Bump in foodborne botulism in Colorado

Posted on March 15, 2021 by Doug Powell

The pandemic brought a rise in home canning and food preservation as evidenced by a scarcity of canning supplies on store shelves and from online retailers, perhaps driven by a bountiful harvest by those who planted home gardens in the spring during the early lockdown period.

The Journal Advocate reports improperly canned food is behind at least some of the several cases of confirmed and suspected foodborne botulism that the Colorado Department of Public Health and Environment (CDPHE) has investigated in the state since September, according to a release from CDPHE Wednesday. Testing from the Centers for Disease Control and Prevention confirmed four of the cases, one is still under investigation, and two test results are pending. All of the confirmed cases occurred along the Front Range, and one of the unconfirmed cases occurred in the Western Slope.

A majority of the cases appear to be unrelated as no common food item was identified. The last two confirmed cases were the result of an improperly canned shared food made in the same household, prompting a warning from CDPHE about home food safety.

“Botulism does not spread from person to person, so there is no risk to the public. However, these cases are a good reminder of how important it is to properly preserve and handle food in the home,” said Nicole Comstock, deputy branch chief, communicable disease branch.

Norovirus outbreak leads to shellfish harvesting ban on stretch of Virginia river

Posted on January 16, 2020 by Doug Powell

WTVR reports health officials announced Saturday an extension of the ban on shellfish harvesting in the waters off Parrot Island in the Rappahannock River in Middlesex County.

The news comes after Virginia Department of Health officials banned the harvesting of oysters and clams in that stretch of the river on Dec. 27 following a Norovirus outbreak in Colorado linked to shellfish harvested from the area.

As a result, oysters harvested between Dec. 1, 2019 through Jan. 11, 2020 are being recalled.

The only oysters affected by the recall were shipped by Rappahanock River Oyster Company from lease numbers 18403, 18417, and 19260 in the Rappahanock River, according to the Virginia Department of Health. The company said the oysters were sold under the Emersum brand name.

Officials noted crabs and fin fish in the river are still safe to catch.

35 sick with Salmonella from 2 Burrito Delights in Colorado

Posted on March 6, 2018 by Doug Powell

The number of confirmed Salmonella cases linked to two Weld County restaurant locations jumped from 21 to 35, the department of health announced Thursday. The source of the foodbourne illness outbreak has been linked to Burrito Delight restaurants in Fort Lupton and Dacono, both of which voluntarily closed on Feb. 22, when the outbreak was first linked to food from the sites.

The Weld County Department of Public Health and Environment (WCDPHE) has still not located the specific source of the outbreak, and laboratory testing results of the employees will not be available until Monday, the department said.

The total number of people with confirmed cases who reportedly ate food catered by Burrito Delight at Aims Community College in Greeley has risen to 17 cases. Thirteen people were confirmed to have Salmonella who ate food at an Aims event Feb. 13, and four people who dined at a Feb. 6 event had confirmed cases. More than 450 people attended the two events at Aims, health officials said.

Going public (not): One dead 33 sick from Salmonella at Colorado restaurant in November

Posted on February 12, 2018 by Doug Powell

The Tri-County Health Department said one person has died from salmonella poisoning related to eating at a restaurant in Aurora (not the Aurora, Ill. of Wayne’s World). The outbreak put three other people in the hospital.

The health department said 33 people were sickened by eating at La California restaurant on Peoria Street in November.

The health department said lab tests show the family combination meal might have led to the poisoning. The meal includes ingredients such as meat, beans and cilantro.

But investigators could not pinpoint what started the outbreak.

The health department said the outbreak affected people who ate at La California from Nov. 4-26. Almost all of the people infected experienced diarrhea and abdominal cramping.

La California is at 1685 Peoria St.

The health department’s report said 13 of the 33 cases are confirmed, and 20 of the cases are probable for salmonella.

The illnesses involved 32 restaurant patrons and one employee.

Twenty-five cases had exposures at the restaurant with their meals within a five-day period from Nov. 10-14.

“It was significantly associated with the illness. But we couldn’t ID a single item in the family combo that was associated with the illness. … Everybody ate everything in the family combo,” Tri County Health spokeswoman Jen Chase told CBS Denver.

