Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2015-2358

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: x

Nom du titulaire (nom légal complet, aucune abbréviation): x

Adresse: x

Ville: x

Pays: x

3.Choisir le (les) sous-formulaire(s) correspondant à l'incident.

Incident chez l'humain

4. Date à laquelle le titulaire d'homologation a été informé pour la première fois de l'incident.

5. Lieu de l'incident.

Pays: CANADA

État: ONTARIO

6. Date de la première observation de l'incident.

02-NOV-13

Description du produit

7. a) Donner le nom de la matière active et, si disponibles, le numéro d'homologation et le nom du produit (incluant tous les mélanges). Si le produit n'est pas homologué, donner le numéro de la demande d'homologation.

Matière(s) active(s)

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ARLA No d'homologation 27428      ARLA No de la demande d'homologation       EPA No d'homologation.

Nom du produit: Demand CS insecticide

• Matière active
  • LAMBDA-CYHALOTHRIN

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ARLA No d'homologation 30075      ARLA No de la demande d'homologation       EPA No d'homologation.

Nom du produit: Bedlam Insecticide

• Matière active
  • D-PHENOTHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE

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7. b) Type de formulation.

Renseignments sur l'application

8. Est-ce que le produit a été appliqué?

Oui

9. Dose d'application.

Inconnu

10. Site d'application (choisir tout ce qui s'applique).

Site: Res. - In Home / Rés. - à l'int. maison

11. Donner tout renseignement additionnel concernant l'application (comment le produit a été appliqué, la quantité utilisée, la superficie de la zone traitée, etc.)

Caller reports that she lives in a residential home that has been converted into two apartment units. She lives in the basement apartment and there is a tenant living in the other unit above her. The main floor unit has a bed bug infestation and XXXX was on site on November 2, 2013 and applied Demand CS and Bedlam pesticides. The caller advised that she was informed by her landlord that she did not need to vacate the premises during the pesticide application and she spoke with the exterminator (XXXXX) before he applied the pesticides on the morning of November 2 advising him that she would be in the basement sleeping.

À être déterminé par le titulaire

12. Selon vous, le produit a-t-il été utilisé en conformité avec le mode d'emploi de L'étiquette?

Inconnu

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Autre

2. Renseignement démographique sur la personne affectée

Sexe: Femme

Âge: Unknown / Inconnu

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• Peau
  • Symptôme - Urticaire
  • Symptôme - Éruption cutanée

• General
  • Symptôme - Autre
  • Specify - allergic reaction

• Peau
  • Symptôme - Sensation de brûlures à la peau
  • Symptôme - Gerçure
  • Symptôme - Sensibilité de la peau
  • Specify - any cold or heat against her skin was extremely painful

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Oui

6. a) Est-ce que la personne a été hospitalisée?

Inconnu

6. b) Pendant combien de temps?

7. Scénario d'exposition

Non professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Contact avec la zone traitée

Quelle était l'activité? upper floor of house treated, subject lives in basement

Autre

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Aucun

10. Voie(s) d'exposition.

Inconnu

11.Durée de l'exposition?

Unknown / Inconnu

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

Unknown / Inconnu

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

The application occurred and she reportedly reacted to the products and required medical treatment for both epidermal and respiratory reactions. The bed bug infestation requires further treatment and the exterminator is to be on site tomorrow. The caller is concerned as medical personnel advised her that she is now very sensitive to these two products and further exposure to them could be very harmful to her. She is also concerned about the safety practices of the exterminator. Caller stated that she broke out in a rash when she woke up from her sleep on Saturday afternoon and was covered in a blotchy rash on most of her body, specifically her face. Another woman staying in the basement apartment with XXXXX was also reportedly affected with similar symptoms, but she ceased experiencing any adverse effects by Saturday evening. XXXXX stated by Saturday night she had broken out in hives, and had a significant rash on most of her body. At this time, XXXXX decided to go to the emergency department of the XXX Hospital. At htis time, she was advised by the attending doctor that she was having an allergic reaction. They could not state exactly what the issue was with the reaction, but the hospital did state that it was very possibly due to the pesticides. A prescription was written for XXXXX for Prednisone, 30mg/day for 5 days, and also for Benadryl, 50mg 3 x /day for five days. On November 5, 2013, XXXXX again went to the XXX Hospital as her symptoms had worsened to the point of what she described as "extreme skin sensitivity". XXXXXstated that by this point her skin was burning and dry-cracking to the point where any cold or heat against her skin was extremely painful, including evenr breath on her face. Also, XXXXX states that her tear ducts were becoming very dry and would not water when in the wind, or crying, etc. During this visit to the hospital emergency department, XXXXX was prescribed Predisone, 50mg/day for 5 days; hydroxyzine, 10mg 3 x / day for 10 days; and also was advised to only use Aveno soap and hand cream. Today, November 13, 2013, XXXXX once again met with the pest technician. XXXXX noticed he arrived at her place of residence this morning at approx. 09:00 hrs. XXXXX stated to XXXXX that he was not planning to use pesticides this time, that he was only going to use steam during this treatment, again on the 3rd floor of the house. XXXXX stated she saw XXXXX taking a box of chemicals inside the house and she asked him if he was going to take them inside. XXXXX stated he was not planning on using them, so XXXXX asked him to leave them outside the house. XXXXX then stated to XXXXX that he beleived her medical issues were between her and her doctor, and that he couldn't see how spraying one room on the third floor would affect her. XXXXX stated that XXXXX completely dismissed the pesticides as having anything to do with her rash. XXXXX stated that XXXXX returned to his truck and picked up a steamer unit, and advised her that only water was in it. However, as XXXXX re-entered the house, he stated that there was "a change in plans". XXXXX believes he was going use the pesticides again with her in the house. XXXXX stated that the house is a 3-storey older home (ie. 1940's) and has a single furnace / HVAC system with all of the ventilation exchanged between all rooms in the home. The basement does not have a separate HVAC system from the rest of the house.

À être déterminé par le titulaire

14. Classification selon la gravité.

15. Donner des renseignements additionnels ici.