The U.S. Department of Agriculture’s Food Safety Inspection Service (FSIS) has identified sanitation concerns contributing to last year’s Listeria monocytogenes outbreak connected to a Boar’s Head facility in Jarratt, Virginia, as well as short-term measures FSIS will take to reduce the likelihood of Listeria outbreaks.

The outbreak, which was tied to liverwurst produced at the facility, sickened 61 people across 19 states and resulted in 10 deaths. Boar’s Head recalled 7 million pounds of ready-to-eat (RTE) meat and poultry produced at the plant between May 10 and July 29.

FSIS – which reviewed Boar’s Head documents and sampling data from January 2022 to September 2024 – says in a new report that “a notable contributing factor” was “inadequate sanitation practices” at the facility, which Boar’s Head indefinitely closed on Sept. 13.

Specifically, FSIS notes instances of noncompliance with sanitation standard operating procedures and sanitation performance standards, such as the presence of meat and fat residue from the previous day’s production on equipment; condensation in the RTE processing area; and structural issues such as cracks, holes and broken flooring that could hold moisture. Other documented conditions included rust, beaded condensation and peeling caulk.

FSIS reports the Jarratt facility was inspected by the Virginia Department of Agriculture and Consumer Services through a Talmadge-Aiken (TA) cooperative agreement. The TA program allows state health officials to inspect meat and poultry facilities with federal grants of inspection on behalf of FSIS. The agency says these state inspectors receive the same FSIS training and meet the same duty requirements as federal inspectors.

FSIS also reports that it inspected other Boar’s Head’s facilities in Arkansas, Indiana, Michigan, and Virginia and sampled for Listeria at those locations. The agency reports that “any identified deficiencies were corrected and monitored in both the short- and long-term.”

In November, Boar’s Head launched a webpage highlighting the food safety efforts it had undertaken following the outbreak, including the formation of a Food Safety Advisory Council chaired by Frank Yiannas. Last month, Boar's Head settled a case brought by the family of Gunter Morgenstein, who died from complications associated with Listeria infection.

In addition to outlining concerns at Boar’s Head facilities, FSIS explored its own processes and procedures related to Listeria controls and found areas for improvement in sampling, inspector training and oversight of federal plants staffed by state inspectors.

The agency announced plans to review weekly Listeria-related risk factors at RTE facilities, including those that are federally inspected and those inspected under the TA program. These risk factors include physical plant modifications, such as new construction; indicators of sanitation problems, such as condensation, roof leaks, damaged equipment or cracked floors; and Listeria species or Listeria monocytogenes positive test results from company testing.

Furthermore, FSIS says it has “clarified state and federal requirements for consistent oversight of the TA program through updated cooperative agreements and instructions.” FSIS currently has TA agreements with inspection bodies in Alabama, Georgia, Illinois, Mississippi, North Carolina, Oklahoma, Texas, Utah, and Virginia.

FSIS says it will add “broader Listeria species testing” to all samples of RTE product, environmental and food contact surfaces. The agency currently tests for Listeria monocytogenes, which is the type that causes illness, but it says testing for other species will provide insight on the effectiveness of a facility’s sanitation program.

FSIS has also asked the National Advisory Committee on Microbiological Criteria for Foods (NACMCF) – a federal advisory committee that provides recommendations to government agencies on microbiological and public health issues – to review FSIS’ regulatory approach to Listeria monocytogenes.

Furthermore, FSIS says it will update instructions and training for food safety instructors to help them “recognize and highlight systemic problems in a standardized way.” The agency will also provide supplemental Listeria monocytogenes training.

FSIS adds it will prioritize in-depth food safety reviews at RTE meat and poultry facilities in fiscal year 2025 to determine if there are any trends that could result in policy changes. FSIS field supervisors will also conduct in-person followup visits when systemic issues are identified a facility.

The agency notes further examination of its Listeria policy is needed before making recommendations for “long-term and comprehensive changes” to its regulatory approach.