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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-4438
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
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: NOVA SCOTIA
6. Date incident was first observed.
13-AUG-19Product 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.
Product Name: Piactive insect repellant
- Active Ingredient(s)
- ICARIDIN
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Personal use / Usage personnel
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
The following was reported: While at an outdoor event in the evening, I borrowed a friend's spray bottle of Piactive insect repellent. Others in my group had used it with no reaction and were pleased with its effectiveness and that it is not scented. I sprayed it on my hands to apply lightly to my face, neck & arms. The asthma / coughing started soon after but I did not connect it to the product right away. I was not aware of the skin symptoms until I arrived home a few hours later. I had been feeling quite warm even though the evening had cooled down. It did work to keep the bugs away but I will never use the product again. Thankfully I had the next day off from work to have time for the Benadryl to work. I went out to purchase calamine lotion and after a 3 minute walk to nearby pharmacy, the rash was more painful in the sunshine.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.
Data Subject
2. Demographic information of data subject
Sex: Female
Age: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Other
- Specify - increased asthma symptoms
- Symptom - Coughing
- Skin
- Symptom - Pain
- Specify - stinging
- Symptom - Red skin
- Symptom - Rash
- Symptom - Burning skin
- Symptom - Photosensitivity
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Application
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
10. Route(s) of exposure.
Skin
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: Increased asthma symptoms, coughing without clearing even after use of rescue puffer. Few hours later experienced heat and burning all areas where product applied. Looked as if very bad sunburn. Stinging rash on face, neck and arms. Worse on face and neck. Benadryl tablets and calamine lotion eased symptoms. Occurred during hotter weather period and uncomfortable. 36 hours or so before skin started to heal. Skin felt extra sensitive to the sun.
