoulders;
U
=
upper
extremities;
L
=
lower
extremities;
T
=
torso,
buttocks.
4
Broke
chain
to
attack
victim.
5
Other
dog
not
involved
in
attack.
January-February
1985,
Vol.
100,
No.
1
57
years).
Ten
victims
(7
of
whom
were
male)-were
10
years
of
age
or
younger,
and
6
(3
males)
were
25
years
of
age
or
older.
"Acquaintances"-persons
who
had
had
previous
contact
with
the
dog-were
the
most
frequent
object
of
severe
attacks
(seven
cases),
followed
by
members
of
the
owner's
family
well
known
to
the
dog
(five
cases)
and
strangers
(four
cases).
No
attempt
was
made
to
determine
how
many
times
acquaintances
had
had
contact
with
their
attackers
before
the
event.
Thirteen
victims
were
knocked
down
or
dragged
to
the
ground
when
they
were
attacked.
Bites
received
during
the
16
attacks
were
located
on
the
head,
neck,
and
shoulders
(11
cases),
torso
and
buttocks
(6
cases),
lower
extremities
(5
cases),
and
upper
extremities
(4
cases).
Six
of
the
dogs
bit
their
victims
in
more
than
one
place.
Setting.
Attacks
took
place
in
the
dog
owner's
yard
(1
I
cases)
or
home
(2
cases),
in
an
adjoining
yard
or
road
(2
cases),
or
away
from
the
owner's
yard
(1
case).
In
seven
cases,
verbal
or
physical
contact
by
the
victim
with
the
dog
preceded
the
attack,
and
the
dog
gave
an
audible
warning
in
seven
cases.
Two
cases
involved
both
prior
contact
by
the
victim
and
warning
by
the
dog.
Members
of
the
victim's
family
witnessed
10
of
the
attacks.
In
five
cases,
dogs
were
chained
at
the
time
of
the
attack.
In
three
other
cases,
dogs
broke
their
chains
to
attack
their
victims.
Case
Descriptions
A
brief
description
of
each
attack
follows.
A
summary
of
the
characteristics
associated
with
the
attacks
is
given
in
the
table.
Case
1.
A
31/2-year-old
chained
Staffordshire
terrier
attacked
its
owner's
4-year-old
daughter
when
the
child
approached
to
pet
the
animal.
The
owner
stated
that
the
dog
would
have
"torn
her
up"
if
he
hadn't
pulled
the
child
to
safety,
but
that
"she
knew
better
than
to
go
around
him."
The
child
was
pinned
to
the
ground
by
the
dog
and
bitten
on
the
neck,
face,
and
arms.
Case
2.
A
1/2-year-old
rottweiler
had
been
purchased
from
a
breeder
2
days
before
the
attack.
The
dog
lunged
at
the
owner's
8-year-old
daughter
when
she
entered
a
room
where
the
dog
was
staying.
The
dog
repeatedly
bit
the
victim
about
the
head
and
face.
Case
3.
An
8-month-old
St.
Bernard
attacked
a
4-year-
old
boy
who
was
visiting
his
divorced
father.
The
father,
who
was
in
the
front
yard
with
the
child,
turned
around
to
see
the
dog
biting
his
son
on
the
face
and
neck.
He
pulled
the
dog
off
the
child
and
shot
the
animal.
Case
4.
A
roaming
2-year-old
Siberian
husky
was
brought
home
by
an
animal
control
officer,
who
left
the
dog
with
his
8-year-old
daughter.
The
officer
heard
the
girl
scream,
rushed
into
the
room,
pulled
the
dog
off the
girl,
and
shot
the
animal.
The
dog
bit
him
in
the
process,
and
the
girl
suffered
a
fractured
skull
and
multiple
facial
lacerations.
Case
5.
During
an
afternoon
picnic,
a
21/2-year-old
boy
wandered
next
door
and
threw
toys
at
the
neighbor's
chained
8-month-old
cocker
spaniel.
When
the
child
got
too
close,
the
dog
knocked
him
down
and
bit
him
repeat-
edly
on
the
face.
The
owner
remarked
that
the
dog
had
tried
to
"finish
him
off."
Case
6.
A
5-year-old
St.
Bernard-German
shepherd
mixed-breed
broke
its
chain,
ran
15
meters,
and
attacked
the
dog
owner's
30-year-old
neighbor.
The
victim,
who
kept
kicking
the
dog,
was
bitten
extensively
below
the
knees.
