Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-0769
2. Registrant Information.
Registrant Reference Number: 180187111
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.
08-NOV-18
5. Location of incident.
Country: UNITED STATES
Prov / State: MICHIGAN
6. Date incident was first observed.
08-NOV-18
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. 2724-808-270
Product Name: Adams Plus Flea And Tick Indoor Fogger Can
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration .09 %
- ETOFENPROX
- Guarantee/concentration .5 %
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration .5 %
- TETRAMETHRIN
- Guarantee/concentration .4 %
7. b) Type of formulation.
Other (specify)
Total Release Fogger
Application Information
8. Product was applied?
Yes
9. Application Rate.
3
Other Units: 1- 3 ounce can
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 November 8, 2018, the owner set the fogger off inside the home. it is unclear if the aquarium air flow system was turned off before fogging.
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
Animal's Owner
2. Type of animal affected
Fish / Poisson
3. Breed
African Cichlids
4. Number of animals affected
4
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?
>2 hrs <=8 hrs / >2 h <=8 h
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
12. How long did the symptoms last?
Unknown / Inconnu
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
A few hours after setting off the fogger, the owner returned home and noticed that four fish in the tank were dead. The owner then contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated that fish are very sensitive to pyrethroids and exposure can result in death. The APSS assistant recommended the owner call back with questions.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
At the time of this report, a necropsy is not pending. It is unclear if the aquarium air flow system was turned off before fogging.