“Major deficiencies associated with the establishment’s physical conditions were observed that could pose imminent threat to product.”

– Conclusion from USDA Food Safety Assessment of Boar’s Head (Jarratt, VA), October 2022

In September/October of 2022, the USDA’s Food Safety and Inspection Service (FSIS) conducted a Food Safety Assessment (FSA) of the Boar’s Head production plant in Jarratt, Virginia.

The FSA, which was conducted by an Enforcement Investigation and Analysis Officer (EIAO), followed on the heels of numerous instances of non-compliance with sanitation, cleaning, and maintenance norms documented by Inspection Program Personnel.

The FSA began on September 27, 2022, with a “walk-through” to evaluate the production facility’s compliance with Sanitation Performance Standards.

During that walk-through, the EIAO observed nearly 100 individual instances of non-compliance, including:

• condensation beading on pipes and ceilings; in some cases directly above ready-to-eat product
• rusting brackets, clamps, and conduits
• peeling paint
• loose caulking
• trash on floor
• smoke and soot collected on ceiling and overhead pipes
• holes in walls and floors
• exposed insulation around piping
• green mold in the vicinity of a crack in a wall
• live insects

The second phase of the FSA focussed on compliance with Sanitation Standard Operating Procedures (SSOP). This part of the assessment was performed only after plant quality assurance personnel had completed their own pre-operation inspection and declared the areas to be ready to begin production.

During the SSOP inspection, performed on September 28th, September 29th, and October 4th, the EIAO documented 46 individual instances of inadequate cleaning and six maintenance issues, including:

• multiple instances of product residue on and around production equipment, including on surfaces that would come into contact with fresh product
• beads of condensation
• numerous missing links in a conveyor belt line

Upon checking the facilities SSOP records for the dates in question, the EIAO discovered that neither the deficiencies nor any corrective action had been documented, as required.

Finally, in the course of reviewing the company’s HACCP plan and records, the EIAO found that multiple sites had been omitted from the list of Food Contact Surfaces in the Environmental Monitoring Program.

What happened next?

NOTHING!

No warning letter. No suspension of operations (except for a 1-hour pause in a single part of the facility).

And, as far as can be determined from subsequent routine inspections, no real change in the company’s attitude or behavior.

The on-site inspector continued to log instances of product residue and “meat over-splash” in areas that had been cleared by plant QA personnel for production.

Mentions of rust continued to appear on the inspection logs.

Insects still crawled onto the pages of the reports.

And condensation periodically beaded on the ceiling, sometimes above a product-contact area.

What about Listeria?

In all of the inspection reports, covering a two-and-a-half year period from January 2022 through July 2024, there is not a single mention of Listeria.

We don’t know whether, and to what extent, the company conducted environmental and finished product testing for Listeria, and there is no indication that the 2022 Food Safety Assessment included any such sampling.

The only testing that has been made public consisted of twelve finished product samples collected by the Virginia Department of Agriculture at the request of the FSIS and analyzed by a USDA laboratory. Listeria monocytogenes was not recovered from those samples.

Some things never change

In mid-September 2002, the CDC alerted the public to an outbreak of Listeria monocytogenes that was responsible for 26 illnesses and 4 deaths. By October 4th, the number of confirmed illnesses had increased to 40. Seven people died and three pregnant women miscarried.

Epidemiological analysis linked the outbreak to sliced turkey deli meat. Eventually, the outbreak strain was found in environmental samples collected at Pigrim’s Pride in Franconia, PA and from ready-to-eat poultry products manufactured by JL Foods (a company unaffiliated with Pilgrim’s Pride).

Both companies had a long history of Listeria monocytogenes contamination in their production facilities, dating back at least to 1990 in the case of JL Foods. In both cases, FSIS closed its collective eyes to multiple instances of non-compliance at both facilties.

What needs to be done?

Food safety regulation and enforcement is suffocating within the FDA. The relatively recent reorganization may help, but feels too much like a rearrangement of deck chairs on the Titanic.

For decades, enforcement of food safety regulations for meat and poultry products within the USDA has taken a back seat to the agency’s mandate as a promoter of US agricultural products and industries. There is an inherent conflict of interest in these dual mandates that cannot be solved by nibbling around the edges.

The current system in the United States is fraught with overlapping jurisdictions and completing interests. Arbitrary definitions can place a single plant be under FSIS jurisdiction for some products and FDA jurisdiction for others.

The only sensible solution is to do what many of the USA’s trading partners have already done.

Combine the food safety mandates of the FDA and FSIS into a single, independent Food Safety Agency.

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On August 28, 2024, the US Centers for Disease Control and Prevention (CDC) revealed that Listeria monocytogenes-contaminated deli meats were responsible for 57 illnesses in 18 states.

All 57 outbreak victims were hospitalized.

Nine people are dead.

The first reported victim in this outbreak (the “index case”) became ill on May 29, 2024. By July 19, 2024, the date on which the investigation began, the CDC was aware of 28 confirmed outbreak cases, including two deaths. That number increased to 34 cases just one week later.

Epidemiological and traceback data all pointed an accusatory finger in the direction of meats sliced at deli counters. Of the 44 people able to be interviewed, 41 (93%) reported eating deli meats. Thirty-nine of the 41 (95%) reported eating meats sliced at a deli. Of the 41 people who answered if they ate liverwurst, 25 (61%) reported deli-sliced liverwurst before getting sick, and 19 reported Boar’s Head brand.

As part of the outbreak investigation, the Maryland Department of Health and Baltimore City Health Department collected an unopened Boar’s Head liverwurst product from a retail store. Lab tests recovered and identified the outbreak strain of Listeria monocytogenes from the liverwurst sample.

