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An Outbreak Waiting to Happen

Beef-Inspection Failures Let In a Deadly Microbe

By Joby Warrick, Washington Post Staff Writer

Monday, April 9, 2001; Page A01

MILWAUKEE -- "Did your daughter eat meat that was pink or red?"

The nurse's question puzzled Connie Kriefall. In an intensive care ward a few steps from where the young mother stood, doctors were struggling to save her only daughter, a 3-year-old with sapphire eyes and a mysterious disease.

In six days, tiny Brianna Kriefall had gone from a healthy preschooler with a tummy ache to a deathly sick child with advanced organ failure. Her kidneys had quit. Her heart was faltering. And now a nurse was asking: Could this be E. coli?

Kriefall's mind raced back to dinner at a Sizzler restaurant the previous week. Brianna had chosen the children's buffet, she remembered. Watermelon, cantaloupe, cheese. Nothing likely to carry E. coli. "That just couldn't be possible," she said.

But the outbreak that killed Brianna and sickened more than 500 others here in July was not only possible, it was foreseeable.A series of systemic failures by government and industry all but guaranteed that potentially deadly microbes would make their way into a kitchen somewhere in America. It was simply a question of when.

For decades, the familiar purple "USDA-inspected" stamp has given Americans confidence that their meat supply is safe. But for the Kriefalls, like thousands of other families stricken by meat-borne pathogens each year, this veneer of safety proved dangerously deceptive.

Wisconsin health investigators later concluded Brianna Kriefall died from eating watermelon that Sizzler workers had inadvertently splattered with juices from tainted sirloin tips. The meat came from a Colorado slaughterhouse where beef repeatedly had been contaminated with feces, E. coli's favorite breeding ground. Federal inspectors had known of the problems at the plant and had documented them dozens of times. But ultimately they were unable to fix them.

Nearly a century after Upton Sinclair exposed the scandal of America's slaughterhouses in his novel "The Jungle," some of thenation's largest meatpacking plants still fail to meet federal inspection guidelines to produce meat free of disease-carrying filth, an investigation by The Washington Post and Dateline NBC has found.

U.S. Department of Agriculture inspectors who patrol the nation's 6,000 meatpacking plants today are armed with more modern tools and tougher standards than ever. But the government's watchdog agency often has lacked the legal muscle and political will to address serious safety threats. It cannot impose civil fines or recall meat even when its inspectors see problems that could lead to outbreaks.

In the Milwaukee case, one of the nation's largest, most modern meatpacking plants Excel Corp.'s Fort Morgan, Colo., facility was cited 26 times over a 10-month period before Brianna Kriefall's death for letting feces contaminate meat, documents show. Despite new government controls on bacteria launched three years ago, the plant shipped out beef tainted with E. coli on at least four occasions. The last shipment delivered the pathogens that ended up in the children's buffet at the suburban Milwaukee Sizzler.

"It was like making Fords without brakes," said Michael Schwochert, a veterinarian and retired federal inspector who worked at the Excel plant. "We used to sit around the office and say, 'They're going to have to kill someone before anything gets done.'"

Excel officials said they were unable to talk about the Milwaukee outbreak, citing litigation. In a statement, Excel said it uses cutting-edge technology to prevent contamination, but food must be properly cooked and handled to ensure safety. "Excel is committed to providing safe food for people," the company said.

A lawyer for the Sizzler franchise in suburban Milwaukee said the restaurant owners still did not know how the outbreak occurred, but had reached settlements with numerous sickened customers. "The owners have been devastated by this outbreak," attorney Ron Pezze Jr. said.

Criticism of the USDA's enforcement record comes as domestic E. coli outbreaks and epidemics of mad-cow and foot-and-mouth disease in Europe heighten concerns about America's meat supply. Contamination similar to that found at Excel was documented at several other plants around the country in an internal agency report a month before the Milwaukee outbreak.

The USDA's inspector general, in a sharply critical review of the agency's inspection system, said the government's safety net for consumers was being compromised by confusing policies, blurred lines of authority and a lack of options for enforcement. At some plants, regulators frequently were finding tainted beef but doing nothing because they simply "were unaware of any actions to take," the report said.

"How long does it take for a 'bad' plant to be listed as bad? We can't tell you," USDA Inspector General Roger Viadero said in an interview, "because [the USDA] has not told the inspector what's bad."

USDA officials at the Excel plant were still searching for that line last June 14 when they sent the last in a series of warnings to the plant's management. Nine days later, records show, a package of contaminated meat left the factory and ended up at the Sizzler in Milwaukee.

"It was like a ticking time bomb by the time it got to the Sizzler restaurant," said William Cannon, attorney for the Kriefall family. "And unfortunately, this ticking time bomb killed Brianna Kriefall."

A Safer System?

The internal struggle over beef quality at the Excel plant would likely have never attracted public attention were it not for two headline-generating events.

The first came in August 1999 with the chance discovery in a USDA random survey of E. coli in Excel beef at an Indiana grocery store.