The
owner,
who
had
been
approaching
to
greet
his
neighbor,
stopped
the
attack
by
strangling
the
dog.
In
a
previous
episode,
the
dog,
while
chained,
had
bitten
another
neighbor
and
had
had
to
be
quarantined.
Case
7.
The
owner
of
a
3-year-old
St.
Bernard
was
walking
hand-in-hand
with
his
31/2-year-old
grandson
to
the
mailbox.
The
dog
jumped
on
the
child
from
behind,
knocked
him
to
the
ground,
and
"went
for
his
head."
The
owner
grabbed
the
dog's
neck
and
pulled
the
animal
off
the
child.
He
later
remarked
that
the
dog
"would
have
killed"
the
boy.
Case
8.
After
straining
at
and
breaking
its
chain,
a
2½2-
year-old
Staffordshire
terrier
jumped
on
its
owner's
visit-
ing
25-year-old
daughter
from
behind
and
knocked
her
to
the
ground.
The
woman
and
her
father
had
been
walking
toward
the
mailbox.
Before
the
father
could
control
the
dog,
it
repeatedly
bit
the
daughter
on
her
buttocks
and
thighs.
Case
9.
A
3-year-old
bulldog,
chained
and
wearing
a
harness,
broke
its
chain
to
attack
a
72-year-old
man
who
was
taking
his
daily
walk
on
the
adjoining
road.
The
man
had
been
knocked
down
and
bitten
over
all
parts
of
his
58
Public
Health
Reports
body
before
the
dog's
female
owner
pulled
the
animal
off
by
its
harness.
Case
10.
A
21/2-year-old
Staffordshire
terrier
slipped
out
of
its
collar
and
attacked
its
owner's
3-year-old
child
90
meters
from
the
family's
trailer.
Flesh
was
consumed
from
the
child's
neck.
The
mother,
who
had
been
next
to
the
trailer,
went
for
help
but
was
not
in
time
to
save
the
child,
who
was
fatally
injured.
A
small
6-month-old
terrier
mixed-breed
(with
the
same
owner)
took
part
in
the
attack
but,
because
of
the
absence
of
smaller
bite
marks
on
the
child's
body,
was
not
judged
a
"severe"
biter.
Case
11.
When
its
owner
opened
the
front
door,
a
4½/2-
year-old
cockapoo
escaped
from
the
house,
ran
barking
to
the
street,
and
attacked
a
66-year-old
woman.
The
woman
reached
out
with
her
hand,
but
the
dog
bit
the
calf
of
her
leg,
held
on
to
it,
and
shook
it
until
the
woman
finally
beat
the
animal
off
with
her
purse.
The
dog
had
bitten
a
child
4
months
before
this
attack.
Case
12.
A
5-year-old
Staffordshire
terrier
was
chained
in
a
yard
where
chickens
were
roaming.
The
dog
had
killed
and
was
eating
a
chicken.
The
10-year-old
son
of
the
terrier's
owner,
who
was
outside
with
his
12-year-
old
brother,
got
too
close
to
the
dog,
and
the
animal
dragged
the
boy
to
the
ground
by
his
buttocks.
The
owner,
hearing
the
child
scream,
ran
from
the
house
and
pried
open
the
dog's
mouth
with
a
knife.
Case
13.
A
31/2-year-old
St.
Bernard,
four
houses
away
from
its
home,
attacked
another
dog
by
the
throat.
When
the
owner
of
the
attacked
dog,
a
42-year-old
woman,
beat
the
St.
Bernard
with
a
hose,
the
animal
knocked
her
down
and
bit
her
on
all
parts
of
her
body.
The
woman
fainted.
A
motorist,
who
saw
her
being
bitten
and
dragged
to
the
road,
succeeded
in
chasing
the
dog
away.
Case
14.
A
chained
10½/2-year-old
Staffordshire
terrier
attacked
its
owner's
4-year-old
son
after
the
boy
hit
it
with
a
newspaper.
The
dog
pinned
the
child
to
the
ground
and
bit
him
about
the
torso,
head,
and
neck.
The
owner
pulled
the
boy
to
safety
after
beating
the
dog
with
a
log.
Case
15.
A
2-year-old
Irish
setter
growled
at
its
47-
year-old
owner,
who
had
returned
home
from
a
5-day
absence.
The
owner
reached
out
to
pet
the
dog,
which
bit
him
on
the
hand,
continued
to
shake
the
hand,
and
would
not
release
it
until
hit
with
a
nearby
log.
Case
16.
