KANSAS CITY, Mo. – Shipments of beef contaminated with E. coli O157:H7 might not have left the XL Foods Inc. plant in Brooks, Alberta, had the company followed proper food safety procedures and its own protocols, according to an independent panel that reviewed the XL Foods beef recall.

In February, Canada's federal government appointed the panel to review the XL Foods Inc. E. coli O157:H7 investigation and recall. The panel issued its findings and recommendations June 6. In its review, the panel said contaminated product would not have left the plant if the company had properly analyzed its E. coli sampling data, responded appropriately to high event periods (HEPs) in late August 2012 and properly implemented and followed its own food safety procedures and protocols.

The beef recall was the largest meat recall in Canadian history. Beef contaminated with E. coli sickened 18 people and prompted the recall of more than 1,800 products. The industry estimated losses stemming from the recall between $16 million and $27 million. XL Foods accounted for 35 percent of Canada’s beef processing capacity, according to the review panel report.

The panel’s hypothesis regarding how the contamination occurred is that a “super shedder”, a cow heavily contaminated with E. coli O157:H7, entered the plant. Pre-harvest intervention could have reduced the levels of the pathogen, but few pre-harvest controls are used systematically in Canada, according to the review. The contaminated carcass moved through the processing line and contaminated a piece of equipment. Adequate equipment sanitation was not performed, and pasteurizing equipment was not operating properly. Proper sanitation and equipment maintenance were significant problems at the Brooks plant, according to the report.

“A unique clone of E. coli O157:H7 identified later strongly suggests a single-point source of contamination,” the panel reported. “As sides of beef continued to pass by this equipment, they were also sporadically contaminated over subsequent production days.”

Meanwhile, XL Foods did not pay attention to increasing positive tests for E. coli in beef trim. It missed a high-event period when levels of E. coli exceeded predetermined thresholds. The company is expected to investigate the cause of HEPs and notify inspectors with the Canadian Food Inspection Agency (CFIA) when HEPs occur. The panel found non-compliant HEPs occurring as far back as December 2011.

“Although 40.9 percent of samples from all pre-grind raw materials produced on December 21, 2011, were presumptive positive for E. coli O157:H7, actions taken by XL Foods Inc. were inconsistent with the company’s guidance decision document,” the review stated. “The latter document instructed the actions to be taken when positives exceed 20 percent in a single production day. Products from and entire shift were released with no further action. There is no documentation that CFIA inspectors were notified of this.”

The company also did not bracket product adequately — identifying and isolating containers processed immediately before and after the positive tested batch with the higher results. This meant contaminated product was leaving the plant and contamination of product continued unchecked until a positive test at Ginger Beef Choice Ltd., Calgary, Alberta, and the Food Safety and Inspection Service findings at the US-Canada border.

Finally, there was a delay of six days before food-safety officials could establish production dates and identify products, according to the review. The information XL Foods initially gave to CFIA agents was coded, and the key to the code was at the company’s headquarters in Edmonton, Alberta — not at the plant. Also, much of the information was in hard copies and had to be examined by hand. During this delay, production continued and contaminated meat was shipped from the plant.

XL Foods, government response lacking

The review panel criticized the company for its lackluster response to the problem. The report noted that XL Foods did not appoint a spokesperson to reach out to consumers, and the decision reflected poorly on its corporate responsibility. Also, when company officials communicated with some of its key customers, they seemed to downplay the problem.

“They emphasized that their decision to recall product was simply to demonstrate their commitment to food safety, despite a strong conviction that the contamination issue was neither significant nor deeply rooted,” the panel reported. “The Retail Council of Canada felt that XL Foods Inc. continued to downplay the seriousness of the event.”

As for the federal and provincial response, the public received conflicting information about the number of illnesses caused by the tainted beef. The panel attributed the problem to the inability of Public Health Agency of Canada (PHAC) and Alberta Health Services to agree on a case definition for a confirmed illness related to the recalled product.

Also, the expanded recalls confused consumers, heightened concerns about the Canadian food supply and caused “recall fatigue”. Additionally, the incremental nature of the recall and staggered release of other information gave the impression that the recall was a bigger event than it actually was, the report stated.

What went right?

Some aspects of Canada’s response to the recall did go well despite some missteps and confusion, the panel said.

“The Pulse-Net system, operated by PHAC, provided an efficient and effective forum for laboratory information exchange among all contributing laboratories,” the panel said in its report. “This in turn, allowed for timely trace back of human illnesses to the contaminated XL Foods Inc. and Costco beef products.”

Other positive findings in the report include:

• The rapid mobilization of the National Emergency Response Team was key to dealing effectively with the event.
• CFIA’s documentation of the incident was well organized and thorough.
• Communication between provincial and federal public health officials was generally effective despite occasional gaps.
• Alberta Health Services quickly identified the link between mechanically tenderized beef produced at a Costco near Edmonton and cases of human E. coli infections.