FSIS Cites Inadequate Sanitation as Contributing Factor to Boar’s Head Listeria Outbreak

The U.S. Department of Agriculture (USDA) Food Safety and Inspection Service (FSIS) released a report summarizing its initial findings and recommendations for improvements in the wake of a large outbreak of Listeria monocytogenes illnesses that occurred between May and November 2024 and was linked to liverwurst produced at a Boar’s Head facility in Jarratt, Va.

During July 2024, FSIS worked closely with public health partners to investigate and identify the source of the outbreak. FSIS then moved rapidly to notify the public, ensure all potentially contaminated product was removed from commerce, suspend inspection and prevent any additional contaminated product from entering commerce.

Once the immediate public health threat had been addressed, FSIS began a thorough review of the outbreak to identify potential contributing factors and evaluate potential regulatory responses. FSIS conducted extensive document reviews and in-person assessments at the Jarratt facility and all FSIS-regulated establishments owned and operated under the Boar’s Head Provisions Corporate umbrella. The document reviews encompassed 2022 through 2024 and included FSIS-generated inspection records, memoranda and microbial testing results, as well as establishment programs, procedures, microbial testing results, corrective actions and findings from Boar’s Head’s internal investigation. FSIS also sent investigators to each of these establishments to conduct in-depth Food Safety Assessments (FSA), including targeted environmental and product microbial testing.

Furthermore, FSIS reviewed its own practices and procedures related to Listeria controls in ready-to-eat (RTE) establishments, including sampling programs, inspector training and instruction and oversight of establishments under state inspection models. The report concludes with measures to better protect the public from Listeria informed by the findings. The findings and recommendations included within do not prejudge any ongoing investigations by USDA or any other entity.

Based on records and observations, FSIS identified several factors that may have contributed to the outbreak. A notable contributing factor was the facility’s inadequate sanitation practices. Observations by Virginia Department of Agriculture and Consumer Services inspection personnel documented in noncompliance records demonstrated multiple instances of noncompliance with Sanitation Standard Operating Procedures and Sanitation Performance Standards. While sanitary conditions were required to be restored for each documented noncompliance, repeated instances of insanitary conditions can present opportunities for growth or sustained presence of Listeria.

Many of the inspection and sampling records used in the review have been requested by the public through Freedom of Information Action (FOIA) requests. To ensure transparency, FSIS said it will post documents to its FOIA Reading Room as they become available.

Read the full review here.