This is another it what will be a long – too long – series of outbreak investigations where we have represented consumers in what I hope will be a cautionary tale, and a learning experience, for manufacturers of food.
Nebraska Beef and its meat-processing plant had a long history of safety and health violations, and had repeatedly been the target of USDA efforts to shut it down, long before I got it in my sights. Nebraska Beef’s history was summarized in a front-page, investigative news article that was published in the Washington Post, which stated:
Nebraska Beef has a contentious history with the USDA. Over the past six years, federal meat inspectors have repeatedly written it up for sanitation violations, and the company has fought back in court.
From September 2002 to February 2003, USDA shut down the plant three times for problems such as feces on carcasses, water dripping off pipes onto meat, paint peeling onto equipment and plugged-up meat wash sinks, according to agency records.
After the third suspension, Nebraska Beef took USDA to court, arguing that another shutdown would put the company out of business. A judge agreed and temporarily blocked the department. The USDA and the company then settled out of court and inspections resumed. However, when federal meat inspectors found more violations, Nebraska Beef sued the department and the inspectors individually, accusing them of bias. The suit was later dismissed. 
The hundreds of safety and sanitation violations from April 2002 through February 2003 include dozens of instances of documented fecal contamination—the major source of E. coli O157:H7—on beef carcasses and other cut meat items. There were also repeated instances where failures were identified in the plant’s E. coli testing program. And nearly every violation for that time period involved the plant’s failure “to prevent insanitary conditions or the adulteration of product.”
Ultimately, it was the history of food safety violations, and the threat the plant and its meat products posed to the public health, that prompted the USDA to conduct a “comprehensive public health assessment…during the week of September 2, 2002.” According to the legal brief later filed by the USDA in its attempt to shut down Nebraska Beef’s plant and operations:
That assessment was conducted because Nebraska Beef was one of the few suppliers of meat products used to prepare ground beef which was identified to contain E. coli O157:H7. The evidence…will show that Nebraska Beef provided a large amount of the meat products used to prepare the contaminated ground beef.
Accordingly, USDA argued that the Court should not prevent it from shutting the plant down, explaining:
FSIS has determined after extensive oversight that Nebraska Beef’s HACCP system is not working, and that its products are being produced under insanitary conditions that may make them unsafe for human consumption…. Anyone who might handle or consume Plaintiffs’ [Nebraska Beef] products is therefore being exposed to greater than normal risk.
There was ample evidence that Nebraska Beef continued to run its meat-processing plant in a way that put the public at a “greater than normal risk” when consuming its products. This risk was because the plant’s HACCP and other safety systems—e.g., Standard Sanitation Operation Procedures (SSOP’s) and E. coli testing program—were insufficient or simply not working.
In 2006, following an outbreak of E. coli linked to Nebraska Beef meat the USDA once more tried to shut down Nebraska Beef’s plant. Specifically:
On August 3, 2006, the Food Safety and Inspection Service (FSIS) issued establishment 19336, Nebraska Beef, a Notice of Intended Enforcement (NOIE). This decision was based on the finding noted during the Comprehensive Food Safety Assessment performed at [its] establishment from July 10, 2006 through August 3, 2006.
Not coincidentally, this time period was the one leading up to and including the same time period as the 2006 Outbreak. In late July and early August 2006, the Minnesota Department of Health (MDH) became aware of an E. coli outbreak among residents of, and visitors to, Longville, Minnesota. MDH began epidemiologic and environmental health investigations of two clusters of E. coli cases, and learned that one cluster was among members of the Salem Lutheran Church in Longville who had attended one of two church spaghetti meals served in July.
MDH conducted a case-control study; seventeen people met the case definition. Of these, three people developed hemolytic uremic syndrome (HUS), and one patient died. Attendance at the church’s July 19 smorgasbord dinner was significantly associated with illness.
MDA and MDH learned that ground beef used to make meatballs for the church meal, as well as the ground beef served by numerous area restaurants, was purchased at Tabaka’s Supervalu, and conducted a trace-back investigation to determine the source of the ground beef. Investigators found that Supervalu sold ground beef from its July 10 shipment of chuck rolls supplied by Interstate Meat to three Longville restaurants in the same time period as the sale to church members.
The MDA traceback of the chuck rolls from Interstate Meat revealed that the “most plausible” source of the chuck rolls delivered to the Supervalu store was the Nebraska Beef processing plant. In addition to this, the USDA reported that a sample of beef trimmings collected on June 14, 2006 at a processing plant cultured positive for E. coli O157:H7, and that the isolate was indistinguishable by PFGE analysis to the outbreak strain. The processing plant was determined to be Nebraska Beef, the company that most likely supplied the implicated chuck rolls to Tabaka’s Supervalu.
Ultimately, MDH concluded that ground beef sold by Tabaka’s Supervalu was the source of the E. coli O157:H7 outbreak in Longville and that the ground beef was likely contaminated at the Nebraska Beef facility before it was received at the Supervalu store. Nebraska Beef’s response was to sue the church.
The NOIE Letter that FSIS sent to Nebraska Beef on August 3, 2006 is replete with examples of unsafe and insanitary practices and conditions at the plant in the months—if not years—leading up to the Longville E. coli outbreak. FSIS notes numerous noncompliances, including: the insufficiency and failure of its E. coli testing program; the failure to maintain or implement SSOP’s in compliance with regulatory requirements; and HACCP system that was inadequate because it “allowed adulterated product to be produced,” and failed to meet numerous other regulatory requirements.
After the Longville E. coli outbreak, Nebraska Beef was involved in another E. coli O157:H7 outbreak linked by FSIS, CDC, and other public health officials to contaminated meat products like those implicated in the present case—i.e., 60-pound boxes of Nebraska Beef chuck rolls. See, e.g. FSIS Recall No. 022-2008. According to FSIS:
[it] has concluded that the production practices employed by Nebraska Beef, Ltd. are insufficient to effectively control E. coli O157:H7 in their beef products that are intended for grinding. The products subject to recall [including chuck rolls] may have been produced under insanitary conditions.
The cited practices and conditions have also been explicitly linked to insufficiencies that were subject to FSIS Noncompliance Reports as far as April 25, 2002 involving, among other things, insanitary practices in the fabrication area—i.e., the part of the plant where carcasses are turned into primal and subprimals.
As of July 17, 2008, the CDC reported 49 confirmed E. coli O157:H7 cases linked both epidemiologically and by molecular fingerprinting to this outbreak. The number of cases in each state was as follows: Georgia (4), Indiana (1), Kentucky (1), Michigan (20), New York (1), Ohio (21), and Utah (1).
The Nebraska Beef plant operated with a broken safety system for years. USDA/FSIS had tried repeatedly to shut the plant down, a fact well-documented in the public record. Nebraska Beef was more interested in fighting the USDA/FSIS – and the ladies of the church – than focusing on the changes it needed to do to make its meat safe.
 Annys Shin and Ylan Q. Mui, Whole Foods Recalls Beef Processed At Plant Long at Odds With USDA, at A01, August 10, 2008; Tice Aff’d, Ex. B.