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Topic:Epidemiology

Epidemiology in horses involves the study of the distribution and determinants of health-related states and events in equine populations. It encompasses the investigation of patterns, causes, and effects of diseases and health conditions within horse populations. This field of study aims to identify risk factors for disease and targets for preventive healthcare. Key components of equine epidemiology include disease surveillance, outbreak investigation, and the study of disease dynamics within herds or regions. Research in this area often focuses on infectious diseases, zoonotic diseases, and the impact of environmental factors on equine health. This page compiles peer-reviewed research studies and scholarly articles that explore various aspects of epidemiology in horses, including disease prevalence, transmission pathways, and strategies for disease prevention and control.
Seroconversion for West Nile and St. Louis encephalitis viruses among sentinel horses in Colombia.
Memorias do Instituto Oswaldo Cruz    January 14, 2012   Volume 106, Issue 8 976-979 doi: 10.1590/s0074-02762011000800012
Mattar S, Komar N, Young G, Alvarez J, Gonzalez M.We prospectively sampled flavivirus-naïve horses in northern Colombia to detect West Nile virus (WNV) and St. Louis encephalitis virus (SLEV) seroconversion events, which would indicate the current circulation of these viruses. Overall, 331 (34.1%) of the 971 horses screened were positive for past infection with flaviviruses upon initial sampling in July 2006. During the 12-month study from July 2006-June 2007, 33 WNV seroconversions and 14 SLEV seroconversions were detected, most of which occurred in the department of Bolivar. The seroconversion rates of horses in Bolivar for the period of M...
Air sampling in the breathing zone of neonatal foals for prediction of subclinical Rhodococcus equi infection.
Equine veterinary journal    January 12, 2012   Volume 44, Issue 2 203-206 doi: 10.1111/j.2042-3306.2011.00450.x
Chicken C, Muscatello G, Freestone J, Anderson GA, Browning GF, Gilkerson JR.Disease caused by Rhodococcus equi is a significant burden to the horse breeding industry worldwide. Early detection of rhodococcal pneumonia, albeit important to minimise treatment costs, is difficult because of the insidious nature of the disease and the lack of definitive diagnostic tests. Objective: To investigate air sampling from the breathing zone of neonatal foals as a predictor of subsequent rhodococcal pneumonia. Methods: Air samples were collected from the breathing zone of 53 neonatal foals (age ≤10 days) and again at the time of routine ultrasonographic screening for R. equi p...
Surveillance for antibodies to West Nile virus in Ireland.
The Veterinary record    January 11, 2012   Volume 170, Issue 7 180 doi: 10.1136/vr.100333
Raleigh PJ, Sammin DJ, Connell J, Markey BK, O'Connor M.No abstract available
Whole genome scan identifies several chromosomal regions linked to equine sarcoids.
Schweizer Archiv fur Tierheilkunde    January 10, 2012   Volume 154, Issue 1 19-25 doi: 10.1024/0036-7281/a000288
Jandova V, Klukowska-Rötzler J, Dolf G, Janda J, Roosje P, Marti E, Koch C, Gerber V, Swinburne J.Despite the evidence for a genetic predisposition to develop equine sarcoids (ES), no whole genome scan for ES has been performed to date. The objective of this explorative study was to identify chromosome regions associated with ES. The studied population was comprised of two half-sibling sire families, involving a total of 222 horses. Twenty-six of these horses were affected with ES. All horses had been previously genotyped with 315 microsatellite markers. Quantitative trait locus (QTL) signals were suggested where the F statistic exceeded chromosome-wide significance at P < 0.05. The QTL...
Analysis of risk factors associated with antibiotic-resistant Escherichia coli.
Microbial drug resistance (Larchmont, N.Y.)    January 9, 2012   Volume 18, Issue 2 161-168 doi: 10.1089/mdr.2011.0213
Ahmed MO, Williams NJ, Clegg PD, van Velkinburgh JC, Baptiste KE, Bennett M.Antimicrobial-resistant bacteria represent a major threat to human and animal health. We compared equine fecal samples (n=264) from 138 horses from hospital and nonhospital (livery stable and riding school) premises in North West England to determine the prevalence of Escherichia coli, Salmonella, and Campylobacter and rates of antimicrobial-resistant E. coli strains. Campylobacter jejuni was detected only in hospitalized horses (1.1%), and no Salmonella was identified. Data analysis of the horses' management and veterinary treatments (Tx) identified risk factors associated with shedding of an...