Raw is risky: 17 sick with Campylobacter from raw milk in Colorado, 2016

Posted on February 9, 2018 by Doug Powell

In August 2016, a local public health agency (LPHA) notified the Colorado Department of Public Health and Environment (CDPHE) of two culture-confirmed cases of Campylobacter infection among persons who consumed raw (unpasteurized) milk from the same herdshare dairy.

In Colorado, the sale of raw milk is illegal; however, herdshare programs, in which a member can purchase a share of a herd of cows or goats, are legal and are not regulated by state or local authorities. In coordination with LPHAs, CDPHE conducted an outbreak investigation that identified 12 confirmed and five probable cases of Campylobacter jejuni infection. Pulsed-field gel electrophoresis (PFGE) patterns for the 10 cases with available isolates were identical using the enzyme Sma. In addition, two milk samples (one from the dairy and one obtained from an ill shareholder) also tested positive for the outbreak strain. Five C. jejuni isolates sent to CDC for antimicrobial susceptibility testing were resistant to ciprofloxacin, tetracycline, and nalidixic acid (1).

Although shareholders were notified of the outbreak and cautioned against drinking the milk on multiple occasions, milk distribution was not discontinued. Although its distribution is legal through herdshare programs, drinking raw milk is inherently risky (2). The role of public health in implementing control measures associated with a product that is known to be unsafe remains undefined.

Investigation and Results

On August 23, 2016, El Paso County Public Health notified CDPHE of two culture-confirmed cases of C. jejuni infection; campylobacteriosis is a reportable disease in Colorado. Both patients reported drinking unpasteurized milk from the same herdshare dairy in Pueblo County. Since 2005, obtaining raw milk by joining a herdshare program has been legal for Colorado residents, but selling raw milk is illegal. By purchasing a share of a herd (cows or goats), shareholders are entitled to a portion of the raw milk.

Because the prevalence of consuming unpasteurized milk is low (2.4% in Colorado, 2006–2007 FoodNet Population Survey; 3.1%, 2009 Colorado Behavioral Risk Factor Surveillance System), two cases of enteric illness with a common exposure to raw milk are unlikely to occur by chance (3,4). In this outbreak, a confirmed case was defined as diarrheal illness with onset on or after August 1, 2016, in a person with known consumption of unpasteurized milk from the same herdshare dairy and culture-confirmed C. jejuni infection. A probable case was defined as diarrhea onset on or after August 1, lasting 1 or more days, in a person with either known consumption of milk from the same herdshare dairy or with an epidemiologic link to a confirmed case.

Cases were identified through routine passive reporting with follow-up interviews, a Health Alert Network broadcast to area providers, and attempts to contact all shareholders. A public health order was issued to obtain a list of shareholders with their contact information after it was not provided by the dairy within 5 days of the initial request. CDPHE attempted to contact shareholders to inform them about the outbreak and assess possible illness. Up to three calls were made to each shareholder household. Epidemiologists contacted laboratories to request that isolates from potential outbreak-associated cases be forwarded to the state public health laboratory.

Among 91 (53%) of 171 shareholder households that responded to requests for follow-up interviews, representing 207 persons in five or more Colorado counties, 12 confirmed and five probable cases were identified (Figure). Among confirmed cases, patients ranged in age from 12 to 68 years (median = 58 years); nine were male. Duration of illness ranged from 3 to >10 days. One hospitalization occurred; there were no deaths. In addition to diarrhea, among the 12 confirmed cases, the majority of patients also experienced fever (10), abdominal pain or cramps (eight), headache (eight), and myalgia (seven); vomiting and bloody diarrhea were reported less frequently (in five and four persons, respectively).

Four milk samples were tested for C. jejuni; pathogen identification and PFGE were performed on available isolates from persons epidemiologically linked to the outbreak. C. jejuni with one of two outbreak PFGE patterns (PulseNet DBRS16.0008 using the enzyme Sma and PulseNet DBRK02.1272 or DBRK02.0028 using the enzyme Kpn) was confirmed in 10 isolates that were available at the public health laboratory and two of the four raw milk samples. The National Antimicrobial Resistance Monitoring System performed antimicrobial susceptibility tests on five representative isolates; all were resistant to ciprofloxacin, tetracycline, and nalidixic acid (1).

