Health Canada
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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-1833
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.
Domestic Animal
4. Date registrant was first informed of the incident.
29-APR-105. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
20-APR-10Product 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. 26494 PMRA Submission No. EPA Registration No.
Product Name: ZODIAC POWERSPOT FLEA & TICK CONTROL FOR DOGS UNDER 14KG
- Active Ingredient(s)
- (S)-METHOPRENE
- PERMETHRIN
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
1Units: mL
10. Site pesticide was applied to (select all that apply).
Site: Animal / Usage sur un animal domestique
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Applied base of neck between shoulder blades. 1 Tube = 1 ml. Spot on treatment.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
Schipperke
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
5
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>8 hrs <= 24 hrs / >8 h <= 24 h
10. Time between exposure and onset of symptoms
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
- Respiratory System
- Symptom - Panting
- Nervous and Muscular Systems
- Symptom - Muscle tremors
- General
- Symptom - Abnormal behaviour
- Specify - spinning
- Symptom - Abnormal behaviour
- Specify - running
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Treatment / Traitement
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Dog was treated with Spot on Zodiac Flea product. Symptoms started after two hours of application. Running, panting, spinning, tremors, all symptoms lasted for at least 12 hours. My dog Bijou will be on the methocarbamole for the next couple of days. This morning - Thurs Apr 22/10 she seemed better. She slept through the night. Please see attached. I am attaching the letter to Wellmark International that I am sending to them. The manufacturer of Zodiac. Letter sent by animal owner {Case #, I am sending in documentation from the Zodiac Flea and Tick as proof on April 20/10 and veterinarian bill in which I would like to receive a refund on. After I applied the Zodiac product to my dog, she did have an adverse effect within a couple of hours after application. I purchased this product at our local Pet Value in (location). Bijou is a 5 year old Schipperke (spade female) that endured an extremely bad reaction to this product. Approx. 7:30 in the evening, I applied this product as to the directions on the package and within 2 hours my dog appeared to be distress. She was running around the house and panting. A short time later, she started to spin in circles and contracted muscle spasms. I called the vet that was on call that evening (12:30am) and recommended that I bath her in a grease cutting detergent. I thoroughly bathed her twice to hopefully remove and remnants of the Flea product. I took her to bed with me and was twitching and spinning until 5:30am in which she finally fell asleep due to exhaustion. I called the vet first thing in the morning and explained the situation and they wanted to see her right away. With a thorough exam, my vet had prescribed Methocarbamole tables and was informed that this would settle the muscle spasms. Attached is the documentation of my vet bill that I would like to be reimbursed for. Pet Valu did refund my money for the product and I am asking you to refund my vet bill. You may reach me at my home phone number and e-mail (#, name)
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
