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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-2936
2. Registrant Information.
Registrant Reference Number: 2013-US-03136
Registrant Name (Full Legal Name no abbreviations): Merck Animal Health (Intervet Canada Corp)
Address: 16750 Transcanada Highway
City: Kirkland
Prov / State: Quebec
Country: Canada
Postal Code: H9H 4M7
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
30-APR-135. Location of incident.
Country: UNITED STATES
Prov / State: NORTH CAROLINA
6. Date incident was first observed.
Unknown
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. PMRA Submission No. EPA Registration No. 773-95
Product Name: ACTIVYL TICK PLUS
- Active Ingredient(s)
- INDOXACARB TECHNICAL
- PERMETHRIN
- Guarantee/concentration 42.5 %
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Yes
9. Application Rate.
.5Units: 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).
On 30 Apr 2013 a hospital manager called to report red and itchy skin reaction several hours after the Activyl Tick Plus Small Dog/Puppies 11 to 22 lbs was applied. The date of application is unknown, the dog recovered after 2 to 3 days after initial application with no treatment given. The dog had a history of heart disease, and recently the dog had a stroke and would not eat or drink. The owners decided to have the dog euthanized on 26 Apr 2013. This was not product related. The product purchased at the veterinary clinic. No more information expected.To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
YesSubform III: Domestic Animal Incident Report
1. Source of Report
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
Maltese
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
12.4
7. Weight (provide a range if necessary )
5.6
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Skin
- Symptom - Itchy skin
- Symptom - Red skin
- Cardiovascular System
- Symptom - Stroke
- General
- Symptom - Adipsia
- Gastrointestinal System
- Symptom - Anorexia
12. How long did the symptoms last?
Unknown / Inconnu
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
Euthanised / Euthanasie
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
On 30 Apr 2013 a hospital manager called to report red and itchy skin reaction several hours after the Activyl Tick Plus Small Dog/Puppies 11 to 22 lbs was applied. The date of application is unknown, the dog recovered after 2 to 3 days after initial application with no treatment given. The dog had a history of heart disease, and recently the dog had a stroke and would not eat or drink. The owners decided to have the dog euthanized on 26 Apr 2013. This was not product related. The product purchased at the veterinary clinic. No more information expected.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