Influence of day of postpartum breeding on pregnancy rate, pregnancy loss rate, and foaling rate in Thoroughbred mares.
Theriogenology    January 5, 2012   Volume 77, Issue 7 1290-1296 doi: 10.1016/j.theriogenology.2011.10.034
Blanchard TL, Thompson JA, Love CC, Brinsko SP, Ramsey J, O'Meara A, Varner DD.Records (years 2005-2007) were analyzed from a Thoroughbred stud farm in central Kentucky. Data from all breeding cycles of foaling mares were tabulated (3184 cycles of 2003 foaling mares bred between 7 and 163 days postpartum). A multiple logistic regression model employing Bayesian statistics was used to adjust for factors that significantly affected outcome; odds ratios (ORs) for pregnancy rate, pregnancy loss rate, and foaling rate were determined to examine the influence of day of postpartum breeding on these parameters. Mares bred before Day 22 (Day 0 = day of foaling) postpartum had a d...
Investigation of allele frequencies for Lavender foal syndrome in the horse.
Animal genetics    January 4, 2012   Volume 43, Issue 5 650 doi: 10.1111/j.1365-2052.2011.02305.x
Gabreski NA, Haase B, Armstrong CD, Distl O, Brooks SA.No abstract available
A diagnostic algorithm to serologically differentiate West Nile virus from Japanese encephalitis virus infections and its validation in field surveillance of poultry and horses.
Vector borne and zoonotic diseases (Larchmont, N.Y.)    January 4, 2012   Volume 12, Issue 5 372-379 doi: 10.1089/vbz.2011.0709
Yeh JY, Lee JH, Park JY, Seo HJ, Moon JS, Cho IS, Kim HP, Yang YJ, Ahn KM, Kyung SG, Choi IS, Lee JB.The detection of West Nile virus (WNV) in areas endemic for Japanese encephalitis virus (JEV) is complicated by the extensive serological cross-reactivity between the two viruses. A testing algorithm was developed and employed for the detection of anti-WNV antibody in areas endemic for JEV. Using this differentiation algorithm, a serological survey of poultry (2004 through 2009) and horses (2007 through 2009) was performed. Among 2681 poultry sera, 125 samples were interpreted as being positive for antibodies against JEV, and 14 were suspected to be positive for antibodies against undetermined...
Predictive risk mapping of West Nile virus (WNV) infection in Saskatchewan horses.
Canadian journal of veterinary research = Revue canadienne de recherche veterinaire    January 3, 2012   Volume 75, Issue 3 161-170 
Epp TY, Waldner C, Berke O.The objective of this study was to develop a model using equine data from geographically limited surveillance locations to predict risk categories for West Nile virus (WNV) infection in horses in all geographic locations across the province of Saskatchewan. The province was divided geographically into low-, medium-, or high-risk categories for WNV, based on available serology information from 923 horses obtained through 4 studies of WNV infection in horse populations in Saskatchewan. Discriminant analysis was used to build models using the observed risk of WNV in horses and geographic division...
Detection of Anaplasma phagocytophilum in ixodid ticks from equine-inhabited sites in the Southeastern United States.
Vector borne and zoonotic diseases (Larchmont, N.Y.)    January 3, 2012   Volume 12, Issue 4 330-332 doi: 10.1089/vbz.2011.0757
Roellig DM, Fang QQ.Anaplasma phagocytophilum is a vector-borne, obligate intracellular bacterium that invades the neutrophils and eosinophils of infected individuals, causing granulocytic anaplasmosis. Equine cases have previously been reported in the United States from California, Florida, and Connecticut, but limited surveillance studies in the Southeast have been conducted. The objective of this study was to determine A. phagocytophilum prevalence in Ixodes scapularis ticks at southeastern U.S. horse-inhabited sites to evaluate the potential risk for equine exposure to A. phagocytophilum-infected ticks in the...
Prevalence and intensity of gastro-intestinal helminths in horses in the Sudano-Guinean climatic zone of Cameroon.