Public health responses to this outbreak consisted of notifying shareholders about the outbreak on three occasions and requiring the dairy to provide additional written notification about the outbreak at milk distribution points. A press release was issued by two LPHAs in response to detecting at least one infection in a person who was not a shareholder but was given milk by shareholders. In addition, a number of shareholders reported sharing milk with nonshareholders who might have been unaware of the outbreak. Although milk sample results were positive for C. jejuni, CDPHE did not close the dairy or stop distribution of its milk because without pasteurization CDPHE could not create standards for safely reopening the dairy (5). Shareholders were, however, urged to discard raw milk distributed since August 1 and were reminded that Colorado statute prohibits redistribution of raw milk.

Discussion

Raw milk from a herdshare dairy was the source of this outbreak of C. jejuni infections, and the investigation highlighted the difficulties inherent in addressing an outbreak related to unpasteurized milk from a herdshare dairy. During three previous herdshare-associated outbreaks in Colorado, public health authorities temporarily took action to stop milk distribution until a series of negative tests were obtained from the milk (Alicia Cronquist, CDPHE, personal communication, December 2017). However, because CDPHE could not ensure that unpasteurized milk would be safe in the future, the decision was made not to close the dairy during this outbreak. In addition, CDPHE’s Division of Environmental Health and Sustainability chose not to make formal recommendations on the dairy’s processes because no protocol improvements short of pasteurization could ensure the product’s safety, even with improved sanitation (5).

All tested isolates’ resistance to three antibiotics was concerning, particularly as fluoroquinolones are frequently used to treat Campylobacter infections in those cases where treatment is indicated. Treatment of antibiotic-resistant Campylobacter infections might be more difficult, of longer duration, and possibly lead to more severe illness than treatment of nonresistant Campylobacter infections (6–8). In 2015, approximately 25.3% of U.S. C. jejuni isolates were resistant to ciprofloxacin, an increase from 21.6% a decade earlier (1).

In collaboration with LPHAs, CDPHE is creating guidelines to address future outbreaks related to raw milk from herdshares. As more states legalize the sale or other distribution of unpasteurized milk, the number of associated outbreaks will likely increase (9,10). The role of public health in responding to raw milk–related outbreaks should be further defined. State-level guidelines might assist with this process.

Corresponding author: Alexis Burakoff, aburakoff@cdc.gov, 303-692-2745.

1Epidemic Intelligence Service, Division of Scientific Education and Professional Development, CDC; 2Colorado Department of Public Health and Environment, Denver, Colorado; 3Pueblo City-County Health Department, Pueblo, Colorado; 4El Paso County Public Health, Colorado Springs, Colorado; 5Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC.

References

CDC. National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS): human isolates surveillance report for 2015 (final report). Atlanta, Georgia: US Department of Health and Human Services, CDC; 2018.

CDC. Food safety: raw milk. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/foodsafety/rawmilk/raw-milk-index.html

CDC. Foodborne diseases active surveillance network (FoodNet) population survey atlas of exposures, 2006–2007. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. https://www.cdc.gov/foodnet/PDFs/FNExpAtl03022011.pdf

Colorado Department of Public Health and Environment. Colorado Behavioral Risk Factor Surveillance System, 2009. [Data on raw milk]. Denver, CO: Colorado Department of Public Health and Environment; 2009. http://www.chd.dphe.state.co.us/Resources/brfss/BRFSS2009results_raw%20milk.pdf

Longenberger AH, Palumbo AJ, Chu AK, Moll ME, Weltman A, Ostroff SM. Campylobacter jejuni infections associated with unpasteurized milk—multiple states, 2012. Clin Infect Dis 2013;57:263–6. CrossRef PubMed

Evans MR, Northey G, Sarvotham TS, Rigby CJ, Hopkins AL, Thomas DR. Short-term and medium-term clinical outcomes of quinolone-resistant Campylobacter infection. Clin Infect Dis 2009;48:1500–6. CrossRef PubMed

Helms M, Simonsen J, Olsen KE, Mølbak K. Adverse health events associated with antimicrobial drug resistance in Campylobacter species: a registry-based cohort study. J Infect Dis 2005;191:1050–5. CrossRef PubMed

Nelson JM, Smith KE, Vugia DJ, et al. Prolonged diarrhea due to ciprofloxacin-resistant Campylobacter infection. J Infect Dis 2004;190:1150–7. CrossRef PubMed

Langer AJ, Ayers T, Grass J, Lynch M, Angulo FJ, Mahon BE. Nonpasteurized dairy products, disease outbreaks, and state laws—United States, 1993–2006. Emerg Infect Dis 2012;18:385–91. CrossRef PubMed

