Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-3878

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 2023SCPU00069614

Registrant Name (Full Legal Name no abbreviations): Syngenta Canada Inc.

Address: 140 Research Lane, Research Park

City: Guelph

Prov / State: Ontario

Country: Canada

Postal Code: N1G4Z3

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

Human

4. Date registrant was first informed of the incident.

22-JUN-23

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

20-JUN-23

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.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: REWARD LANDSCAPE AND AQUATIC HERBICIDE

• Active Ingredient(s)
  • DIQUAT, PRESENT AS DIBROMIDE
    • Guarantee/concentration 37.3 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

No

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

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.

Medical Professional

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Difficulty swallowing

• Renal System
  • Symptom - Low urine output
  • Symptom - Creatinine increased

• Gastrointestinal System
  • Symptom - Other
  • Specify - Erosions in esophagus

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?

10

Day(s) / Jour(s)

7. Exposure scenario

Unknown

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

Poisoning from ingestion of the pesticide

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

10. Route(s) of exposure.

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

2023SCPU00069614- The reporter, a health care professional, indicates an exposure to a pesticide containing the active ingredient diquat dibromide. Two days before the day of initial contact with the registrant, the reporter indicated the patient accidentally took a large gulp of the concentrated product. Four hours after the exposure the patient was admitted to a local hospital for evaluation and supportive care. Over the following 1-2 days the patient developed decreased urination and difficulty swallowing. On the day of initial contact the patient was admitted to the reporter's hospital for continuation of symptoms. On follow-up call one day after the day of initial contact the reporter indicated the patient's creatinine was elevated but was starting to decrease, and the patient had a lot of erosions in their esophagus but was starting to feel better. On follow-up calls four and six days after the day of initial contact, the reporter indicated the patient was continuing to improve. On follow-up call eleven days after the day of initial contact, the reporter indicated the patient had continued to improve and had been discharged from the hospital. No additional information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.