How ignored warnings at Boar’s Head plant led to a deadly listeria outbreak

In mid-July, as listeria infection cases multiplied across the United States, Maryland health officials who track foodborne illnesses grew increasingly alarmed. The outbreak was spreading at a much more rapid rate than normal for listeria.

Two people — in Illinois and New Jersey — had already died and more than two dozen had fallen ill in the previous seven weeks. The health officials feared many more would succumb.

"We were getting a lot of cases in a very short window of time," said Sophia Wozny, an epidemiologist who tracks outbreaks with her colleagues at the state health department.

The Centers for Disease Control and Prevention had identified the strain of listeria that was sickening and killing people. But its source remained a mystery. The sooner the culprit could be found, the more deaths and illnesses would be prevented.

Wozny and her colleagues were in regular contact with local health departments as well as their counterparts in other states and at the CDC. They shared information on cases and pored over questionnaires filled out by those who had been sickened to learn what they had eaten in the weeks before they became ill. As they read the responses, one item kept appearing: liverwurst.

Boar's Head was the brand cited by many of the respondents. "We know we have to act," Wozny remembered thinking at the time. "This has gone on too long."

A health department worker went to a Baltimore store, purchased an unopened 3.5-pound tube of Boar's Head liverwurst and delivered it to the state lab for testing. Lab workers ground the meat in an industrial blender to create a "liverwurst smoothie" — a method to ensure that no parts of the product went untested.

A preliminary result showed the presence of listeria, but they needed evidence that the bacteria was alive and infectious. Confirmation arrived days later on July 25. Wozny and a colleague alerted the CDC and the U.S. Department of Agriculture, which oversees food safety inspections.

Tracking the origin of the contaminated liverwurst was simple. Boar's Head only produced liverwurst at its Jarratt, Va., plant, a sprawling facility surrounded by a tall security fence on a sleepy back road 55 miles south of Richmond. The USDA notified the company of the positive test that same day. Boar's Head recalled its liverwurst and nine other products made on the same processing line. Four days later, it recalled more than 70 other products made at the plant — including millions of pounds of ham, bologna, bacon and frankfurters.

The beginning of the end of the outbreak was in sight. But for many, it was too late. At least 59 people were hospitalized and 10 are known to have died so far, according to the CDC. It is the largest listeria outbreak since 2011 when tainted cantaloupes led to 147 illnesses, including 33 deaths.

To reconstruct the hunt for the deadly agent and chronicle the conditions that led to the outbreak, The Washington Post conducted more than two dozen interviews with former Boar's Head managers; victims, their families and lawyers; public health officials and food safety experts; and reviewed more than 150 pages of documents.

The sleuthing that determined the cause of the outbreak happened quickly. But there is mounting evidence in government reports and from interviews with former employees that the conditions that caused the outbreak had been building over time. Filthy work areas, aging equipment and haphazard cleaning at the Jarratt plant may have made some of its products microbial time bombs waiting to explode.

On July 29, the USDA halted operations at the Jarratt facility, saying in a suspension letter issued to the company two days later that it had "inadequate controls" to prevent the spread of a bacteria that thrives in damp conditions and spreads easily to food by direct contact with contaminated surfaces.

Boar's Head would not respond to questions about the problems outlined in inspection reports or recounted by employees.

"Due to ongoing litigation, we cannot comment on any aspect of the Jarratt plant beyond the information already available on our website ," company spokeswoman Elizabeth Ward said in an email. "We deeply and sincerely regret the tragic impact of the listeria outbreak."

Red flags in inspections of Boar's Head plant Concerns about conditions at Boar's Head's Jarratt plant were not new to USDA officials.

Two years ago, federal food inspectors warned that "major deficiencies" at the Jarratt facility could pose an " imminent threat " to food safety during an audit of the plant according to government inspection reports released in recent weeks by the USDA.

In the year leading up to the plant's suspension in July, government inspectors notified the plant's managers of one or more "noncompliances" with federal regulations on 57 separate days. The issues cited included "dirty" machinery, flies in pickle containers, "heavy meat buildup" on walls and blood in puddles on the floor.

