Public Comments

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August 3, 2026
Jeffrey M. Zirger
Information Collection Review Office
Centers for Disease Control and Prevention
1600 Clifton Road NE, MS H21-8
Atlanta, Georgia 30329
Re: Docket No. CDC-2026-0925; Document No. 2026-11011
Dear Dr. Zirger:
The International Fresh Produce Association (IFPA) appreciates the opportunity to comment on CDC's proposed
three-year extension of the CNHGQ. IFPA represents growers, processors, distributors, and other stakeholders
across the fresh produce supply chain, and we share CDC's goal of identifying outbreak sources quickly,
accurately, and based on the strongest available evidence.
We offer the following recommendations in response to the agency's stated interest in whether the collection has
practical utility (Item 1), and in enhancing the quality, utility, and clarity of the information collected (Item 3).
Recommendation 1: Consider the likelihood that Cyclospora has established endemically in the United
States and likely routes of exposure for an endemic waterborne parasite.
As currently structured, and as reflected in this notice's own background, the CNHGQ was adapted from a
bacterial-outbreak questionnaire and modified specifically to capture produce-related food exposures. To our
understanding, it does not currently include structured questions on recreational water activities (such as
swimming in lakes, rivers, or pools) or private/municipal drinking water sources.
This is a meaningful gap given Cyclospora's biology. Cyclospora cayetanensis is, at its core, a waterborne
parasite: humans are its only known host, and contamination reaches the environment through water affected by
human waste, whether via agricultural runoff, aging or compromised sewer infrastructure, or municipal system
overflows. The parasite requires a period of warmth and moisture in the environment to become infectious,
conditions historically more consistently met in the tropical and subtropical regions where cyclosporiasis has
been endemic. Documented increases in average U.S. temperatures raise a reasonable question worth CDC's
consideration: whether conditions supporting this maturation process domestically are becoming more
consistent and widespread than in past decades, potentially shifting cyclosporiasis from a primarily travel- and
import-associated illness toward one with a more sustained domestic environmental transmission cycle. This
notice itself notes that cyclosporiasis cases typically rise during the spring and summer months, the same period
in which heavy rainfall and elevated temperatures most commonly contribute to combined sewer overflow events
and to the warm, moist conditions the parasite requires to become infectious. If domestic conditions are
increasingly capable of sustaining this cycle, systematically capturing water exposure in the CNHGQ becomes

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even more important, not less, as investigators work to distinguish domestically-acquired cases from imported
ones.
Because molecular typing methods for C. cayetanensis cannot independently identify genetically linked clusters,
a limitation this notice itself acknowledges, the hypothesis-generating interview is doing outsized work in shaping
the direction of an entire investigation. If water exposure is not systematically asked about, it cannot be
systematically ruled in or out, regardless of its actual relevance to a given outbreak. Not considering the likely
hypothesis that Cyclospora is endemic in the U.S. is a structural risk that investigations may be biased toward
food-vehicle hypotheses by default, not because the evidence points there, but because the tool used to generate
hypotheses does not ask about the alternative.
For CDC's consideration, we propose the following draft question language:
1. Drinking water source: "In the 2 weeks before you became ill, what was your main source of drinking
water? (Public/municipal water system; community water distribution system; private well; bottled water
only; other, please specify)"
2. Drinking water outside the home: "In the 2 weeks before you became ill, did you drink water at any of the
following locations? (Check all that apply: a restaurant, please specify which one; an office; a gym or
recreational facility; a place of worship; another household on a private well; another household on a
community water system; none of the above)"
3. Location of outside water consumption: "If you consumed tap water outside your residence, please
provide the zip code(s), neighborhood(s), or township(s) where that water was consumed."
4. Recreational water exposure: "In the 2 weeks before you became ill, did you swim in, wade in, or otherwise
have contact with any of the following? (Check all that apply: public or private swimming pool; public or
private hot tub or spa; splash pad or water park; lake; river or stream; pond; irrigation canal or ditch; hose
spray; water fountain; none of the above) If yes, please provide the exact location(s) of each exposure."
5. Water quality disruption awareness: "Are you aware of any recent flooding, heavy rainfall, sewer overflow,
or boil-water advisory in your area in the 2-4 weeks before you became ill? (Yes/No/Not sure; if yes, please
describe) If you were aware of a boil-water advisory, did you boil your water before drinking it?"
6. Septic system use: "Do you use a septic system for waste disposal? (Yes/No) If yes, when was your septic
system last serviced?"
7. Occupational water/waste exposure: "Do you routinely work at or with any of the following? (Check all that
apply: water treatment facilities; sewage treatment facilities; public toilets; portable toilets; stormwater
facilities; biosolids or other soil amendments; none of the above)"
8. Recent camping exposure: "Have you recently camped at a site relying on private, local, or community
drinking water systems, or on non-centralized waste disposal? (Yes/No) If yes, please provide the exact
location of the campsite."
9. Occupational or hobby exposure to soil/waste: "In the 2 weeks before symptom onset, did your occupation
or hobbies involve exposure to any of the following? (Check all that apply: soil amendments or garden soil;
plumbing; sewage or sewer systems; construction or utility work; laboratory handling of human feces;
biosolids; none of the above)"

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Recommendation 2: Review historical, unresolved cyclosporiasis investigations for exposures that were
reported but not captured as structured data.
This notice states that during 2000-2014, many reported cases could not be directly linked to an outbreak or to a
particular food vehicle, in part due to insufficient data. We recommend CDC examine what exposures, if any, were
reported by case-patients in those unresolved investigations but were not captured as structured, analyzable data
elements at the time. If patterns exist across historical unresolved cases, whether related to water, environmental
exposures, or something not yet considered, incorporating relevant questions into the CNHGQ could help
investigators identify or rule out those factors more systematically in future outbreaks, rather than relying on ad
hoc follow-up once an investigation is already underway.
Recommendation 3: Consider routine wastewater surveillance to better understand Cyclospora's
endemicity in the United States.
Separately from the CNHGQ itself, we'd encourage CDC to consider whether routine wastewater testing for
Cyclospora cayetanensis could help establish a clearer baseline understanding of the parasite's endemicity
across different U.S. regions. Wastewater surveillance has proven valuable for tracking other pathogens, and
applying a similar approach here could help distinguish sporadic, imported-produce-driven cases from a more
sustained domestic environmental presence, particularly relevant given the temperature and seasonality
considerations raised above. A better baseline understanding of where and how consistently this parasite is
present in U.S. wastewater would also give context for interpreting individual outbreak investigations: a positive
water exposure reported through the CNHGQ recommendations above would mean something different in a
region with an established endemic presence than in one where the parasite is rarely detected.
On burden (Item 4):
We recognize CDC's interest in minimizing burden on ill individuals being interviewed during an already difficult
time. We do not believe adding a small number of structured water-exposure questions would meaningfully
increase the 45-minute average burden per response cited in this notice. A brief, well-designed set of questions
covering recreational water activities and drinking water source would add minutes, not a substantially longer
interview, while potentially closing a significant gap in the hypothesis-generating process.
We would welcome the opportunity to discuss these recommendations further with CDC's Information Collection
Review Office, and we appreciate the agency's continued work to strengthen the tools available for investigating
this uniquely challenging pathogen.

Respectfully submitted,

Max Teplitski, Ph.D.
Chief Science Officer, IFPA