The review of the XL Foods Inc. beef recall and E. coli O157:H7 outbreak last year in Canada found that the Canadian Food Inspection Agency (CFIA) had a “relaxed attitude” toward safety standards and XL Foods did not act quickly enough to fix the problem. That outbreak, which occurred September and October 2012, sickened 18 people. The report lists similarities with the 2008 Listeria outbreak, which killed at least 20 people.
Panel members met with beef producers and processors, health authorities and academics, the retail industry, and union representatives for XL Foods and the CFIA. Inadequate responses played the most critical part in the huge recall and outbreak. More than 1,800 products were removed from the market in Canada and in the United States.
The Panel said, “we found a relaxed attitude towards applying mandatory procedures. We found one of the country’s largest beef processors unprepared to handle what turned out to be the largest beef recall in Canadian history. As the company had never conducted any mock recalls on a scale that remotely mimicked a real event, XL Foods Inc. found itself overwhelmed with the recall that occurred.”
On September 4, 2012, CFIA inspectors received confirmation of E. coli O157:H7 in beef trimmings, which was traced back to XL Foods Inc.’s Brooks plant. On that same day, the CFIA was notified by the USDA’s FSIS that they had found E. coli O157:H7 in trimmings exported to the U.S.
The CFIA determined that the contaminated batch tested by FSIS wasn’t distributed to Canadians, so they decided not to issue a recall. Instead, they looked for the source of contamination and requested test and distribution information from XL Foods. It took XL Foods six days to provide the CFIA with that information.
Over the next 11 days, the CFIA worked with XL Foods. On September 12, USDA’s FSIS confirmed two positive samples and product was destroyed. On September 13, DNA results matched two illnesses in Canada with the samples tested at the U.S. border on August 30, 2012. But the formal recall wasn’t issued until September 15, 2012, and a Health Hazard Alert (HHA) wasn’t issued until September 16, 2012.
The Panel found that high event period days at XL Foods were not “as high on the agenda as they should have been.” High event periods (HEP) are periods in which slaughter establishments experience high rates of E. coli O157:H7 in trim samples. There was no indication that the company was identifying and analyzing results for trends and therefore couldn’t establish and correct the root cause of the problem. In addition, the CFIA identified non-compliance associated with high event periods as far back as December 2011. Products from entire shifts were released with no further action. And the CFIA inspectors were not notified of this issue.
In the U.S., FSIS recommends that establishments use a threshold of 5% positive tests before having to take correction action. XL Foods set the bar for an HEP at 10%. But in the last week of August 2012, E. coli O157:H7 was found in over 11% and just under 9% of samples tested, and the company took no action to determine the root cause of these trends.
Secondly, XL Foods was not applying its own Food Safety Enhancement Program (FSEP) procedures and did not implement bracketing protocol, which removes containers of beef before and after the contaminated sample. Because the potentially contaminated beef wasn’t bracketed, it was shipped out of the plant. Therefore all products with the same production date had to be recalled. The CFIA wasn’t monitoring the company’s FSEP as closely as they should have.
Finally, XL Foods implemented a food safety plan in 2009, but did not improve it since then. They were using the N60 sampling protocol, but weren’t using the latest methodology (the N60+ sampler) which is more likely to detect contamination. XL Foods’ recordkeeping of monitoring activities and validation of procedures and equipment maintennce was deficient. And sampling techniques were inconsistent. XL Foods was also not reviewing its Hazard Analysis and Critical Control Point (HACCP) plan on a regular basis. XL Foods labeling did not have the information required by the CFIA to establish links between positive tests.
The CFIA stumbled too. The information first given to the Agency was coded and couldn’t be acted upon. CFIA made their initial information request verbally, which didn’t convey a sense of urgency. CFIA staff repeatedly extended deadlines for receiving required data. And the CFIA made many “non-prioritized” information requests. The Agency didn’t coordinate its requests through a single CFIA official, so the plant contact received similar requests from different people within the Agency. Finally, expanded recalls led to recall fatigue among the public.
In conclusion, it is the Panel’s view that “had XL Foods Inc. analyzed its E. coli O157:H7 sampling data and responded approrpiately to HEPs in late August, the contaminated shipments would likely have been contained and not left the plant. Secondly, a robust and well-managed FSEP may have prevented the contamination problem by ensuring an effective sanitation program and well-managed recall system. Lastly, the time the company took to submit required information allowed considerably more contaminated product to enter the marketplace than should ahve been the case.”
The Panel recommends that a strong food safety culture must be developed within plants, and adopted buy plant and CFIA staff at all levels. There must be greater emphasis on training and continuing education of CFIA inspection staff. Inspectors should devote less time to evaluating specimens for pathology and more time training protocols. The Minister of Health should assess the effectiveness of the Agency’s activities related to its meat program. The CFIA must enforce oversight responsibilities at the plant. And, among other recommendations, the CFIA should adopt a benchmark of 5% for E. coli O157:H7 in beef trim and expand the scope of contaminant testing to include non-O157:H7 STECs. The government has accepted all 30 recommendations and “has begun taking action,” according to Agriculture Minister Gerry Ritz.