Mungai EA, Behravesh CB, Gould LH. Increased outbreaks associated with nonpasteurized milk, United States, 2007–2012. Emerg Infect Dis 2015;21:119–22. CrossRef PubMed

Outbreak of Fluoroquinolone-Resistant Campylobacter jejuni Infections Associated with Raw Milk Consumption from a Herdshare Dairy — Colorado, 2016

Morbidity and Mortality Weekly Report; February 9, 2018; 67(5);146–148

Alexis Burakoff, MD; Kerri Brown, MSPH; Joyce Knutsen; Christina Hopewell; Shannon Rowe, MPH; Christy Bennett; Alicia Cronquist, MPH

https://www.cdc.gov/mmwr/volumes/67/wr/mm6705a2.htm

8 sick with E. coli from Colorado fair

Posted on August 16, 2017 by Doug Powell

At least eight people are sick with Shiga toxin-producing E. coli after spending time at the Mesa County Fair, which ran from July 25-29 in Grand Junction.

The Post Independent reports Mesa County Public Health officials have been working with representatives from the fair and those who became sick to find the source of the illness.

Shiga toxin-producing E. coli is common in cattle, sheep and goats. It can be contracted through direct contact with these animals or contact with things in close proximity to the animals that may have been cross contaminated.

Mesa County Public Health officials have also been in close communication with child-care providers and health-care providers to determine the magnitude of the outbreak, and to prevent further spread of the illness.

People can become sick between two and 10 days after being infected with Shiga toxin-producing E. coli.

Going public, Colorado-style: 16 sick with Salmonella at Oscar’s of Breckenridge

Posted on August 9, 2016 by Doug Powell

Kaeli Subberwal of Summit Daily reports that 16 employees and patrons at a popular Breckenridge taco bar came down with Salmonella poisoning in July. This outbreak led Summit County health officials to shut down the restaurant until the issue was addressed — a process that took six days.

Morgan Stovall had been working at Oscar’s of Breckenridge for only three shifts when the health inspectors arrived.

“I guess we knew we were getting a health inspection,” she said, “but we thought they would just come in and make sure we were using gloves and everything; but that health inspector came in with someone higher up who deals with outbreaks.”

The health inspection on July 15 was prompted by three cases of salmonella that were reported to the state health department after Oscar’s patrons went to their medical providers and were diagnosed with the foodborne illness.

“The only common exposure among the three confirmed illnesses is consuming food at Oscar’s restaurant during the week before becoming ill. Specifically, ill persons visited Oscar’s on July 1 and July 4,” read a letter from the Colorado Department of Public Health and Environment to Amy Wineland, the director of Summit County Public Health.

Though Oscar’s is back in business, some workers are still suffering the consequences of the outbreak.

“It’s been nearly 3 weeks, and I’m still testing positive,” employee Brittany Doyne wrote in an email. “I feel I should be compensated for all 3 of my jobs, not just Oscar’s. I’m missing out on thousands of dollars I would have earned had Oscar’s not gotten me sick. Nearly all of what little savings I have is gone now.”

How the sick employees are being compensated while out of work is unclear.

Typhoid fever spread from asymptomatic restaurant worker in Colorado

Posted on June 17, 2016 by Doug Powell

On September 11, 2015, a single case of typhoid fever, caused by Salmonella Typhi infection, was reported to the Colorado Department of Public Health and Environment (CDPHE).

Because the patient (patient A) had symptom onset September 2 and had traveled internationally for 4 days 60 days before symptom onset, the case initially was thought to be travel-associated* (1,2).

On October 1, a second case of S. Typhi infection was reported in patient B, with symptom onset September 20. Patient B reported no international travel or contact with ill persons or known carriers. Patients A and B resided approximately 6 miles (10 kilometers) apart and had no discernible epidemiologic connection. Family members of patients A and B tested negative for S. Typhi. CDPHE and the Weld County Department of Public Health and Environment (WCDPHE) investigated to 1) determine whether these cases represented a larger outbreak, 2) identify common exposure sources, and 3) stop transmission. Investigators determined that the typhoid fever in both patients and in a third patient (patient C) was associated with eating in the same restaurant during a 5-day period.

