Academy Comments to CDC re: Standardized National Hypothesis Generating Questionnaire

August 22, 2016

Information Collection Review Office
Centers for Disease Control and Prevention
1600 Clifton Road NE., MS-D74
Atlanta, Georgia 30329

Re: Using the Standardized National Hypothesis Generating Questionnaire during Multistate Investigations of Foodborne Disease Clusters and Outbreaks (Docket No. CDC-2016-0054)

Dear Sir or Madam,

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit these comments to the Centers for Disease Control and Prevention (CDC) regarding its information collection "Using the Standardized National Hypothesis Generating Questionnaire during Multistate Investigations of Foodborne Disease Clusters and Outbreaks" (Docket No. CDC-2016-0054). Representing more than 100,000 registered dietitian nutritionists (RDNs),1 nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation's health through food and nutrition across the lifecycle. Every day we work with Americans in all walks of life — from prenatal care through end of life care — providing nutrition care services and conducting nutrition research.

A. Academy of Nutrition and Dietetics' Position on Food Safety

It is the position of the Academy that the public has the right to a safe food supply and to that end we support the ongoing collaboration among food and nutrition professionals, academics, representatives of the agricultural and food industries, and appropriate government agencies.2 Reducing foodborne illnesses is one of the objectives of Healthy People 2020 and food safety is recommended in the 2010 Dietary Guidelines for Americans.3 Every year, over 48 million Americans get sick, 128,000 are hospitalized, and 3,000 die from foodborne illnesses, according to the Centers for Disease Control. The Economic Research Service of the U.S. Department of Agriculture estimated that in 2015, fifteen identified pathogens result in over $15.5 billion in annual costs from foodborne illness.4 In light of the health risks and financial costs associated with foodborne illness and to assist congressional efforts to ameliorate them, the Academy adopted three principles for federal food safety authority:

  1. Food authority should be science-based and consistently applied to all foods regulated by all agencies for domestic and imported foods. The Academy supports the concept of a single food safety agency to protect the public's health.
  2. Food authority should be collaborative across national, state, and local agencies and between government and industry partners to foster more robust, consistent, accurate and timely communication and data sharing that leads to efficient and effective decision-making processes.
  3. Food protection should include statutory authority by government regulatory agencies for traceability and recall, supported by research, epidemiology and inspection programs.5

B. Value of Proposed Information Collection

The Academy supports the use of the proposed information collection questionnaire, which is both necessary and will have both short-term and long-term practical utility. In the short-term the questionnaire standardizes information gathering and will make it easier for all jurisdictions to cooperate without redundancy and enables different units to uniformly gather information, leading to better long-term use of the information.

However, we are concerned that CDC's estimate of the burden of the proposed information collection may not consider the nature of the shared burden on all those collecting this complex information. Specifically, we question whether the collection poses a greater than intended burden on local units in the event of an outbreak, because the data collection will begin at the local level where this sporadic event may not be presently budgeted.

C. Recommendations for Enhancing Proposed Information Collection

The Academy respectfully offers several recommendations below for enhancing the quality, utility and clarity of information to be collected:

  1. The CDC needs to establish a national training module(s) for individuals who will collect and use the collected information. Some sections of the form require judgment as to where to include information (e.g., multiple uses of "deli"); in some cases, unanticipated follow-up questions may be helpful. We encourage CDC to consider whether enhanced training could address these issues. Specifically, online training and certificate training could be very helpful because it would train the potential interviewer and possibly offer continuing education to the professional completing the training, and the training could be completed at convenient times. Training could also be updated as new issues arise, thereby keeping the training "fresh." "Fresh" training is especially important at the local level, as that is likely where the first interviewers start the process and because it may not be practical to train every sanitarian, environmental health specialist, and other worker in advance of an outbreak.
  2. As noted in the instrument, the individual responding to the questionnaire could be the patient or a surrogate. The Academy suggests broadening the scope beyond "your (your child's)" to include spouses, parents, or other individuals for whom the respondent may be the caretaker and additionally to include the relationship of the respondent to the patient on the form. We also respectfully suggest that it would be useful to include the time spent by the caretaker with the patient during the week for which data are collected.
  3. The Academy offers the below suggestions for improving particular sections of the instrument:
    1. Section 2, Question 3: Consider adding "c. Ongoing."
    2. Section 4, Question 4: Include "liquids" in the listing. We note this might include supplements such as Ensure®, Boost®, energy drinks, or sports drinks. CDC should consider whether such an inclusion would be more common than the listing "teas."
    3. Section 5: Add "Meals on Wheels" to the list of sources of food at home. Meals on Wheels and similar programs deliver a significant number of foods to at-risk populations and should be included.
    4. Section 6: Add the following to the list of foods outside the home: "Italian" and other ethnic foods representing the cultural diversity of the United States; expand the category "School or other institutional setting" to specifically include "Hospital, Senior Congregate Meal Center;" and add "Vending machine" and "Eating in other people's homes" as categories.
    5. Section 7:
      1. We question whether brand names for deli-sliced items eaten outside the home would typically be known by the patient; if not, this would likely require follow-up at the place of purchase and may be confusing to the patient.
      2. For Question 10, the question asks if the meat consumed was pink. We note that this same question would applies to patties formed at home, which is the question that follows the preformed patty question. Instead, asking a simple question at the end of this section such as "Do you or your child (surrogate) eat your burgers without cooking (tasting during prep) or with a pink or red center?" would apply to both questions.
    6. Section 11, Question 3: Most individuals are unlikely to be able to name a type or variety of grape purchased at a market, but may be able to identify the color (green, red, black) grape they purchased.
  4. The Academy suggests including questions related to consumption of bananas, rice and beans, and fermented vegetables such as sauerkraut or kimchi.
  5. The Academy encourages the CDC to consider the use of an online form completed directly by the consumer as an alternative to the proposed instrument. The existing form provides much needed information for those able and willing to complete it on a phone interview. However, we note that the existing form is lengthy, which could be problematic for individuals being interviewed who have multiple competing distractions (e.g., young children, dinner preparation, work obligations). We encourage the CDC to ascertain whether providing the instrument in a format that could be emailed might enhance completion for those expressing an interest in receiving it electronically. In addition, the proposed questionnaire anticipates that the patient or surrogate can recall intakes over a seven-day period, but we note that even 24-hour recall surveys administered by a trained professional may present reliability concerns.

D. Conclusion

The Academy sincerely appreciates the opportunity to offer comments on the proposed information collection to CDC's Standardized National Hypothesis Generating Questionnaire, and we would welcome the opportunity to discuss the above issues with CDC in the future. Please contact either Jeanne Blankenship by telephone at 312-899-1730 or by email at jblankenship@eatright.org or Pepin Tuma by telephone at 202-775-8277 ext. 6001 or by email at ptuma@eatright.org with any questions or requests for additional information.

Sincerely,

Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Pepin Andrew Tuma, Esq.
Senior Director
Government & Regulatory Affairs
Academy of Nutrition and Dietetics


1 The Academy recently approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.

2 Cody MM, Stretch T. Position of the Academy of Nutrition and Dietetics: food and water safety. J Acad Nutr Diet. 2014;114(11):1819-29.

3 US Department of Health and Human Services. Food safety. Healthy People 2020 Web site. Accessed August 16, 2016.

4 Economic Research Service. Economic Burden of Major Foodborne Illnesses Acquired in the United States (May 2015). Accessed August 16, 2016.

5 Cody MM, Stretch T. Position of the Academy of Nutrition and Dietetics: food and water safety. J Acad Nutr Diet. 2014;114(11):1819-29.