Tropical parasitology    January 1, 2012   Volume 2, Issue 1 45-48 doi: 10.4103/2229-5070.97239
Lem MF, Vincent KP, Pone JW, Joseph T.It is important to understand the biology and health impact of parasites affecting horses in the Western highlands of Cameroon. Objective: to evaluate the prevalence and intensity of infection of gastrointestinal helminths in these animals. Methods: A total of 894 horses (367 males and 527 females), and aged ≤1 to ≥7 years old were examined. A parasitological investigation of faeces was carried out using two techniques: concentration method of Full Born Willis (flotation in saturated solution of sodium chloride) and Mc Master Technique. Conclusions: From the results the overall prevalence ...
Recombinant envelope protein (rgp90) ELISA for equine infectious anemia virus provides comparable results to the agar gel immunodiffusion.
Journal of virological methods    December 30, 2011   Volume 180, Issue 1-2 62-67 doi: 10.1016/j.jviromet.2011.12.012
Reis JK, Diniz RS, Haddad JP, Ferraz IB, Carvalho AF, Kroon EG, Ferreira PC, Leite RC.Equine infectious anemia (EIA) is an important viral infection affecting horses worldwide. The course of infection is accompanied generally by three characteristic stages: acute, chronic and inapparent. There is no effective EIA vaccine or treatment, and the control of the disease is based currently on identification of EIAV inapparent carriers by laboratory tests. Recombinant envelope protein (rgp90) was expressed in Escherichia coli and evaluated via enzyme-linked immunosorbent assay (ELISA). There was an excellent agreement (95.42%) between the ELISA results using rgp90 and agar gel immunod...
Monitoring of the West Nile virus epidemic in Spain between 2010 and 2011.
Transboundary and emerging diseases    December 30, 2011   Volume 59, Issue 5 448-455 doi: 10.1111/j.1865-1682.2011.01298.x
García-Bocanegra I, Jaén-Téllez JA, Napp S, Arenas-Montes A, Fernández-Morente M, Fernández-Molera V, Arenas A.West Nile virus (WNV) is a mosquito-transmitted flavivirus recognized as an emerging and re-emerging pathogen in different countries. This study describes the monitoring of the first WNV epidemic in Spain between 2010 and 2011. Between September and December 2010, 36 outbreaks of WNV in horses were reported in three different provinces of Andalusia (southern Spain), with no apparent spread outside this area. The temporal distribution and the clinical signs observed during the WNV epidemic in Spain were, in general, similar to those reported in Europe and in the Mediterranean Basin. Morbidity, ...
Emergence of novel equine arteritis virus (EAV) variants during persistent infection in the stallion: origin of the 2007 French EAV outbreak was linked to an EAV strain present in the semen of a persistently infected carrier stallion.
Virology    December 29, 2011   Volume 423, Issue 2 165-174 doi: 10.1016/j.virol.2011.11.028
Miszczak F, Legrand L, Balasuriya UB, Ferry-Abitbol B, Zhang J, Hans A, Fortier G, Pronost S, Vabret A.During the summer of 2007, an outbreak of equine viral arteritis (EVA) occurred in Normandy (France). After investigation, a link was suggested between an EAV carrier stallion (A) and the index premise of the outbreak. The full-length nucleotide sequence analysis of a study reference strain (F27) isolated from the lung of a foal revealed a 12,710 nucleotides EAV genome with unique molecular hallmarks in the 5'UTR leader sequence and the ORF1a sequence encoding the non-structural protein 2. The evolution of the viral population in the persistently infected Stallion A was then studied by cloning...
Development and laboratory evaluation of two lateral flow devices for the detection of vesicular stomatitis virus in clinical samples.
Journal of virological methods    December 29, 2011   Volume 180, Issue 1-2 96-100 doi: 10.1016/j.jviromet.2011.12.010
Ferris NP, Clavijo A, Yang M, Velazquez-Salinas L, Nordengrahn A, Hutchings GH, Kristersson T, Merza M.Two lateral flow devices (LFD) for the detection of vesicular stomatitis (VS) virus (VSV), types Indiana (VSV-IND) and New Jersey (VSV-NJ) were developed using monoclonal antibodies C1 and F25VSVNJ-45 to the respective VSV serotypes. The performance of the LFDs was evaluated in the laboratory on suspensions of vesicular epithelia and cell culture passage derived supernatants of VSV. The collection of test samples included 105 positive for VSV-IND (92 vesicular epithelial suspensions and 13 cell culture antigens; encompassing 93 samples of subtype 1 [VSV-IND-1], 9 of subtype 2 [VSV-IND-2] and 3...