CDPHE defined a case of typhoid fever as clinically compatible illness with isolation of S. Typhi during July 1–October 15 and identification of an isolate with one of two pulsed-field gel electrophoresis (PFGE) outbreak patterns that differed by one band. A carrier was defined as a person who had contact with patients, reported no recent illness, and had S. Typhi with either of the PFGE outbreak patterns in an isolate from a rectal swab or stool specimen. Case finding included searching PulseNet for other isolates that might have been associated with the Colorado cases (3). On October 13, CDPHE issued a health alert notification to clinicians, local public health authorities, and laboratories to be vigilant for additional cases and to encourage reporting. During October 1–9, CDPHE and WCDPHE used the Salmonella National Hypothesis Generating Questionnaire (4), credit card receipts, food recall, shopper card records, and social media to identify potential exposures shared by patients A and B during the 60 days preceding symptom onset. Investigators found that the two patients had fresh produce purchases from the same grocery stores and had six common restaurant exposures.

On October 19, CDPHE was notified of a third Weld Country resident who had tested positive for S. Typhi infection. Patient C had symptom onset September 15 and reported no recent travel or relation to patient A or B. Patient C was interviewed using the Salmonella questionnaire, and credit card receipts were reviewed. Patient C did not shop at the same grocery stores as patients A or B, but all three patients had eaten at restaurant A during August 16–20, 2015. Patients A and C were hospitalized. Isolates from patients B and C had indistinguishable PFGE patterns (pattern 2), and the isolate from patient A had a 1-band difference (pattern 1), which met the PFGE outbreak definition.

CDPHE hypothesized that a chronic S. Typhi carrier might be working in food service at restaurant A, where food is prepared using fresh ingredients. Possible transmission routes were investigated through environmental assessments and staff interviews; food service staff members were asked to be tested for S. Typhi. Environmental assessments performed on October 27 found no deficiencies in hand hygiene or other food handling issues. Administrators from restaurant A provided a list of all current and former employees who worked in food handling during August 10–August 20, 2015. These more conservative dates were chosen because food might have been served as many as 4 days after preparation, and because of concerns regarding the accuracy of credit card statement dates.

On October 28, current restaurant employees were confidentially interviewed at a local clinic by CDPHE and WCDPHE regarding international travel, symptoms, and work tasks. Because bacterial shedding can be intermittent, employees were requested to collect rectal swab specimens from themselves on October 28 and November 3 for culture and PFGE testing of isolates. All employees were allotted paid time to be interviewed and provide specimens. By October 29, a total of 28 (100%) current employees had responded and provided one or more rectal swab specimens. On October 30, CDPHE was notified by the state health laboratory that S. Typhi had been isolated from one employee. The isolate’s PFGE pattern was indistinguishable from outbreak pattern 1, the pattern of patient A.

Interviews with the infected restaurant worker revealed travel to a country with endemic typhoid fever 15 years earlier, but no recent symptoms, and no contact with any ill persons. The worker was excluded from food service work, treated with azithromycin for 28 days, and monitored with stool testing until three consecutive specimens obtained ≥1 month apart were negative for S. Typhi (2). Restaurant A agreed to keep the worker’s job open and allow him to return to work once he was no longer a carrier.

Typhi infection is a nationally notifiable condition; in Colorado, reporting is required within 24 hours of case detection. Notable clinical symptoms of typhoid fever include insidious onset of fever, and headache, constipation, chills, myalgia, and malaise (1). Unlike other Salmonella species, S. Typhi does not commonly cause diarrhea, and vomiting typically is not severe (1).

Typhi infection is endemic in many low-income countries; an estimated 22 million cases and 200,000 deaths occur each year (2). In the United States, approximately 5,700 cases of typhoid fever are reported annually; the majority occur among travelers (1). In Colorado during 2009–2014, on average, six cases of confirmed typhoid fever were reported annually; all cases were associated with international travel or attributed to a household member or close contact with a carrier. Humans are the only reservoir for S. Typhi; disease is transmitted via the fecal-oral route, typically by contaminated food or water. Chronic carriage occurs in 2%–5% of cases (1,2), and shedding of S. Typhi in chronic carrier stools can be intermittent.

This investigation highlights the potential for chronic S. Typhi carriers to cause illness in other persons, even years after infection. When cases of typhoid fever not associated with travel are detected, rapid and thorough interviewing is essential. Social media posts and credit card receipts to detect common exposures can be useful. The high cooperation rate among workers at the restaurant, which is rare in foodborne outbreak investigations, was attributed to the restaurant’s support and accommodation, demonstrating the importance of collaboration among local public health, state public health, public health laboratories, patients, and industry for successful investigations.

