CDC Response to Public Comment

September 30, 2016

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

Dear Jeanne Blankenship and Pepin Tuma,

The Outbreak Response and Prevention Branch of the Division of Foodborne, Waterborne, and Environmental Diseases Division of the Centers for Disease Control and Prevention (CDC) appreciates the comments provided by the Academy of Nutrition and Dietetics regarding the update to the information collected “Using the Standardized National Hypothesis Generating Questionnaire (SNHGQ) during Multistate Investigations of Foodborne Disease Clusters and Outbreaks" (Docket No. CDC-2016-0054). We sincerely appreciate the Academy’s support of the use of the proposed information collection questionnaire.

A. Response to the Value of Proposed Information Collection

The burden estimates calculated for OMB submissions are focused on the burden to the general public. Data collection during the course of an investigation should not pose a greater than intended burden to local health departments. Local health officials are regularly tasked with investigating sporadic foodborne illnesses and single jurisdiction foodborne outbreak investigations (i.e. a restaurant or church potluck outbreak). Data collection for multi-state foodborne outbreak investigations represents a small portion of their day to day responsibilities because multi-state outbreaks usually have ill persons scattered across multiple jurisdictions, so the time and energy invested at the local level to investigate these outbreaks is shared across jurisdictions.

B. Response to the Recommendations for Enhancing Proposed Information Collection

1. The CDC has created a training program called Epi-Ready in collaboration with the National Environmental Health Association and the Council of State and Territorial Epidemiologists. Epi-Ready is a two-day, in-person workshop for environmental and public health professionals at the state and local health department level who are responsible for investigation of foodborne illness outbreaks. Training on use of the SNHGQ is a major component of the workshop.

2. During the Epi-Ready training workshop, reference documents are provided which help to guide interviewers through the process of SNHGQ administration. These reference documents include examples of additional surrogate categories. The full list of surrogate categories is not included on the physical form in order to reduce the length of the questionnaire.

3. Responses to improving particular sections of the instrument:

   1. Section 2, Questions 3: We do not include an “ongoing” option in this question for two reasons. The first is that by the time an ill person is interviewed with this questionnaire it is weeks after their initial onset of illness and the majority of cases have recovered. Secondly, for the subset of cases that do have a longer course of illness, filling out the date of interview as the “End date” allows epidemiologists to estimate the amount of time that the person was ill.

   2. Section 4, Question 4: This recommendation was accepted

   3. Section 5: This recommendation was accepted

   4. Section 6: This section is used as a prompt to trigger the interviewee’s memory about where they may have eaten during the time of interest. Including a full list of every possible type of ethnic restaurant would contribute to interviewee-fatigue because of the increase in time burden to the interviewee who would be as they listen to the full list of restaurant categories. We will include the “school or other institutional setting” to include “hospital and senior congregate meal centers”. We do not include vending machines in this questionnaire because the single serving, processed, pre-packaged food items sold in vending machines have a much lower risk of bacterial contamination as compared to the other food exposures assessed in the questionnaire.

   5. Section 7:

      1. This recommendation was accepted.

      2. This recommendation was accepted.

      3. Based on previous experience administering this questionnaire, respondents understand that the “type and variety” question includes color of the grape.

4. The recommendation to include fermented vegetables was accepted. The recommendation to include bananas, rice, and beans was declined. These food items are not normally associated with multi-state foodborne outbreaks due to the way these foods are grown, prepared, and eaten.

5. We have considered creating an electronic version of the form in the past but we feel that the benefits of having an in person interviewer outweigh the concerns regarding length. An interviewer has the ability to ask follow-up questions regarding ambiguous responses and it allows them to probe for details about specific food exposures or possibly other exposures not captured by the questionnaire. Many novel sources of foodborne outbreaks are identified through this method of “conversational” interviewing. It also gives the respondent an opportunity to ask clarifying questions if they are confused by specific sections or questions on the SNHGQ. We agree that ability to recall food consumption over a seven-day period can lead to recall bias.

B. Conclusion

The CDC sincerely appreciates the comments and suggestions provided by the Academy on the proposed updates to the Standardized National Hypothesis Generating Questionnaire. The comments from the Academy have led to a number of alterations to the SNHGQ which will help to improve its effectiveness as a data collection tool during the course of multi-state foodborne outbreak investigations.

Sincerely,

Colin Basler, DVM, MPH, DACVPM

Veterinary Epidemiologist

Outbreak Response and Prevention Branch

Division of Foodborne, Waterborne, and Environmental Diseases

Centers for Disease Control and Prevention