A
21/2-year-old
cocker
spaniel,
housed
in
a
backyard
pen,
attacked
its
owner's
visiting
3-year-old
nephew
when
he
and
his
aunt
entered
the
pen.
The
dog
knocked
the
child
down
on
his
stomach
and
repeatedly
bit
him
on
the
back
and
shoulders.
The
owner
picked
the
boy
up
and
kicked
the
dog
(which
was
hanging
on
to
the
child's
clothes
and
raised
off
the
ground)
until
it
let
go.
Discussion
These
events
were
similar
in
many
respects
to
those
reported
by
Pinckney
and
Kennedy
(2):
*
In
neither
this
sample
nor
theirs
were
attacks
by
stray
dogs
recorded.
*
At
least
88
percent
of
the
bites
in
both
samples
oc-
curred
in
or
adjacent
to
the
owners'
yards
or
in
their
homes.
*
More
than
60
percent
of
the
dogs
in
both
samples
had
records
of
previous
aggression.
*
The
majority
of
the
victims
were
children
8
years
of
age
or
younger,
with
1-
to
8-year-old
males
predominat-
ing
at
least
2:1
over
females.
*
The
most
frequent
location
of
bites
was
the
head
and
neck
region
(more
than
68
percent
in
both
samples).
The
sex
and
age
of
the
dogs
in
the
Pinckney
and
Kennedy
survey
were
not
reported.
It
would
have
been
informative
to
determine
whether
young,
reproductively
intact
males
constituted
a
large
proportion
of
the
dogs
in
their
study
also.
The
most
striking
difference
between
the
two
samples
was
in
the
percentage
of
infants
attacked.
In
the
Pinckney
and
Kennedy
sample,
31
percent
of
the
victims
were
1
year
of
age
or
younger,
while
none
was
in
this
sample.
In
addition,
in
the
earlier
sample,
16
attacks
(22
per-
cent)
were
by
German
shepherds,
compared
with
1
attack
by
a
shepherd
mixed-breed
in
this
study.
Regional
dis-
tributions
of
breeds
may
explain
some
of
this
discrep-
ancy;
however,
determining
dog
populations-much
less
breed
representation
in
a
community-is
extremely
diffi-
cult
(4,5).
Only
1
of
the
16
dog
attacks
(case
10)
resulted
in
fatality.
However,
the
most
frequent
site
of
bite
injuries
was
the
head
and
neck
region
in
both
this
sample
(11
of
16
cases)
and
the
Pinckney
aqd
Kennedy
sample
(33
of
the
41
cases
for
which
injury
location
was
specified).
In
January-February
1985,
Vol.
100,
No.
1
59
Prevention
the
latter
study,
information
concerning
bite
location
and
corresponding
cause
of
death
was
not
presented,
although
hemorrhage
and
shock
were
reported
to
be
the
causes
of
death
in
most
of
the
patients
(2a).
In
this
study,
"severe"
dog
attacks
were
selected
on
the
basis
of
their
behavioral
similarity
to
attacks
resulting
in
fatality.
The
incidence
of
severe
attacks
(16
cases)
among
total
reported
attacks
(5,711
cases)
was
approx-
imately
2.8
per
1,000.
Approximately
70
percent
of
these
severe
attacks
involved
bites
on
the
head
and
neck,
a
location
for
which
death
because
of
hemorrhage
and
shock
is
likely.
Thus,
if
these
figures
are
representative,
a
potential
for
2
fatalities
per
1,000
dog
bites
may
exist
nationwide.
Among
the
16
severe
attacks
reported
on
here,
there
was
only
1
fatality
(case
10),
although
the
number
of
deaths
one
would
predict,
based
on
a
risk
of
2
fatalities
per
1,000
dog
bites,
is
approximately
11.
Whether
a
severe
attack
results
in
death,
however,
may
depend
on
whether
an
adult
is
present
to
intervene.
In
case
10,
death
occurred
before
the
3-year-old
victim's
pregnant
mother
could
solicit
help
to
rescue
her
child.
In
each
of
the
other
15
cases,
either
the
victim
or
an
intervening
adult
suc-
cessfully
stopped
the
attack,
albeit
with
extreme
diffi-
culty
(for
example,
by
beating
the
dog
with
a
log,
kick-
ing,
or
shooting
it).
Borchelt
and
associates
(1)
have
suggested
that,
unlike
less
serious
attacks,
attacks
that
result
in
death
usually
occur
when
no
one
but
the
victim
is
present.
