Boar’s Head listeria outbreak demonstrates lack of food safety culture

Mold. Dripping water. Meat residue. Insects. These are some of the horrors inspectors found at the Boar’s Head facility in Jarratt, Virginia — the same facility that produced deli meat tainted with Listeria monocytogenes. Over the course of 12 months, inspectors recorded almost 70 blatant violations.

As of Aug. 28, the Centers for Disease Control and Prevention (CDC) reported nine deaths and 57 hospitalizations. The outbreak is believed to have begun in May, and CDC’s investigation commenced on July 19. It can take up to 10 weeks for symptoms of listeriosis to appear. More illnesses may yet be reported.

“This is the largest listeriosis outbreak since the 2011 outbreak linked to cantaloupe,” CDC said on its website.

Production at the Jarratt establishment is suspended, yet adulterated products may still be in circulation. CDC posted that some of the products have sell-by dates of October 2024. “Look for ‘EST. 12612’ or ‘P-12612’ inside the USDA mark of inspection on the product labels,” CDC cautioned.

Bailey McWilliams, a public affairs specialist for the Food Safety and Inspection Service (FSIS) at the U.S. Department of Agriculture (USDA), said the plant “remains closed until the establishment is able to demonstrate it can produce safe product. This facility is inspected by the Virginia Department of Agriculture and Consumer Services (VDACS) as part of the Talmadge-Aiken Cooperative Inspection Program, where some states provide federal inspection services.“ The state’s program must be “at least equal to“ USDA’s program and approved by USDA.

Frank Yiannas, former deputy commissioner, Food Policy & Response, Food and Drug Administration (FDA), called this outbreak egregious and a failure on multiple fronts. Sixty-nine noncompliances, recorded from Aug. 1, 2023, to Aug. 2, 2024, are posted online as part of the Freedom of Information Act (FOIA).

On June 26 at 2:35am, the inspector wrote, “I observed what appeared to be mold and hard meat residue on the entry and exit sides of both sets of the green flap doors. The walls had denaturing liquid splattered, dried meat and pickle. There were also whitish, discolored muscles of meat lying near the trash compactor with flies surrounded [sic] them. There was also inedible combos and containers that had multiple green color flies circling around the denatured product.”

The last available entry, on July 27, 2024, at 8:45pm, noted clear liquid was falling from patches on the ceiling. A nearby fan was blowing the liquid into a hallway that contained uncovered hams. A day earlier at 8:39pm, the inspector observed beaded condensation dripping over product. Meat and product residue coated the handle and electrical box of a rusty pallet jack. On July 25 at 4:36am, the inspector notified the quality assurance manager of condensation, black mold, rust and dust.

Previous reports cited standing water, a clogged drain and various insects in different parts of the plant. The presence of “heavy, discolored meat buildup” was a frequent observation during inspections. According to CDC, listeria can remain on surfaces like meat slicers, even at refrigerated temperatures.

McWilliams commented that VDACS inspectors found instances of noncompliance, and the establishment implemented corrective actions in keeping with FSIS regulations. “FSIS is working closely with VDACS to ensure the establishment has an effective system in place to produce safe food for the public,” she said.

Yiannas noticed that FOIA records indicate inspectors were in the plant frequently. “Clearly the misses were not based on the frequency of regulatory inspection, but rather on the quality of the inspections and maybe even their effectiveness in ensuring appropriate corrective actions were being taken and root issues were being addressed,” he said.  

Repeated citations for sanitation and maintenance issues reveal a lackadaisical working environment in a facility that appears to have operated around the clock. “You can have the best documented policies, procedures and rules in the world, but if they’re not consistently put into practice by people, they’re useless,” Yiannas continued. “That's why this concept of a food safety culture is so important. In fact, I think it has been at the heart of every foodborne outbreak I’ve worked on, whether in the public or private sector. When an organization has a strong food safety culture, they're going to do the right things, formulate their products with safety in mind, and operate in a sanitary manner 24/7 — not just because it’s the law or the inspector has arrived, but because it’s simply the right thing to do and they care about their customers’ safety.”

The failure of management and employees to keep food safety top of mind is costly, not only to the consumers who were sickened by Boar’s Head’s products but to the company, too. In multiple cases the reports mentioned liverwurst, franks, hams and bologna. According to Boar’s Head’s recall notification, only liverwurst has been found to be adulterated with Listeria monocytogenes. However, many other products from the same plant were also recalled. Ham, frankfurters, bologna, salami, olive terrine loaf, bacon, bratwurst, knockwurst, kielbasa and pork loin are just a few of the potentially dangerous products. Everything that was produced in that plant and purchased before July 31 is under recall.

On Aug. 30, the first wrongful death lawsuit was filed in Sarasota County, Florida. Gunter Morgenstein, a Holocaust survivor, died on July 18, just over two weeks after buying liverwurst and consuming it over several days. The lawsuit, filed on behalf of Morgenstein’s widow and son by Ron Simon & Associates, demands a jury trial.

“We hope to bring awareness and changes to the dangerous and unsanitary conditions at Boar’s Head, so that others don’t suffer the same fate,” the Morgenstein family said in a statement. Simon’s law firm has established a Boar’s Head Listeria Claim Center to assist victims of the outbreak.