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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-4474

2. Registrant Information.

Registrant Reference Number: 1196182

Registrant Name (Full Legal Name no abbreviations): McLaughlin Gormley King Company

Address: 8810 Tenth Ave North

City: Minneapolis

Prov / State: MN

Country: USA

Postal Code: 55427-4319

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

Domestic Animal

4. Date registrant was first informed of the incident.

29-JUN-13

5. Location of incident.

Country: UNITED STATES

Prov / State: MINNESOTA

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. 1021-1866

Product Name: MULTICIDE 29133

  • Active Ingredient(s)
    • D-PHENOTHRIN
    • PIPERONYL BUTOXIDE
      • Guarantee/concentration .15 %

7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - Out Home / Rs - l'ext.maison

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

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

To be determined by Registrant

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

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Labrador Retriever

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

100.00

lbs

8. Route(s) of exposure

Unknown

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

  • Blood
    • Symptom - Thrombocytopenia
  • General
    • Symptom - Death
    • Symptom - Lethargy
    • Symptom - Listless
  • Nervous and Muscular Systems
    • Symptom - Collapse

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?

Yes

14. b) How long was the animal hospitalized?

6

Hour(s) / Heure(s)

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify Defined point of exposure not evident or witnessed. Exposure based on speculation.

17. Provide any additional details about the incident

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

6/29/2013 Caller is a veterinarian treating a dog in the clinic who had a sudden collapse today. The owners were using the product outside in their yard yesterday, and their dogs were outside with them at the time. No direct exposure was witnessed. This morning they awoke to find the dog lethargic and then collapsed. Blood work shows thrombocytopenia. The dog has been given intravenous fluids and steroids, and seems to be responding to treatment. 7/8/2013 Follow-up with the treating veterinarian completed.. The dog passed away later in the day after the original call. Veterinarian does not think the dog's symptoms were related to the product. The dog had some type of hemorrhagic disease, and the final diagnosis was autoimmune thrombocytopenia.


To be determined by Registrant

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

Death

19. Provide supplemental information here

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 can not 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. Any relationship between the use of this product and the delayed development of the complications reported in this case is inconceivable and lacks biological plausibility. Secondly, the product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. Even had casual or incidental contact with a surface treated with this pesticide occurred, such serious illness as reported in this dog is unexpected. Even if true pyrethroid toxicity were to occur in this case it would manifest with acute neurological complications, primarily in the form of tremors and or seizure which were not reported in this incident. The veterinarian treating this animal did not believe the pesticide was the cause of this dog's illness.