Among the details in the reports:

Jan. 9, 2024 — "Black mold like substance was seen throughout the room ... with the spots being as small as a pinhead and as large as a quarter."

Feb. 7, 2024 — "Sides of the doors and door frames for Smokehouses ... were found to have significant buildup of dried meat and product residue."

Feb. 21, 2024 — "Rancid smell in the cooler."

Boar's Head previously said its plant team had " immediately remediated " noncompliance notifications issued by inspectors.

In May, as the citations continued to pile up, Ashley Solberg, then 35 weeks pregnant with her second child, was vacationing in Florida where she said she purchased and ate Boar's Head deli products. A week later after returning home to Minnesota, Solberg became "severely ill, suffering from diarrhea, fever, chills, headaches, and body aches, among other symptoms," according to a lawsuit she filed against Boar's Head in August.

Facing a fever that wouldn't go away for days and having ruled out covid and the flu, Solberg, 33, went to a hospital where bacteria was discovered in her bloodstream, she said in an interview.

Solberg was admitted and began an intensive antibiotics treatment. "I was still having fevers, so it was pretty awful," she said. Test results showed she had contracted a listeriosis infection. She remained in the hospital for six days and after being discharged, spent another eight days on a course of IV antibiotics at home, according to the lawsuit.

As she underwent treatment, Solberg worried about her baby. The ultrasound looked normal, but doctors told her "they really wouldn't know what the outcome was going to be until she was born," Solberg said. "It was pretty terrifying."

The Minnesota Department of Health and the CDC would later perform genome sequencing on the samples Solberg provided. In late July the sequencing results came back: It matched the listeria outbreak strain that had sickened so many others.

Her newborn daughter is healthy, Solberg said, but learning more about the conditions that existed in the Jarratt plant has been "upsetting."

"It seems like something that could have been avoided," she said.

Ward, the Boar's Head spokeswoman, said the company is unable to comment on any lawsuits at this time.

For one former employee at the Jarratt plant, the news that the outbreak originated at the facility was not surprising.

"I left because I could see it coming," said the longtime employee who resigned at the beginning of the summer and spoke on the condition of anonymity because they did not want to be connected with the company. "That place was ... nasty."

The former employee described sewer lines that overflowed in employee locker rooms and on the plant's main floor, as well as unsanitary machinery and a generally dismissive approach by managers when issues were raised by employees.

"The management team was always more stuck on filling orders than making sure the plant was clean," the former employee said.

Terrence Boyce, the plant's sanitation manager for more than seven months in 2023, described a pattern of "neglect."

Months after his arrival at the Jarratt plant, he jotted down a list of problems that he said he shared with the management team.

"Drains are not being cleaned daily," he wrote on March 29, 2023, according to handwritten notes he provided to The Post, outlining more than two dozen observations.

"Maintenance — not reliable at all."

"Poor scrubbing habits."

All of the sanitation issues could have been easily remedied, he said. But he said plant management told him he did not have to fix everything so fast.

Boyce, who first spoke with a local television station about what he characterized as outdated sanitation practices, said he wanted to implement a more robust drain-cleaning program to prevent listeria and other bacteria from breeding. That never came to fruition.

He said he was fired in late summer 2023 after one of his staff members had been injured on the job. Boyce said he refused to change the report to say what the plant manager wanted it to say, according to a whistleblower complaint he filed with the Virginia Occupational Safety and Health Program that he shared with The Post. A July 26 email from the state Office of Whistleblower Protection indicates Boyce's complaint is under review.

Boyce wrote in his complaint that management had begun to threaten his job in August after he raised concerns about workplace safety. In an "unsatisfactory job performance" notice Boyce shared with The Post, the assistant plant manager wrote on Aug. 8, 2023, that "sanitation performance is going backwards" and they had received complaints that "areas are not clean." They characterized him as a "know it all" who is "argumentative and abrasive." Boyce disputed the company's characterization of his performance in an interview.

Boar's Head did not comment on Boyce's allegations.

