Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-2789

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

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

Human

Domestic Animal

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

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)

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PMRA Registration No. 27428      PMRA Submission No.       EPA Registration No.

Product Name: DEMAND CS INSECTICIDE

• Active Ingredient(s)
  • LAMBDA-CYHALOTHRIN

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PMRA Registration No. 15255      PMRA Submission No.       EPA Registration No.

Product Name: DRIONE INSECTICIDE DUST

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS
  • SILICA AEROGEL

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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: 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).

The following was reported: On July 4, 2018 the landlord retained the services of x to apply a pesticide in the complainant's residence for the control of cockroaches. His wife and their 20 cats were present in the residence during the application. The cats were allegedly confined to a bedroom during the treatment and for a period of time following, but inspectors observed that there was no litter box in the bedroom. The exterminator claims to have made a perimeter treatment (a band 10 to 15cm wide) along the moldings of the apartment, except in the bedroom where the cats were confined. This information is consistent with the observations of the regional inspectors.

To be determined by Registrant

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

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing

• Nervous and Muscular Systems
  • Symptom - Headache

• General
  • Symptom - Weakness

• Gastrointestinal System
  • Symptom - Diarrhea

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

2

Day(s) / Jour(s)

Unknown

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

The following was reported: The complainant's wife had severe symptoms (coughing, headache, weakness and diarrhea) following the pesticide application, which required that she be hospitalized for a couple of days (July 11 - 12, 2018). According to the exterminator, the tenant (complainant's wife) entered the dwelling a few times for brief periods during the treatment, despite the exterminator having told her to remain outside. The tenant, who was treated by a Public Health doctor, had another episode of symptoms after having moved to a different apartment. The doctor questionned whether the symptoms could be related to pesticide exposure since the second episode occurred when there was no application of pesticides.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Cat / Chat

3. Breed

Siamese

4. Number of animals affected

10

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

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

• General
  • Symptom - Death

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

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

Exact number not known, but at least 10 of 20 cats belonging to the complainant died following application of pesticide(s) in the complainant's apartment. The cats were allegedly confined to a bedroom during and after the pesticide treatment, however regional inspectors noted that there was no litter box in the bedroom. Only one litter box was observed in the apartment (near the living room).

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To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here

Possible autopsy results for 3 cats pending

Subform III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Cat / Chat

3. Breed

Siamese

4. Number of animals affected

10

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

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

• General
  • Symptom - Malaise
  • Specify - Sick NOS

• Gastrointestinal System
  • Symptom - Weight loss
  • Symptom - Vomiting

• General
  • Symptom - Lethargy

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

Unknown/Inconnu

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

Exact number not known, but at least 10 of 20 cats belonging to the complainant appeared unwell following application of pesticide(s) in the complainant's apartment. Regional inspectors noted that the surviving cats appeared emaciated, lethargic, and some were vomiting. The cats were allegedly confined to a bedroom during and after the pesticide treatment, however regional inspectors noted that there was no litter box in the bedroom. Only one litter box was observed in the apartment (near the living room).

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To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here