The second was the Milwaukee E. coli outbreak last summer. In one of the worst such incidents in state history, more than 500 people got sick, 62 with confirmed E. coli infections.

What happened between the two incidents starkly illustrates how problems at modern meat plants test the limits of the USDA's new inspection and meat safety system.

Located on a dry plain 80 miles northeast of Denver, the Excel factory is an imposing agglomeration of smokestacks and aircraft hangar-sized buildings covering 2 million square feet. The only outward sign that the plant produces beef is the line of trucks delivering cattle to the stockyard. That, and the ubiquitous smell cow manure with a hint of decaying meat.

Inside, much of the butchering is done the old-fashioned way, by workers using various sorts of knives. At the front of the line is the "knocker," who uses a pistol-like device to drive a metal bolt into the steer's head the law requires that animals be rendered insensible to pain before slaughtering. Another worker slits the animal's throat to drain the blood. Others in turn remove limbs, hide and organs.

At line speeds of more than 300 cattle per hour, things frequently go wrong. Organs tear and spill their contents. Fecal matter is smeared and splattered.

The presence of fecal matter greatly increases the risk of pathogens, which is why USDA inspectors enforce a "zero-tolerance" policy for fecal contamination on meat carcasses. Meat smeared with fecal matter is supposed to be pulled off the line and cleaned by trimming. But there is no law that requires raw meat to be free of pathogens; the exception is for ground beef. Thus, raw meat must carry a label that specifies it must be properly cooked.

In 1993, the Jack in the Box food poisonings on the West Coast killed four children and awakened Americans to E. coli 0157, a mutant bacterial strain that lurked in undercooked ground beef. Three years later, the Clinton administration officially scrapped a century-old system that relied on the eyes and noses of federal inspectors called "poke and sniff" in favor of a preventative system of controls developed by the industry with federal supervision.

That system, supported by food safety experts and many consumer groups, was called the Hazard Analysis and Critical Control Point system, or HACCP (pronounced hass-ip). Under HACCP, companies create their own plans for addressing safety threats a "hazard analysis" and their own methods of dealing with threats "control points." The theory is that hazards arise at many points in the production process, and steps can be taken to minimize risks from pathogens. The measures can range from lowering room temperatures to dousing meat with a chlorine rinse to kill germs.

In a nod to consumer groups, HACCP introduced mandatory testing for microbes for the first time. Plants would be subjected to testing for salmonella and a benign form of E. coli, but not the deadly E. coli 0157:H7.

Three years into HACCP implementation, the reviews are decidedly mixed. The rate for deadly E. coli illness remains steady, with 73,000 people stricken and 61 killed a year, according to the U.S. Centers for Disease Control and Prevention.

But a steady decline in disease rates for salmonella and several other pathogens since 1996 has prompted UDSA officials and many consumer groups to declare HACCP a major success.

"The nation's food supply is safer than ever," Thomas J. Billy, administrator of the Food Safety Inspection Service, said in a statement in response to questions about HACCP's performance. "Our data shows the level of harmful bacteria has been markedly reduced."

But pathogens remain a major concern. The USDA estimates that salmonella is present in 35 percent of turkeys, 11 percent of chickens and 6 percent of ground beef. Each year, food-borne pathogens cause 76 million illnesses and 5,000 deaths, according to the CDC.

According to critics, gaps in HACCP still allow too many pathogens to slip through.

The report by the USDA's inspector general last summer said meat companies were manipulating the new system to limit interference from inspectors. For example, by their placement of control points, plants can effectively dictate which parts of the process inspectors can fully monitor.

Viadero said the agency was "uncertain of its authorities" and had "reduced its oversight short of what is prudent and necessary for the protection of the consumer."

"After what I've seen," Viadero said in an interview, "if my hamburgers don't look like hockey pucks, I don't eat them."

Meat inspectors and consumer groups like HACCP's microbe-testing requirements, but some argue the new system is an "industry-honor system" that puts consumers at greater risk. Under the old system, meat with fecal matter on it was trimmed to remove pathogens. Now, inspectors say, chemical rinses can wash off visible traces of fecal matter without removing all the pathogens.

"It's the biggest disaster I've seen," said Delmer Jones, president of the National Joint Council of Food Inspection Locals, which represents most of the government's 7,600 meat inspectors. "We're vulnerable to more deaths and no one seems to care."

Last fall, two Washington watchdog groups, the Government Accountability Project and Public Citizen, released results of an unscientific poll of 451 inspectors. While a majority approved of HACCP in concept, more than three-fourths said their ability to enforce the law had declined.

One inspector scribbled these words:

"HACCP ties our hands and limits what we can do. If this is the best the government has to offer, I will instruct my family and friends to turn vegetarian."

Schwochert, formerly the night shift inspector-in-charge at Excel's Fort Morgan Plant, worked 15 years in private business before joining the USDA. He prided himself on his ability to work with industry, but he felt that HACCP made his job even tougher.

"I've never seen anything so slow to respond," he said.

