Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-5191
2. Registrant Information.
Registrant Reference Number: 2013-US-06090
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.
19-JUL-13
5. Location of incident.
Country: UNITED STATES
Prov / State: NEW YORK
6. Date incident was first observed.
16-JUL-13
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. 773-94
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.
4
Units: 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 19 Jul 2013 a veterinarian reported a possible adverse reaction following the use of Activyl Tick Plus for Dogs and Puppies (over 44 lb and up to 88 lb). The Activyl Tick Plus was purchased at the vet clinic on 12 Jul 2013 and applied to the dog by the owner on 15 Jul 2013. The dog was described as not being right and was staggering on 16 Jul 2013. By 17 Jul 2013 the dog was recumbent and had developed diarrhea. Treatment options are being considered. The veterinarian also reported that another dog appeared dumb for a week after application of Activyl Tick Plus in April of 2013. Follow-up is pending. Follow-up on 29 Jul 2013: The dog was euthanized on 20 Jul 2013. No more information is expected.
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
Siberian Husky
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
11
7. Weight (provide a range if necessary )
65.0
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
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Nervous and Muscular Systems
- Nervous and Muscular Systems
12. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
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 19 Jul 2013 a veterinarian reported a possible adverse reaction following the use of Activyl Tick Plus for Dogs and Puppies (over 44 lb and up to 88 lb). The Activyl Tick Plus was purchased at the vet clinic on 12 Jul 2013 and applied to the dog by the owner on 15 Jul 2013. The dog was described as not being right and was staggering on 16 Jul 2013. By 17 Jul 2013 the dog was recumbent and had developed diarrhea. Treatment options are being considered. The veterinarian also reported that another dog appeared dumb for a week after application of Activyl Tick Plus in April of 2013. Follow-up is pending. Follow-up on 29 Jul 2013: The dog was euthanized on 20 Jul 2013. No more information is expected.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here