USDA: Poor Sanitation to Blame for Boar’s Head Listeria Outbreak

Inadequate sanitation practices and non-compliance with Standard Operating Procedures (SOPs) at a Boar’s Head Facility in Virginia played a key role in a listeria outbreak last year that killed 10 people and left dozens hospitalized across 19 states. 

Published on January 10th, the report summarizes the USDA’s Food Safety and Inspection Service (FSIS) findings and recommendations in the wake of the outbreak. The 

The USDA report states that on July 12, 2024, the FSIS opened an investigation into the outbreak and, by November 21, 2024, declared the outbreak over. The FSIS investigation included extensive document reviews and in-person assessments at all FSIS-regulated establishments owned and operated by Boar’s Head Deli Meats. The documents spanned 2022 through 2024 and included FSIS-generated inspection records, memoranda, microbial testing results, and findings from an internal Boar’s Head investigation. 

The FSIS also conducted a Public Health Risk Evaluation (PHRE) which reviewed all relevant inspection records and determined that an in-depth assessment was needed.

The outbreak was traced back to a Jarratt, Virginia production facility, referred to in the report as M12612. The report said “based on records and observations,” the FSIS identified several key factors that may have contributed to the outbreak. 

“A notable contributing factor was the facility's inadequate sanitation practices…while sanitary conditions were required to be restored for each documented noncompliance, repeated instances of unsanitary conditions can present opportunities for growth or sustained presence of Lm (Listeria monocytogenes).”

These factors include meat and fat residue left on equipment from the previous day, condensation dripping directly onto products, and structural-related issues (cracks, holes, and broken flooring) that could hold moisture and lead to wet conditions. 

The inspectors said they also found multiple ways in which the company’s processes and procedures related to Listeria controls could be improved, including in training.  

Moreover, the report said better tools and training for inspection personnel are key. 

“Inspection personnel should consider whether repeated noncompliance findings collectively signal a broader systemic failure at an establishment. In order for inspectors to elevate systemic problems with an establishment’s food safety system for action, they must have the ability and tools to recognize patterns and determine when multiple deficiencies suggest a systemic issue,” the report states. 

The report also notes how the USDA is prioritizing training for inspectors and food safety reviews at ready to eat meat and poultry facilities. The USDA is also updating protocols for food safety review follow-ups to ensure corrective actions are taken. 

A spokesperson for Boar’s Head told NPR this week that “we continue to actively cooperate with the USDA and government regulatory agencies on matters related to last year's recall, and we thank them for their oversight."

In September, Boar’s Head indefinitely closed the Jarratt plant at the center of the outbreak. 

A history of violations 

In September, the Associated Press reported that the Jarrat plant was previously cited for 69 noncompliance instances in 2024. 

The violations included incidents involving mold, insects, liquid dripping from ceilings, and meat and fat residue on the walls.

The documents state that in visits held between August 1 2023 and August 1 20-24, inspectors found “black patches of mold” on the ceiling and flies “going in and out” of pickle vats. They also reported seeing “meat overspray on walls and large pieces of meat on the floor.”

Millions of pounds of products 

The outbreak made major headlines and brought the issue of food safety and listeria contamination to readers across the country. 

Boar’s Head recalled more than 7 million pounds of deli and poultry during the outbreak over the summer as cases spread to more than a dozen states. The products were also distributed to the Cayman Islands, Dominican Republic, Mexico, and Panama. 

The contamination was discovered on a liverwurst sample collected by the Maryland Department of Health that tested positive for Listeria monocytogenes. 

In August, the Baltimore Banner reported that after seven people in Maryland became ill, state epidemiologists began interviewing them about what they had eaten. The patients had an average age of 74, leading investigators to think they might have been eating a product that is popular with an older generation. This led them to liverwurst, a German sausage made from pork or beef livers. The investigators bought an unopened package of liverwurst at a Baltimore grocery store and they tested positive for listeria.

According to the Centers for Disease Control, Listeria infection is particularly dangerous for pregnant women, newborns, people with weakened immune systems, and adults aged 65 or older. 

The CDC estimates that each year in the United States, 1,600 people are infected with Listeria, and 260 people die from the infection.

To learn more about the importance of sanitation in food safety, read our interview with sanitation and food safety expert David Blomquist