Of
the
four
cases
they
investigated,
the
only
nonfatal
attack
involved
an
11-year-old
boy
who
had
been
dragged
to
the
ground
and
repeatedly
bitten
by
a
pack
of
dogs.
The
dogs
stopped
their
attack
when
a
motorist
intervened
and
pulled
the
boy
to
safety.
In
the
other
three
cases,
the
victims-an
81-year-old
female
invalid,
a
10-year-old
girl,
and
a
14-year-old
boy-were
alone
at
the
time
of
the
attacks.
Taken
together,
these
data
seem
to
indicate
that
2
fatalities
per
1,000
dog
bites
is
a
reasonable
estimate
if
the
victims
are
physically
unable
to
stop
the
attack
or
if
adults
are
not
in
a
position
to
intervene.
Efforts
to
prevent
severe
dog
bites
should
be
focused
primarily
at
the
level
of
the
owner.
Information
concern-
ing
the
factors
that
contribute
to
a
severe
bite
must
be
made
available
to
dog
owners
so
that
the
appropriate
preventive
measures
can
be
taken.
The
following
steps
are
suggested:
1.
As
a
starting
point,
people
should
know
that
previous
signs
of
aggression
by
a
dog
may
be
predictive
of
a
severe
attack.
In
this
study,
there
were
14
cases
in
which
previous
incidents
of
aggression
could
be
determined.
In
eight
of
these
cases,
the
dogs
involved
had
bitten,
lunged
at,
or
snapped
at
people
previously.
In
two
other
cases,
the
attacking
animals
had
previously
been
reported
for
aggression
against
other
male
dogs.
Owners
should
be
educated
about
and
sensitized
to
the
potential
seriousness
of
any
early
signs
of
aggression
in
their
pets.
Young,
reproductively
intact
males
would
seem
to
be
especially
dangerous.
Perhaps
local
health
departments,
veterinary
associations,
or
humane
societies
could
take
the
initiative
in
providing
their
communities
with
appropriate
informa-
tion.
2.
Once
sensitized
to
the
potential
dangers
of
an
ag-
gressive
dog,
owners
should
be
encouraged
to
seek
help
from
specialists
formally
trained
in
the
diagnosis
and
treatment
of
animal
behavior
problems.
Recent
reports
have
described
successful
procedures
for
the
diagnosis
and
treatment
of
different
kinds
of
aggression
in
dogs
(6-9).
The
treatments
may
include
combinations
of
sur-
gical,
pharmacological,
and
behavioral
therapies
and
are
quite
different
from
attempts
to
control
aggressive
behav-
ior
through
obedience
training.
3.
Additional
efforts
to
reduce
dog
bite
incidents
should
be
focused
at
the
level
of
the
potential
victim.
A
program
of
education
in
dog-bite
avoidance,
directed
toward
likely
victims,
has
been
suggested
elsewhere
(1).
One
merely
has
to
listen
to
a
victim's
or
witnesses'
attribution
of
the
causes
of
a
dog
bite
to
discover
how
unaware
the
general
public
is
of
the
danger
signs
that
are
associated
with
attacks
by
dogs.
Apart
from
shedding
some
light
on
the
characteristics
of
severe
attacks
by
dogs,
this
survey
raises
many
ques-
tions
that
as
yet
remain
unanswered.
For
example:
*
Only
seven
victims
reported
interacting
with
the
dog
before
the
attack.
What
are
the
properties
of
victims'
behaviors
that
elicit
an
attack?
*
Only
seven
victims
reported
a
warning
of
attack
by
the
dogs
involved.
Do
dogs
provide
danger
signs
or
signals,
60
Public
Health
Reports
before
an
attack,
that
the
victims
do
not
recognize
or
respond
to
appropriately?
Do
victims
maintain
an
attack
by
continuing
to
move
or
struggle?
*
In
8
of
the
16
cases,
the
dog
involved
either
was
chained
or
broke
loose
from
its
chain
to
attack
its
victim.
Does
restricting
a
dog
in
this
manner
actually
increase
the
chances
of
a
severe
bite?
Clearly,
more
detailed
study
is
necessary
to
clarify
the
behavioral
sequence
preceding
severe
attacks.
References
..................................
1.
Borchelt,
P.
L.,
Lockwood,
R.,
Beck,
A.
M.,
and
Voith,
V.
L.:
Attacks
by
packs
of
dogs
involving
predation
on
human
beings.
Public
Health
Rep
98:
57-66,
January-February
1983.
2.
Pinckney,
L.
E.,
and
Kennedy,
L.
