Public Comments

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

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.

 Available
 at

https://www.healthypeople.gov/2020/topics-­‐‑objectives/topic/food-­‐‑safety?topicid=14.

 Accessed
 August
 16,

2016.

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

4
 Economic
 Research
 Service.

 Economic
 Burden
 of
 Major
 Foodborne
 Illnesses
 Acquired
 in
 the
 United
 States

(May
 2015).

 Available
 at
 http://www.ers.usda.gov/media/1837791/eib140.pdf.

 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.

  2

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:

a)   Section
 2,
 Question
 3:
 Consider
 adding
 “c.
 Ongoing.”

b)   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.”

c)   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.

d)   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.

e)   Section
 7:

i.   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.

ii.   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.

  3

f)   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.

C.

 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
 [email protected]
 or
 Pepin
 Tuma
 by
 telephone
 at
 202-­‐‑775-­‐‑8277
 ext.

6001
 or
 by
 email
 at
 [email protected]
 with
 any
 questions
 or
 requests
 for
 additional

information.

Sincerely,

Jeanne
 Blankenship,
 MS
 RDN

Vice
 President

Policy
 Initiatives
 and
 Advocacy

Academy
 of
 Nutrition
 and
 Dietetics

  4

Pepin
 Andrew
 Tuma,
 Esq.

Senior
 Director

Government
 &
 Regulatory
 Affairs

Academy
 of
 Nutrition
 and
 Dietetics