Two years before a deadly listeria outbreak, U.S. inspectors warned that conditions at a Boar’s Head plant posed an “imminent threat” to public health, citing extensive rust, deli meats exposed to wet ceilings, green mold and holes in the walls.
But the U.S. Agriculture Department did not impose strict measures on the plant, in Jarratt, Va., which could have ranged from a warning letter to a suspension of operations.
Since then, other inspections found that many of the problems persisted, but again, the plant continued to process tons of beef and pork products, including liverwurst.
Genome sequencing tests by public health officials in New York and Maryland tied a strain of listeria found in Boar’s Head liverwurst to the bacteria from people who died or fell ill, according to the Centers for Disease Control and Prevention.
The company recalled its liverwurst late in July. Days later, Boar’s Head expanded the recall to cover more than 3,500 tons of meat — including ham and other items made in the Jarratt facility, one of several it operates.
Production at the meat processing center has been temporarily stopped. Boar’s Head said it was disinfecting the plant and trying to determine the cause of the suspected contamination. Nine elderly people have died and dozens were hospitalized in the worst listeria outbreak in years.
Public health experts have expressed worry that those numbers could increase, because symptoms can emerge weeks later. They also noted that consumers might not be aware of the recall, and some of the products do not expire until October.
Like other meat processors, the plant is supposed to have U.S.D.A.-trained inspectors on site at all times that the facility is operating. After the outbreak became public, the U.S.D.A. initially released one year of the inspectors’ reports from Aug. 1, 2023 to Aug. 2, 2024.
The agency later released reports dating to January 2022, which showed that a federal food safety assessment took place in September and October of 2022. During that review, records show, inspectors were already finding rust, mold, garbage and insects on the plant floors and walls.
Several food safety experts have said in interviews that the recurring instances of unsanitary conditions should have spurred stricter enforcement.
“They shouldn’t have allowed this company to keep producing ready-to-eat products, lunch meat that’s going to go on people’s tables, when they’re seeing this level of violation,” said Sarah Sorscher, a food safety regulatory expert at the Center for Science in the Public Interest, a nonprofit advocacy group. “Consumers had to die before this plant got shut down, really is the bottom line.”
A spokeswoman for Boar’s Head said the inspectors’ finding of an imminent threat in 2022 was not followed with any enforcement action after the federal agency reviewed the results of product and environmental testing, plant records and observations.
Asked by The New York Times about the assessment in 2022, the U.S.D.A. did not respond directly. A spokeswoman said the agency was conducting a review of the circumstances leading to the outbreak, adding that the Jarratt plant would remain closed until the department was confident that the company could produce safe foods. The agency said it was also looking at other Boar’s Head facilities, which operate in Indiana, Michigan, Arkansas and Brooklyn, N.Y.
U.S.D.A. records show that if an investigator identifies an “imminent threat,” the agency “may take immediate action.” It remains unclear what prompted the review in September 2022.
Carl Custer, a former U.S.D.A. food microbiologist who assisted in investigations, said in an email that he was surprised the agency did not either shut down the facility in 2022 or require the company to keep the meats on the site until they cleared tests for contamination. He said a district office would be responsible for taking any action.
Daniel Engeljohn, a former U.S.D.A. food safety policy official, said that the company’s production methods would have placed the Jarratt plant in the agency’s category of higher-risk food facilities. But the agency deems deli meat processing inherently risky, because people eat the meat without cooking it first, another step that can kill bacteria.
Food safety experts said the Jarratt facility employed practices that were widely used decades ago.
U.S.D.A. records show that it relied on sanitation alone, which meant that the facility was supposed to conduct routine tests and keep the plant clean to limit bacteria in finished products. The company did not immediately respond to questions about these practices.
Those methods are commonly used by deli meat producers, department records show.
Under U.S.D.A. guidelines to guard against listeria that were finalized in 2015, companies also have the option of conducting a “kill step” that could involve irradiation or applying intense pressure to smash bacteria after the meat is cooked and packaged. Another alternative for deli meat companies is the use of vinegar-, salt- or citric acid-based additives that limit bacterial growth.
During the September 2022 review, U.S.D.A. investigators found lapses in Boar’s Head’s sanitation at the 44-year-old plant.
The records show that U.S.D.A. inspectors noted leaking pipes that dripped water onto the floor and condensation beaded along a 20-foot strip of ceiling above ready-to-eat food. They reported dozens of holes in the walls of the facility and “numerous” patches of green mold. They saw live beetles in the bathroom hallway. And they alerted plant workers to meat residue on food-contact surfaces.
In a room for packaging ready-to-eat hot dogs, investigators reported finding dirt, screws and trash on the floor. In the room where liverwurst was produced, rust covered portions of the walls and ceiling, paint was peeling off a wall and “product residue” was found on the floor.
Mr. Engeljohn said it would be typical for inspectors to move forward with strong enforcement if the problems could not be remediated promptly and if they observed unsanitary food production.
He said the records showed that while investigators saw the potential for food contamination, the inspectors did not appear to have observed direct contamination. He said the evidence of an aging plant was “the nature of the food processing industry.”
Records show that the problems noted in 2022 persisted, with mold, rust, pooled water and condensation documented during inspections in 2023 and 2024. Food safety experts said the moisture and evidence of it in the rust were troubling, because listeria thrives in cold, wet conditions like those in the plant.
A Boar’s Head spokeswoman said the agency performed thousands of inspection tasks in a year. When it finds problems, she said, company employees remedy the issues immediately.
Phyllis Entis, an expert who worked for Canada’s food-safety agency and consulted with companies for 20 years, said the U.S.D.A. could have taken swift and strong action in 2022. It could have pulled its inspectors from the plant, which would immediately prevent the facility from legally shipping meat.
“There is just too much of a leaning toward letting the industry enforce itself, letting the companies get away with stuff that could easily be stopped,” said Ms. Entis, who is the author of the book “Tainted: From Farm Gate to Dinner Plate, Fifty Years of Food Safety Failures.”
Where the listeria originated remains unclear. Officials from Virginia’s agriculture department, who inspect the plant on behalf of the U.S.D.A, said federal authorities requested that they take 12 samples of packaged meat to monitor for listeria. All results were negative, a spokeswoman said.
The U.S.D.A. did not respond to questions about the facility’s testing procedures.
James Marsden, a consultant and former food safety executive for Chipotle, said he once helped a plant try to find listeria and never discovered it. Ultimately his team deployed a facility-wide ozone treatment to kill all of the bacteria.
He said an outcome of this tragedy could be an update to the U.S.D.A.’s listeria rules that allow plants to ship deli meat without an added step to inhibit or kill bacteria.
“It’s maybe not tight enough to totally prevent disease,” he said. “Obviously it’s not.”
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