Typhoid fever outbreak associated with an asymptomatic carrier at a restaurant ― Weld County, Colorado, 2015

MMWR Morb Mortal Wkly Rep 2016;65:606–607. June 2016, DOI: http://dx.doi.org/10.15585/mmwr.mm6523a4.

Jessica Hancok-Allen, Alicia B. Cronquist, JoRene Peden, Debra Adamson, Nereida Corral, Kerri Brown

http://www.cdc.gov/mmwr/volumes/65/wr/mm6523a4.htm?s_cid=mm6523a4_x

‘Oversimplified method’ Colorado seeks to ban letter grades

Posted on April 7, 2016 by Doug Powell

A Colorado House Bill aiming to update restaurant inspection regulations has Weld County leaders again fighting for local control.

House Bill 1401, introduced late last week, would ban summarizing inspection results with a letter, number or any other “oversimplified method.”

County leaders overhauled the inspection page online in late 2014. Among the updates was a change in grading. Instead of using ambiguous words to rate a restaurant’s safety level, they began using an A-F system.

“It makes it much easier for the citizens of Weld County to look at a restaurant to see how they’re doing,” said Mike Freeman, chairman of the Board of Weld County Commissioners. “People don’t know what ‘critical’ is.”

The inspection process never changed; state law would forbid that. The update changed only how information was presented to the public.

Although various restaurant owners attended meetings to criticize the rule change, county leaders say they believe the change has been a boon to residents. Not only is the A-F grading system more transparent, it encourages restaurant owners to step up, Freeman said.

“They don’t want to see Ds and Fs,” he said. “It’s a very positive impact.”

Within the last year, Weld County saw 50 percent fewer inspections receiving an F, Environmental Health Director Trevor Jiricek wrote in a letter. Inspections getting either a D or an F dropped to 19 percent from 28 percent.

Web traffic on the new inspection page increased 100 percent over that time, Jiricek wrote. Leaders say it’s because residents can actually glean something from the page now.

The use of restaurant inspection disclosure systems as a means of communicating food safety information

Filion, K. and Powell, D.A. 2009. Journal of Foodservice 20: 287-297.

The World Health Organization estimates that up to 30% of individuals in developed countries become ill from food or water each year. Up to 70% of these illnesses are estimated to be linked to food prepared at foodservice establishments.

Consumer confidence in the safety of food prepared in restaurants is fragile, varying significantly from year to year, with many consumers attributing foodborne illness to foodservice. One of the key drivers of restaurant choice is consumer perception of the hygiene of a restaurant. Restaurant hygiene information is something consumers desire, and when available, may use to make dining decisions.

Filion, K. and Powell, D.A. 2011. Designing a national restaurant inspection disclosure system for New Zealand. Journal of Food Protection 74(11): 1869-1874

The World Health Organization estimates that up to 30% of individuals in developed countries become ill from contaminated food or water each year, and up to 70% of these illnesses are estimated to be linked to food service facilities. The aim of restaurant inspections is to reduce foodborne outbreaks and enhance consumer confidence in food service. Inspection disclosure systems have been developed as tools for consumers and incentives for food service operators. Disclosure systems are common in developed countries but are inconsistently used, possibly because previous research has not determined the best format for disclosing inspection results. This study was conducted to develop a consistent, compelling, and trusted inspection disclosure system for New Zealand. Existing international and national disclosure systems were evaluated.

Two cards, a letter grade (A, B, C, or F) and a gauge (speedometer style), were designed to represent a restaurant’s inspection result and were provided to 371 premises in six districts for 3 months. Operators (n = 269) and consumers (n = 991) were interviewed to determine which card design best communicated inspection results. Less than half of the consumers noticed cards before entering the premises; these data indicated that the letter attracted more initial attention (78%) than the gauge (45%). Fifty-eight percent (38) of the operators with the gauge preferred the letter; and 79% (47) of the operators with letter preferred the letter. Eighty-eight percent (133) of the consumers in gauge districts preferred the letter, and 72% (161) of those in letter districts preferring the letter. Based on these data, the letter method was recommended for a national disclosure system for New Zealand.

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