The recalls

On July 26, 2024, Boar’s Head Provisions Co., Inc. (based in Jarratt, VA) recalled all of its liverwurst products currently on the market, as well as several other deli products that had been manufactured on the same date as the sample of liverwurst from which the outbreak strain was recovered. The company expanded its recall four days later to include all outstanding products —approximately 7 million pounds of deli meats.

The recalled deli meats were distributed to retail locations throughout the USA and some were exported to the Cayman Islands, Dominican Republic, Mexico, and Panama.

The California Department of Public Health has posted a list of all retail outlets in the state where the recalled products were sold. These include large grocery chains, such as Albertson’s, Pavilions, Sprouts, Safeway, and Von’s, as well as numerous small chains and independent deli stores.

Elsewhere, consumers must rely on supermarket recall notices. The following is a list of supermarket chains that have posted notices on their websites. Follow the links to access the recall notices.

• BigY
• Defense Commissary Agency
• Fry’s Food Stores
• H-E-B
• Kroger stores
• Lowes Foods
• Price Chopper
• Schnucks
• ShopRite
• Sprouts Farmers Market
• Target

This list is far from comprehensive. For example, stores belonging to the Alberton’s group have not posted recall notices for Boar’s Head products.

Scope of the outbreak

Most of the reported outbreak victims live in the eastern half of the continental USA.

Confirmed cases have been documented in Arizona (1), Florida (3), Georgia (2), Illinois (1), Indiana (1), Maryland (8), Massachusetts (3), Minnesota (1), Missouri (3), New Jersey (5), New Mexico (1), New York (17), North Carolina (1), Pennsylvania (2), South Carolina (2), Tennessee (1), Virginia (4), and Wisconsin (1).

Both South Carolina victims died. The other seven deaths occurred in Florida, Illinois, New Jersey, New Mexico, New York, Tennessee, and Virginia.

According to the CDC, the true number of outbreak cases is likely higher than the 57 reported cases. People who suffer mild illnesses may not seek medical attention and their infections go unreported.

Comparison to past outbreaks

Since 2018, the CDC has reported on five Listeria monocytogenes outbreaks (including the current one) linked to consumption of deli meats or deli-sliced meats.

Year	Food	Cases	Hospital-izations	Deaths	States
2018	Deli Ham	4	4	1	2
2019	Deli-sliced meats & cheeses	10	10	1	5
2020	Deli meats	12	12	1	4
2022	Deli meats & cheese	16	13	1	6
2024	Meat sliced at delis	57	57	9	18

The current Boar’s Head outbreak accounts for more illnesses, hospitalizations, and deaths than all four previous deli-related outbreaks combined.

How did we get here?

As a manufacturer of meat and poultry products, Boar’s Head falls under the jurisdiction of the US Department of Agriculture’s Food Safety and Inspection Service (FSIS).

Unlike companies regulated by the US Food and Drug Administration (FDA), FSIS-regulated processors are inspected daily. In the case of Boar’s Head, the FSIS contracted with the Virginia Department of Agriculture and Consumer Services (VDACS) to perform those inspections.

In January 2014, FSIS issued a 143-page guidance document, “FSIS Compliance Guideline: Controlling Listeria monocytogenes in Post-lethality Exposed Ready-to-Eat Meat and Poultry Products.” The document was intended to assist processors in navigating the requirements of the agency’s Listeria rule.

In this document, the FSIS warns that, “Facilities maintenance personnel should be informed that Listeria thrives in moisture and that it is important that they vigilantly look for leaking roofs, drips, standing water, and condensation.”

Between August 1, 2023, and August 2, 2024, the VDACS inspector recorded a total of 69 instances of non-compliance, including multiple cleaning and sanitation issues, maintenance and repair issues, clogged drains, incomplete documentation, accumulation of black mold, live and dead insects, thick coatings of dust, multiple instances of condensation, leaking hot water pipe, and green algal growth in standing water.

During that same time period, the VDACS inspector submitted just twelve samples to the FSIS laboratory for analysis, none of which were positive for Listeria monocytogenes. It is unclear whether these were finished product or environmental samples.

What’s next?

Production has been shut down at the Jarratt facility until the source of the contamination can be identified and corrected.

The following statement appears on the Boar’s Head website:

We deeply regret the impact this recall has had on affected families. No words can fully express our sympathies and the sincere and deep hurt we feel for those who have suffered losses or endured illness.

We are conducting an extensive investigation, working closely with the USDA and government regulatory agencies, as well as with the industry’s leading food safety experts, to determine how our liverwurst produced at our Jarratt, Virginia facility was adulterated and to prevent it from happening again.

Production has been paused at our Jarratt, Virginia facility since we initiated the expanded recall in late July. We will not resume operations at this facility until we are confident that it meets USDA regulatory standards and Boar’s Head’s highest quality and safety standards.

Since last week’s release of the most recent data, multiple players have called for a congressional investigation into the actions of the company and the FSIS. Senator Blumenthal is among those who have called for a federal probe.

“The outbreak of listeria in Boar’s Head meat products should have been caught, could have been stopped by the United States Department of Agriculture,” Blumenthal was quoted by 12News Connecticut as saying. “I want an investigation as to why those lax inspection procedures caused these deaths and sicknesses.”

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Interested in learning more about food safety and the history of foodborne disease outbreaks and investigations?

Click on the link to listen to a short excerpt, then follow the buy links to add a digital, print or audio copy to your personal library.

TAINTED is available in digital format from all major on-line retailers. Press the button to go directly to your preferred digital bookstore.