Incident Report
Subform I: General Information
1. Report Type.
Update the report
Incident Report Number: 2009-5411
2. Registrant Information.
Registrant Reference Number: X
Registrant Name (Full Legal Name no abbreviations): X
Address: X
City: X
Prov / State: X
Country: X
Postal Code: X
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
07-AUG-09
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)
PMRA Registration No. 24175
PMRA Submission No.
EPA Registration No.
Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE INSECTICIDE
PMRA Registration No. 15330
PMRA Submission No.
EPA Registration No.
Product Name: PRO 110 ULV INSECTICIDE
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- PYRETHRINS
PMRA Registration No. 25673
PMRA Submission No.
EPA Registration No.
Product Name: TEMPO 20 WP INSECTICIDE
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
Site: Res. - In Home / Rés. - à l'int. maison
Préciser le type: Apartment, residence
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
One applied by fogging and one applied around perimeter. I have not been able to get information as to which was used in fogging. (.)Dragnet should not have been used this way) The following is the application rate used last week in another apartment in my building. Dragnet 0.5% Permethrin PC24175-110ULV 1.0%.
I do not know if the same application was used in my apartment in August'09.Reported to PMRA Ottawa. Talked to Iulia Popa (Call line), Ilze Rupners (CLSROD B.C.),Also to Dept. of Environment-Pesticide Control in Surrey B.C.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Data Subject
2. Demographic information of data subject
Sex: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Burning skin
- Specify - Face burning
- Nervous and Muscular Systems
- Nervous and Muscular Systems
- Symptom - Difficulty talking
- Specify - Impaired speech
- Skin
- Symptom - Paresthesia
- Symptom - Rash
- Skin
- Symptom - Other
- Specify - rough
- Symptom - Peeling skin
- Specify - scaly skin
- Nervous and Muscular Systems
- Symptom - Headache
- Symptom - Memory loss
- Symptom - Confusion
4. How long did the symptoms last?
>2 mos and <=6mos />2 mois et <=6mois
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? Living in treated area
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
10. Route(s) of exposure.
Skin
Eye
Respiratory
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>24 hrs <=3 days / >24 h <=3 jours
13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)
First symptoms occured day after spraying August8'09. Tingling and prickling all over body. Went to walk-in clinic doctor did not know what to recommend other that if it got worse go to the ER. August 10 reaction was much worse. Face burning and red ; eyes glossy; speech impaired. Caller neighbour who took me to ER doctor called Poison Control Center. They said I was having an allergic reaction to the Permethrin. Prescribed Benadryl. August 11 went to see my family doctor who said it was not an allergic reaction but that I had been poisoned by the Permethrin. He advised leaving the apartment for 3-4 week. Before returning to my Apt. I had it washed down. I am continuing to have symptoms. Burning all over body; dry mouth;trembling;nausea;paresthesia. Large rash all over thighs. Patches of rough and scaly skin. Dec07'09. Went to ER was given RX.:Hyderm1% and Apo-hydroxyzin 10mg. Every reaction is worse than last. This is not enough room for me to go into every detail but this has been going on for 4 months. Also get very cold with severe reaction. Headaches. Effects cognitive functiosn, memory, confusion. Apartment was sprayed on August 7'09 for bedbugs. Do not know but see above.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.