Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-6504
2. Registrant Information.
Registrant Reference Number: 130135730
Registrant Name (Full Legal Name no abbreviations): Wellmark International
Address: 100 Stone Road West, Suite 111
City: Guelph
Prov / State: Ontario
Country: Canada
Postal Code: N1G5L3
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
27-SEP-13
5. Location of incident.
Country: UNITED STATES
Prov / State: WISCONSIN
6. Date incident was first observed.
21-SEP-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. 2724-490
Product Name: Vet Kem Siphotrol Plus II Premise Spray
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration .085 %
- D-PHENOTHRIN
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration 2 %
- PERMETHRIN
- Guarantee/concentration .35 %
- PIPERONYL BUTOXIDE
- Guarantee/concentration 1.4 %
7. b) Type of formulation.
Other (specify)
aerosol
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - In Home / Rés. - à l'int. maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
On September 18, 2013 the owner sprayed the product in the basement of her home. 2 cats lived in the basement, and although it is unknown if they were down there when the product was used, it is suspected that they may have been exposed to the product via an unknown route.
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
Medical Professional
2. Type of animal affected
Cat / Chat
3. Breed
Domestic Shorthair
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
10.0
7. Weight (provide a range if necessary )
8.0
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>24 hrs <=3 days / >24 h <=3 jours
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- General
- Symptom - Parasitism
- Specify - Flea Infestation
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
On September 21, 2013 the owner discovered that the cat had died and was covered with fleas. On September 27, 2013 the owner's regular veterinary staff contacted the Animal Product Safety Service (APSS) to obtain help. The APSS veterinarian said that central nervous system (CNS) signs would not be expected if the product was used appropriately. A necropsy was not available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
The APSS veterinarian stated that the substance was not considered to be related to causing the clinical situation.
Subform III: Domestic Animal Incident Report
1. Source of Report
Medical Professional
2. Type of animal affected
Cat / Chat
3. Breed
Domestic Shorthair
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
9.0
7. Weight (provide a range if necessary )
8.0
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>24 hrs <=3 days / >24 h <=3 jours
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- General
- Symptom - Parasitism
- Specify - Flea Infestation
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
On September 21, 2013 the owner discovered that the cat had died and was covered with fleas. On September 27, 2013 the owner's regular veterinary staff contacted the Animal Product Safety Service (APSS) to obtain help. The APSS veterinarian said that central nervous system (CNS) signs would not be expected if the product was used appropriately. A necropsy was not available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
The APSS veterinarian stated that the substance was not considered to be related to causing the clinical situation.