A.:
Traumatic
deaths
from
dog
attacks
in
the
United
States.
Pediatrics
69:
193-196
(1982);
(a)
p.
194.
3.
Winkler,
W.
G.:
Human
deaths
induced
by
dog
bites,
United
States,
1974-75.
Public
Health
Rep
92:
425-429,
September-October
1977.
4.
Beck,
A.
M.:
Letter
to
the
editor.
Community
Animal
Control
3(2):
4-5
(1984).
5.
Flinn,
C.
M.:
Letter
to
the
editor.
Community
Animal
Control
3(2):
6,24-25,32
(1984).
6.
Borchelt,
P.
L.:
Aggressive
behavior
of
dogs
kept
as
com-
panion
animals:
classification
and
influences
of
sex,
re-
productive
status
and
breed.
Appl
Animal
Ethol
10:
45-61
(1983).
7.
Borchelt,
P.
L.,
and
Voith,
V.
L.:
Classification
of
animal
behavior
problems.
In
Symposium
on
animal
behavior,
Vet-
erinary
Clinics
of
North
America,
Vol.
12,
No.
4,
edited
by
V.
L.
Voith
and
P.
L.
Borchelt.
W.
B.
Saunders
Co.,
Philadelphia,
pp.
571-585,
1982.
8.
Hart,
B.
L.:
Canine
behavior.
Veterinary
Practice
Publish-
ing,
Santa
Barbara,
Calif.,
1980.
9.
Wright,
J.
C.,
Fillingim,
R.,
and
Nesselrote,
M.:
Classifica-
tion
of
behavior
problems
in
dogs:
influence
of
age,
breed,
sex
and
reproductive
status.
Paper
presented
at
the
Animal
Behavior
Society
meeting,
Cheney,
Wash.,
August
13-17,
1984.
A
Civilian-Military
Partnership
to
Reduce
the
Incidence
of
Gonorrhea
DONALD
E.
WOODHOUSE,
MPA
JOHN
J.
POTTERAT,
BA
JOHN
B.
MUTH,
MD,
MPH
CHRISTOPHER
1.
PRATTS,
BA
RICHARD
B.
ROTHENBERG,
MD,
MPH
JAMES
S.
FOGLE
11
Mr.
Woodhouse,
a
Venereal
Disease
Program
Representative
with
the
Colorado
Department
of
Health
between
1979
and
1982,
currently
attends
law
school
in
Denver.
Mr.
Potterat,
Mr.
Pratts,
and
Mr.
Fogle
are
with
VD
Control,
El
Paso
County
Health
Department,
501
N.
Foote
Ave.,
Colorado
Springs,
Colo.
80909.
Dr.
Muth
is
Director,
El
Paso
County
Health
Department.
Dr.
Rothenberg
is
Director,
Bureau
of
Chronic
Disease
Prevention,
New
York
State
Health
Department,
Albany.
Tearsheet
requests
to
Mr.
Potterat.
Synopsis.....................................
To
reduce
the
incidence
of
gonorrhea
in
the
Colorado
Springs,
Colo.,
area,
casefinding
measures
(interview-
ing
of
patients
and
tracing
of
contacts)
were
conscien-
tiously
applied
by
the
local
health
department,
in
coop-
eration
with
the
U.S.
Army,
to
more
than
90
percent
of
reported
cases
during
a
3-year
period.
Nearly
4,000
cases
of
gonorrhea-2,127
civilian
and
1,811
military-
were
interviewed;
they
named
7,399
contacts.
A
total
of
1,141
cases
of
gonorrhea
were
newly
identified
and
patients
brought
to
treatment
in
Colorado
Springs
as
a
result.
Implementation
of
these
measures
was
associated
with
a
12.9
percent
overall
decline
in
gonorrhea
inci-
dence.
This
decline
was
most
pronounced
in
the
civilian
population
(20
percent),
while
little
change
in
incidence
occurred
in
the
military
population.
The
data presented
suggest
that
the
orderly
application
of
casefinding
epi-
demiology,
allied
with
other
control
program
initiatives,
can
interrupt
transmission
of,
and
prevent,
disease.
IN
THE
UNITED
STATES,
civilian
and
military
public
health
officers
are
urged
to
cooperate
in
the
control
of
venereal diseases
by
the
Seven
Point
Agreement
of
1967
(1),
an
accord
between
the
Departments
of
Defense,
Transportation,
and
Health
and
Human
Services
and
re-
gional
health
agencies.
Its
intent
is
to
curb
impo