Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-4351

2. Registrant Information.

Registrant Reference Number: 150079577

Registrant Name (Full Legal Name no abbreviations): Wellmark International

Address: 100 Stone Road West, Suite 111

City: Guelph

Prov / State: Ontario

Country: Canada

Postal Code: N1G5L3

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

15-JUN-15

5. Location of incident.

Country: UNITED STATES

Prov / State: NORTH CAROLINA

6. Date incident was first observed.

12-JUN-15

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2724-274

Product Name: Starbar Golden Malrin Fly Bait 1% Methomyl

• Active Ingredient(s)
  • (Z)-9-TRICOSENE
    • Guarantee/concentration .049 %
  • METHOMYL
    • Guarantee/concentration 1 %

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7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

No

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

German Shepherd

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

0.173

7. Weight (provide a range if necessary )

16.0

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Anorexia

• General
  • Symptom - Lethargy

• Gastrointestinal System
  • Symptom - Bloody diarrhea

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify Relay

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

On June 12, 2015 the dog developed symptoms. On June 14, 2015 the dog died. On June 15, 2015 the regular veterinarian contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated methomyl is a hot carbamate insecticide with a narrow margin of safety; clinical signs include muscarinic signs excessive salivation, lacrimation, urination, defecation, dyspnea, emesis (SLUDDE), miosis, bradycardia, and dyspnea (due to goblet cell secretions). The APSS veterinarian also stated the nicotinic signs include tremors, twitching, weakness and paresis; the onset is generally rapid. The APSS veterinarian also noted if not a lethal exposure, signs are expected to resolve spontaneously due to the reversible nature of carbamate toxicity. The APSS veterinarian further stated activated charcoal (a/c) can be given if no significant signs, atropine controls muscarinic signs, tremors and seizures can be treated (tx) with diazepam, oxygen as needed (prn), and other symptomatic and supportive (sym/supp) care. The APSS veterinarian finally stated that this relay exposure would not result in significant clinical signs and to rule out other causes for the signs. A necropsy was recommended, but the body was not available. The APSS veterinarian recommended to call back back with questions.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

The APSS veterinarian stated that the substance was considered to have a doubtful likelihood of causing the clinical situation.