The danger of having all your eggs in one basket–winter crash of the re-introduced Przewalski’s horses in the Mongolian Gobi.
PloS one    December 28, 2011   Volume 6, Issue 12 e28057 doi: 10.1371/journal.pone.0028057
Kaczensky P, Ganbataar O, Altansukh N, Enkhsaikhan N, Stauffer C, Walzer C.Large mammals re-introduced into harsh and unpredictable environments are vulnerable to stochastic effects, particularly in times of global climate change. The Mongolian Gobi is home to several rare large ungulates such as re-introduced Przewalski's horses (Equus ferus przewalskii) and Asiatic wild asses (Equus hemionus), but also to a millennium-old semi-nomadic livestock herding culture.The Gobi is prone to large inter-annual environmental fluctuations, but the winter 2009/2010 was particularly severe. Millions of livestock died and the Przewalski's horse population in the Gobi crashed. We u...
Heritability estimates for racing performance in Japanese Thoroughbred racehorses using linear and non-linear model analyses.
Journal of animal breeding and genetics = Zeitschrift fur Tierzuchtung und Zuchtungsbiologie    December 28, 2011   Volume 129, Issue 5 402-408 doi: 10.1111/j.1439-0388.2011.00982.x
Tozaki T, Miyake T, Kakoi H, Gawahara H, Hirota K, Nakano Y, Kurosawa M.This study evaluated the differences between linear and non-linear modelled heritability estimates of racing performance based on lifetime earnings (LE) and lifetime ranking (LR) in Japanese Thoroughbred racehorses. The heritability estimate (h(2) = 0.25) obtained from a non-linear model based on formal Japan Racing Association ranking was much higher than that obtained from a linear model based on the original trait phenotype (h(2) = 0.11). The linear models showed slightly higher heritability estimates under the trait categorizations than under the original phenotypes, while the non-linear c...
A clinical case of dourine in an outbreak in Italy.
Veterinaria italiana    December 24, 2011   Volume 47, Issue 4 473-472 
Scacchia M, Cammà C, Di Francesco G, Di Provvido A, Giunta R, Luciani M, Marino AM, Pascucci I, Caporale V.In May 2011, dourine was reported in Italy following the declaration of a positive result observed in a stallion undergoing routine testing for stud purposes. Clinical signs, anatomo-histopathological findings and laboratory results that resulted in the confirmation of diagnosis of dourine in a clinically affected mare, which was the likely source of infection in the stallion, are described.
Complete molecular genome analyses of equine rotavirus A strains from different continents reveal several novel genotypes and a largely conserved genotype constellation.
The Journal of general virology    December 21, 2011   Volume 93, Issue Pt 4 866-875 doi: 10.1099/vir.0.039255-0
Matthijnssens J, Miño S, Papp H, Potgieter C, Novo L, Heylen E, Zeller M, Garaicoechea L, Badaracco A, Lengyel G, Kisfali P, Cullinane A, Collins PJ....In this study, the complete genome sequences of seven equine group A rotavirus (RVA) strains (RVA/Horse-tc/GBR/L338/1991/G13P[18], RVA/Horse-wt/IRL/03V04954/2003/G3P[12] and RVA/Horse-wt/IRL/04V2024/2004/G14P[12] from Europe; RVA/Horse-wt/ARG/E30/1993/G3P[12], RVA/Horse-wt/ARG/E403/2006/G14P[12] and RVA/Horse-wt/ARG/E4040/2008/G14P[12] from Argentina; and RVA/Horse-wt/ZAF/EqRV-SA1/2006/G14P[12] from South Africa) were determined. Multiple novel genotypes were identified and genotype numbers were assigned by the Rotavirus Classification Working Group: R9 (VP1), C9 (VP2), N9 (NSP2), T12 (NSP3), ...
Genetic analyses of new movement traits using detailed evaluations of warmblood foals and mares.
Journal of animal breeding and genetics = Zeitschrift fur Tierzuchtung und Zuchtungsbiologie    December 20, 2011   Volume 129, Issue 5 390-401 doi: 10.1111/j.1439-0388.2011.00980.x
Becker AC, Stock KF, Distl O.Detailed movement evaluations of warmblood foals and mares were performed in connection with regular breeding events of the Oldenburg horse breeding societies in 2009 and 2010. Unfavourable movement characteristics considered indicative for impaired balance were noted by a special judge (SJ) and the regular judges of the breeding events (RJ) and served as the basis for definition of new movement traits. Detailed movement information on 3374 foals and 2844 mares showed that more severe findings like irregular motion pattern in hind legs or irregularity in general motion pattern occurred only sp...