Jeff Hoye, who served as the plant's manager from early 2021 until spring 2022, cited other problems. He said he reported repeated instances of water backing up in coolers that held the plant's meat products to Boar's Head corporate offices. Workers would then assess what products needed to be thrown away. Other issues, like mold on two walls of the plant, were fixed quickly, he said. During his time at the plant, he said the corporate office was immediately notified about noncompliance violations flagged by inspectors.

Boar's Head did not directly respond to questions about former employees' characterizations of the plant.

"We understand the gravity of this situation and the profound impact it has had on affected families," the company wrote in a letter to customers in September. "Comprehensive measures are being implemented to prevent such an incident from ever happening again."

The USDA denied a public records request from The Post for the food safety audit from 2022 as well as a July public health risk evaluation of the plant and results of any testing for listeria bacteria performed over the past year because it said releasing the records "could reasonably be expected to interfere with enforcement proceedings."

In its letter suspending Boar's Head's Jarratt operations , the USDA said the facility did not have a written plan specifying staff use of personal protective equipment when moving between processing lines. Inspectors on-site witnessed employees interact with equipment used for different products without changing PPE, according to the letter.

Additionally, officials saw "clear liquid" fall from a patch in the ceiling. A fan mounted to the ceiling was "blowing the leaking clear liquid" near where uncovered hams were stored.

"This indicates your establishment's failure to maintain sanitary conditions," wrote a USDA official, whose name was not released.

The official also flagged that a pallet jack used to move racks of ham had tested positive for listeria, which, along with the contaminated liverwurst, demonstrates the plant's "current sanitation is inadequate to prevent ... the adulteration of products."

The plant relied on sanitation and testing for bacteria to prevent listeria contamination — which food safety experts say is the weakest method government regulators allow — instead of applying additional measures such as pasteurization, intense heat and antimicrobial sprays to kill unwanted bacteria, according to the USDA's July suspension notice .

The Post contacted more than a dozen employees at the Jarratt plant seeking information about conditions inside the facility. Most did not reply or said they did not want to comment. Post reporters who went to the plant on two separate occasions seeking interviews were ordered off the premises by security.

Boar's Head later faulted the liverwurst production process at Jarratt as the root cause of the listeria outbreak and permanently discontinued the product. The company did not specify what the process entailed.

"In response to the inspection records and noncompliance reports at the Jarratt plant, we will not make excuses," the company said in its letter to customers. "This is a dark moment in our company's history, but we intend to use this as an opportunity to enhance food safety programs not just for our company, but for the entire industry."

Flaws in the nation's food safety system Food safety experts say the pattern of violations at the Jarratt plant raises questions about why it wasn't closed sooner and suggests a failed food safety system.

"Together these issues, along with the repeated reports of insects, signal there were broader problems with infrastructure and operating procedures that USDA should have made the plant address before it rose to the level of a deadly outbreak," Sarah Sorscher, the director of regulatory affairs for the nonprofit Center for Science in the Public Interest, told The Post.

The reported violations at the Jarratt plant were "extreme and out of the ordinary," said Brendan Flaherty, a Minneapolis personal injury lawyer who specializes in food safety cases and is representing several clients, including Solberg, pursuing legal action against Boar's Head.

But Flaherty also pointed the finger at the regulatory system meant to keep food processing plants operating safely. Too often, he said, regulators defer to the companies they're supposed to be monitoring.

The USDA expects companies to take a proactive look at noncompliance records, determine if they have a systemic problem and spend the money to fix it, Flaherty said. "And that just doesn't happen in practice until people get sick or there's a huge recall."

The USDA food safety program is responsible for regulating certain chicken, beef and pork products, and inspectors are required to be on-site at every processing plant. A USDA spokeswoman said Virginia inspectors were charged with examining the Jarratt plant on behalf of the agency and filing their reports into a federal data system, giving federal officials access to the pattern of violations found at the Jarratt plant.

Every month, the data system uses an algorithm to detect trends that may warrant additional attention. The Jarratt plant did not meet the threshold for an alert, according to two Senate aides who have been briefed on the USDA investigation and who spoke on the condition of anonymity to speak candidly.

