Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-5029

2. Registrant Information.

Registrant Reference Number: 1830257

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.

27-MAY-16

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW HAMPSHIRE

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. 1021-2684-89459

Product Name: Adams Flea And Tick Dip For Dogs And Cats

  • Active Ingredient(s)
    • PIPERONYL BUTOXIDE
      • Guarantee/concentration 3 %
    • PYRETHRINS
      • Guarantee/concentration .3 %

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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).

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

Other / Autre

specify Exotic

3. Breed

Ferret

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

2.30

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • Blood
    • Symptom - Hypoglycemia
  • General
    • Symptom - Death
  • Nervous and Muscular Systems
    • Symptom - Difficulty getting up
    • Symptom - Collapse

12. How long did the symptoms last?

Persisted until death

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?

Unknown

15. Outcome of the incident

Died

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

8/26/2016 The following report was forwarded for documentation. The report states that owner used the flea dip on a ferret on 5/28/2016 as well as a dewormer. The following morning the ferret had an episode where he seemed to race around for a short time and then collapsed. He was recumbent and not responsive. The veterinarian suspected the ferret was hypoglycemic. They gave Karo syrup at the emergency clinic, and he became somewhat responsive. On 5/29/2016 ferret's clinical status was listed as death. 6/6/2016 No necropsy was performed. 6/10/2016 Toxicologist interacted with ferret owner. Toxicologist reviewed the case with the owner. Toxicologist stated it is not the insecticide or dewormer that caused the ferret to die, and could have been neoplasia or heart disease. Without a necropsy the cause will never be known.


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.