West Nile fever outbreak in horses and humans, Spain, 2010.
Emerging infectious diseases    December 17, 2011   Volume 17, Issue 12 2397-2399 doi: 10.3201/eid1712.110651
García-Bocanegra I, Jaén-Téllez JA, Napp S, Arenas-Montes A, Fernández-Morente M, Fernández-Molera V, Arenas A.TO THE EDITOR: West Nile virus (WNV) is a member of the genus Flavivirus within the Japanese encephalitis antigenic complex. The enzootic virus cycle involves transmission between avian hosts and ornithophilic mosquitoes, whereas humans and horses are considered dead-end hosts. Given the recent increase of WNV infection in humans and horses in Europe, concern has been raised regarding public and animal health.
Animal diseases caused by orbiviruses, Algeria.
Emerging infectious diseases    December 17, 2011   Volume 17, Issue 12 2325-2327 doi: 10.3201/eid1712.110928
Madani H, Casal J, Alba A, Allepuz A, Cêtre-Sossah C, Hafsi L, Kount-Chareb H, Bouayed-Chaouach N, Saadaoui H, Napp S.Antibodies against bluetongue virus were detected in cattle, sheep, goats, and camels in Algeria in 2008. Antibodies against epizootic hemorrhagic disease virus were detected in cattle, but antibodies against African horse sickness virus were not detected in horses and mules. Epizootic hemorrhagic disease in northern Africa poses a major risk for the European Union.
Experimental infection of horses with Hendra virus/Australia/horse/2008/Redlands.
Emerging infectious diseases    December 17, 2011   Volume 17, Issue 12 2232-2238 doi: 10.3201/eid1712.111162
Marsh GA, Haining J, Hancock TJ, Robinson R, Foord AJ, Barr JA, Riddell S, Heine HG, White JR, Crameri G, Field HE, Wang LF, Middleton D.Hendra virus (HeV) is a highly pathogenic zoonotic paramyxovirus harbored by Australian flying foxes with sporadic spillovers directly to horses. Although the mode and critical control points of HeV spillover to horses from flying foxes, and the risk for transmission from infected horses to other horses and humans, are poorly understood, we successfully established systemic HeV disease in 3 horses exposed to Hendra virus/Australia/Horse/2008/Redlands by the oronasal route, a plausible route for natural infection. In 2 of the 3 animals, HeV RNA was detected continually in nasal swabs from as ea...
Nonruminant Nutrition Symposium: Involvement of gut neural and endocrine systems in pathological disorders of the digestive tract.
Journal of animal science    December 16, 2011   Volume 90, Issue 4 1203-1212 doi: 10.2527/jas.2011-4825
Furness JB, Poole DP.The functioning of the gastrointestinal tract is under the control of the most extensive system of peripheral neurons in the body, the enteric nervous system, and the largest endocrine system of the body, the GEP endocrine system. The enteric nervous system in large mammals contains 500 million neurons, and the GEP endocrine system produces more than 30 hormones. Numerous enteric neuropathies affecting both humans and animals have been described and digestive disorders affect commercially important species, such as horses and cattle. The most severe enteric neuropathies (e.g., lethal white syn...
[Pyrrolizidine alkaloids and seneciosis in farm animals. Part 2: clinical signs, species-specific sensitivity, food residues, feed contamination, limit values].
Tierarztliche Praxis. Ausgabe G, Grosstiere/Nutztiere    December 15, 2011   Volume 39, Issue 6 363-372 
Petzinger E.At the forefront of pyrrolizidine alkaloid (PA) poisoning is the chronic ingestion of contaminated hay, which causes liver damage resulting in an ongoing fatal liver cirrhosis or in the veno-occlusive disease in liver or lung, respectively. The symptomatology of PA-poisoning is not identical for all animal species, and also includes central nervous symptoms. In affected horses significantly elevated levels of hepatogenic serum enzymes and an increase of the retention time for bromosulfophthalein indicates the fatal outcome of the intoxication. Chronic seneciosis of horses is incurable. Rabbits...