"The concern is were folks asleep at the wheel here?" said one of the aides.

A USDA spokeswoman said the algorithm is not the primary way problems are detected, but instead provides additional data. She said the agency is continuing its investigation to determine what changes may need to be made to ensure issues are flagged quickly and action is taken.

In addition, the department said it is taking a "holistic look" at Boar's Head plants across the country as it continues to investigate the factors contributing to the outbreak at the facility. Its review will also focus on what changes should be made to state inspection guidelines to prevent gaps in oversight and any lessons that can be broadly applied to the meat industry.

On Capitol Hill, lawmakers are demanding answers from Boar's Head and federal officials.

Sen. Richard Blumenthal (D-Conn.), who has a history of introducing food safety bills, is calling for an independent investigation by the USDA's inspector general and asking the Justice Department and USDA to determine whether criminal charges — a rare consequence — should be brought against Boar's Head officials.

In a letter to Boar's Head leaders, Rep. Jennifer McClellan, a Virginia Democrat whose district includes Jarratt, asked why violations occurred repeatedly and whether government inspectors were routinely present at the facility, as required by law.

Larry Helfant, the company's chief operating officer, responded that inspectors were on-site every day.

"If inspectors identify something that needs to be addressed, we address it, as was the case with each issue raised by USDA in the recently released reports," Helfant wrote in a letter McClellan's office shared with The Post. "More specifically, during that last 12-month period, inspectors performed thousands of inspectional tasks at our Jarratt, Virginia facility and identified 69 issues that were corrected at the time by our local plant management. To be sure, we mention this not as an excuse, but as context."

Lost lives and livelihoods Garshon Morgenstein is still trying to process his father's death in July. Gunter Morgenstein was "a very big personality that can never be replaced," his son said in a recent interview. "It's been tough."

A longtime resident of Newport News, Va., Gunter Morgenstein was an 88-year-old Holocaust survivor, who his son said was hidden by neighbors from the Nazis in Germany and eventually made it to the United States where he got married and had a long career as a hairstylist.

He loved his wife, his friends and his family, his son said.

He also loved to eat liverwurst sandwiches.

On June 30, Morgenstein purchased Boar's Head liverwurst and other Boar's Head products, according to a lawsuit filed by his family in August. "In the coming days, he consumed them on various occasions," the lawsuit alleges. "He subsequently became ill, suffering from weakness, diarrhea, fatigue, and a fever." On July 8, as his condition worsened, Morgenstein was admitted to the hospital. Three days later, blood test results returned positive for listeria bacteria.

Over the next week, doctors treated Morgenstein with heavy doses of antibiotics as well as IV fluids, heart rate control medications and pain relief medicine, but his fever remained and his health declined further, according to the lawsuit. A physician's note stated, "Despite all aggressive measures, his clinical condition ... continued to deteriorate so family decided eventually to provide him comfort measures only. Patient pronounced on 7/18 at 4.10 am."

Morgenstein died a week before health officials determined that the Boar's Head plant 80 miles from his home was the apparent source of what killed him.

His son said he felt anger as he read accounts of the conditions in the Jarratt plant. "To let something go like that and operate with people eating anything that comes out of that facility is just unbelievable," he said.

Some of the recalled Boar's Head products have sell-by dates into October, meaning the deli meats may still be in consumers' refrigerators and on their sandwiches.

Boar's Head did not respond to Morgenstein's allegations.

After the USDA halted operations at the Jarratt plant on July 29, Boar's Head planned to begin a deep clean of the facility that would include testing to find out what had gone wrong and fix ongoing issues. All production stopped but employees continued to report for their shifts that now included assisting in the cleanup and disinfecting efforts.

On Friday, Sept. 13 — 46 days after the USDA suspended the Jarratt plant's operations — workers were summoned to a meeting at a nearby community center. Some who spoke with The Post said they had expected the company to announce plans for fully reopening the plant.

Instead, Boar's Head leaders dropped a bombshell . The plant, the largest private employer in Greensville County , would close. More than 500 workers would lose their jobs.