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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2021-0078
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: BRITISH COLUMBIA
6. Date incident was first observed.
01-APR-20Product 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: Advantage II
- Active Ingredient(s)
- IMIDACLOPRID
- Guarantee/concentration 9.1 %
- PYRIPROXYFEN
- Guarantee/concentration .46 %
- IMIDACLOPRID
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: 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).
The pest control product Advantage II (PCP number not specified) was applied to cats and a dog, along with the veterinary product Frontline.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: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Depression
- Symptom - Difficulty walking
- Symptom - Memory loss
- Symptom - Muscle pain
- Symptom - Muscle weakness
- Symptom - Staggering
- Symptom - Other
- Specify - electric shock sensations in limbs
- Symptom - Headache
- Symptom - Muscle twitching
- Specify - restless leg syndrome
- General
- Symptom - Fatigue
- Symptom - Joint pain
- Gastrointestinal System
- Symptom - Diarrhea
- Symptom - Other
- Specify - painful bowel movements
- Eye
- Symptom - Other
- Specify - floaters
- Skin
- Symptom - Itchy skin
- Specify - itchy lump
- Eye
- Symptom - Other
- Specify - flashing
4. How long did the symptoms last?
>6 mos / > 6 mois
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)
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 subject indicated that after applying the products, her gut symptoms began overnight, while the neuromuscular, general, and skin signs developed over time. She indicated that the muscle pain experienced often felt like electric shocks and like the muscles were burning. Weakness was noted in walking and in opening jars. She felt joint pain that in her spine felt as if her spine were falling apart. She developed floaters and flashing lights in her field of vision. She noted cognitive impairment and had headaches. She had begun seeing a physician and optometrist, but due to circumstances outside of her control had to stop. She indicated that she was feeling down and overwhelmed by the situation.
