Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-6376

2. Registrant Information.

Registrant Reference Number: 2022-US-028577

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: N1G 5L3

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

Domestic Animal

4. Date registrant was first informed of the incident.

30-JUL-22

5. Location of incident.

Country: UNITED STATES

Prov / State: MINNESOTA

6. Date incident was first observed.

30-JUL-22

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, 10 lbs

• 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?

Unknown

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

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Golden Retriever

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

13

7. Weight (provide a range if necessary )

35

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Convulsions

• Gastrointestinal System
  • Symptom - Foaming at mouth

• Nervous and Muscular Systems
  • Symptom - Seizure

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify Speculated exposure

17. Provide any additional details about the incident

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

On 30 Jul 2022, the dog may have ingested an unknown amount of the product. Approximately 10 minutes later the dog developed convulsions and foaming at the mouth. On the night of 30 Jul 2022, the dog developed a prolonged seizure and died. Animal owner clarified that they were speculating about the initial exposure and it is unknown if the dog ingested the product. The dog was not evaluated by a veterinarian and a necropsy was not performed. No further information is expected.

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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

Assessment: Clinical signs following methomyl exposure can include those related to muscarinic receptors (including excessive salivation or foaming at the mouth) and the nicotinic receptors (tremors, convulsions, and seizures among other neurological symptoms). The clinical signs described in this case, including death, are consistent with those caused by methomyl; however, these clinical signs are not specific to only methomyl exposure. Further information regarding the exposure of the dog to the product, as well as physical exam findings and necropsy of this geriatric dog would allow for further assessment of causality. The information contained in this report is based on self-reported statements provided to the registrant during telephone interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and cannot form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews. This product should not be anywhere that a pet or child may have access.