The influence of mare numbers, ejaculation frequency and month on the fertility of Thoroughbred stallions.
Equine veterinary journal    December 14, 2011   Volume 44, Issue 5 535-541 doi: 10.1111/j.2042-3306.2011.00525.x
Allen WR, Wilsher S.Although considerable variation in per cycle pregnancy rates exists between Thoroughbred (TB) stallions, there is little information on factors that may influence this figure. Objective: To assess the influence of month, mare numbers and mating frequency on the fertility of TB stallions standing on studfarms in East Anglia, England. Methods: The daily breeding records of 31 TB stallions mating 3034 mares on 4851 occasions during the 2010 season were surveyed and related to first scan pregnancy rates. The influences of mare book size, month, number of matings per day and mating frequency or abs...
Equine encephalosis virus: evidence for circulation beyond southern Africa.
Epidemiology and infection    December 14, 2011   Volume 140, Issue 11 1982-1986 doi: 10.1017/S0950268811002688
Oura CA, Batten CA, Ivens PA, Balcha M, Alhassan A, Gizaw D, Elharrak M, Jallow DB, Sahle M, Maan N, Mertens PC, Maan S.Prior to the recent outbreak of equine encephalosis in Israel in 2009, equine encephalosis virus (EEV) had only been isolated from equids in South Africa. In this study we show the first evidence for the circulation of EEV beyond South Africa in Ethiopia, Ghana and The Gambia, indicating that EEV is likely to be freely circulating and endemic in East and West Africa. Sequence analysis revealed that the EEV isolate circulating in The Gambia was closely related to an EEV isolate that was isolated from a horse from Israel during the EEV outbreak in 2009, indicating that the two viruses have a com...
Investigation of strongyle EPG values in horse mares relative to known age, number positive, and level of egg shedding in field studies on 26 farms in Central Kentucky (2010-2011).
Parasitology research    December 14, 2011   Volume 110, Issue 6 2237-2245 doi: 10.1007/s00436-011-2755-z
Lyons ET, Tolliver SC, Kuzmina TA.A parasite study was done in 1,300 horse mares on 26 farms in Central Kentucky over a 5-month period in 2010 and 2011. The mares included 1,114 Thoroughbreds (TB) on 24 farms, 64 Standardbreds (SB) on 1 farm, and 122 mixed light horse types (MLH) on 1 farm. The objective of this research was to determine strongyle eggs per gram of feces (EPG) counts for evaluation by known age, number positive, and level of egg shedding by the mares. This was done to establish strongyle EPG profiles for the mares to aid in determining whether antiparasitic treatment was necessary. Eggs found were considered th...
Complex dynamic upper airway collapse: associations between abnormalities in 99 harness racehorses with one or more dynamic disorders.
Equine veterinary journal    December 13, 2011   Volume 44, Issue 5 524-528 doi: 10.1111/j.2042-3306.2011.00516.x
Strand E, Skjerve E.Many horses demonstrate dynamic collapse of more than one upper respiratory tract (URT) structure during high-speed treadmill videoendoscopy (HSTV). Objective: To report the frequency of complex dynamic URT collapse in harness racehorses and determine if an association exists between occurrence of certain disorders. Methods: Retrospective study of 99 Standardbreds and Coldblooded trotters that had one or more dynamic URT disorders identified during HSTV between 1998 and 2006. The horses underwent HSTV using a protocol that included periods of free head carriage and poll flexion until fully fat...
[Traumatology and sport injuries in professional and amateur show-jumping competitors].
Sportverletzung Sportschaden : Organ der Gesellschaft fur Orthopadisch-Traumatologische Sportmedizin    December 12, 2011   Volume 25, Issue 4 222-226 doi: 10.1055/s-0031-1273483
Lechler P, Walt L, Grifka J, Waltl V, Renkawitz T.The objective of this study was to investigate the frequency, extent, and effective preventive measures of sport injuries in professional and amateur-show jumping competitors. In a retrospective study design, 264 show-jumping riders (105 professionals, 159 amateurs) were interviewed by means of a standardised questionnaire. In total, 636 injuries were reported in detail. Injuries were categorised into severity grade I (36.0 %) (not requiring medical attention), grade II (34.6 %) (single medical treatment), grade III (20.9 %) (several outpatient medical treatments) and grade IV (8.5 %) (req...