"Nothing in my professional training or life gave me the tools for dealing with what was going on. It was a calamity of errors. If it weren't so serious, it would be funny."

Showdown at Excel

By the late summer and fall of 1999, Schwochert was accustomed to tussling with Excel's managers over problems ranging from filthy, urine-soaked employee washrooms to occasional findings of fecal matter on carcasses. But the skirmishes intensified dramatically on Sept. 13, after the USDA found E. coli 0157 in a package of Excel beef at the Indiana grocery store.

The discovery, part of a routine survey of grocery stores and meatpacking plants, triggered a series of reviews of the Excel plant's food-safety practices.

The measures began with two weeks of E. coli testing. Inspectors found E. coli not once but twice, in the first three days of testing. The USDA ordered the contaminated meat seized, but it was too late. Some of the meat had been loaded onto a delivery truck.

"Not only were those samples positive, but that meat had left the plant," Schwochert said. Excel tracked down the truck and returned the meat to the plant.

USDA documents show the combination of E. coli positives and the improper shipment of the contaminated beef prompted the government to impose its harshest sanction: A district supervisor "withheld inspection" from the plant, forcing Excel to shut down for three days. On Sept. 28, the plant reopened under the threat of another suspension if new violations occurred.

They did, but no suspension followed. By Sept. 29, inspectors were finding so much fecal contamination on carcasses that Schwochert said he tried to close the plant again, even though he felt he lacked the authority to do so. At the last minute, the plant's top supervisor agreed to shutter the factory voluntarily for the rest of the day, Schwochert said.

Excel promised to retrain its workers and fine-tune its carcass-dressing system, although details of its plan are considered proprietary information. But more contaminated carcasses turned up two days later, and regularly after that, agency records show:

Oct. 1: "Fecal contamination observed . . . sample failed to meet zero-tolerance requirements."

Oct. 2: "Identifiable fecal deficiencies on two carcasses (out of 11)."

Oct. 4: "Fecal contamination splotched in an area 1 inch by 4 inches . . . carcasses retained."

Oct. 9: "Deficiencies were observed on six carcasses (out of 11).

In company memos, Excel responded that the inspectors were focusing on "unrelated" and "isolated" incidents. But USDA district supervisors took a different view. One USDA letter called the company's explanations "incredible, frivolous and capricious." Another specifically suggested Excel was putting its customers at risk.

"In the light of recent E. coli positives, I would think that food safety and preventive dressing procedures would be of utmost importance on your corporate agenda," Dale Hansen, the FSIS's circuit supervisor in Greeley, Colo., wrote on Nov. 29 to Marsha Kreegar, Excel's regulatory affairs superintendent.

USDA's enforcement records contain no response to that letter. Excel has declined to make officials at the Fort Morgan plant available for interviews.

For five months, the USDA chose not to impose new sanctions, despite 14 additional citations for fecal contamination and a host of other problems. Government records also describe mice infestation, grease and rainwater leaking onto meat; unsanitary knives; equipment sullied with day-old meat and fat scraps; and carcasses being dragged across floors.

USDA inspectors asked their supervisors for guidance. How many violations before the plant is suspended again? Three? Five?

"The question was asked by myself or in my presence at least 10 times," Schwochert said, "and we never got a clear answer."

On May 23, the USDA threatened another suspension. "Recent repetitive fecal findings on product produced by your firm demonstrates that the HACCP plan at your facility is not being effectively implemented to control food safety hazards," USDA District Manager Ronald Jones wrote to Excel General Manager Mike Chabot.

Excel was given three days to make changes then a three-day extension, after Excel's initial proposals proved less than convincing.

Finally, on June 14, based on Excel's promise to improve its process, USDA withdrew its threat with an additional warning. "Your firm will be required to consistently demonstrate that your slaughter process is under control, meeting food-safety standards," the agency wrote.

On June 23, a sealed package of sirloin tips contaminated with E. coli was loaded into an Excel truck bound for Milwaukee.

A Family's Ordeal

The Sizzler restaurant on South Milwaukee's Layton Avenue was one of Brianna's favorite places, even if she could never quite remember its name. To her 3-year-old mind it was just the restaurant "up the hill."

"We used to pass it all the time, and she'd have a fit if we didn't go there," her father, Doug Kriefall, recalled.

On the night of July 17, her parents were happy to oblige. It was the end of a harried workday for a young family juggling two careers and two kids, and the lure of a quick and inexpensive night out was irresistible. As a bonus, Sizzler offered an adult menu as well as a special salad bar stocked with kids' favorites: macaroni and cheese, fresh fruit, dinosaur-shaped chicken nuggets.

Emotionally, the family was still in shock from the loss of a baby girl just seven weeks earlier. The girl the family calls Haley was stillborn. The loss reopened old wounds: Connie Kriefall had lost six fetuses in eight years before finally giving birth to Brianna in May 1997.

"She was my miracle baby," the mother said. "It was the best Mother's Day present any mom could ever get."

The couple's difficulty in having children made Connie Kriefall an exceptionally careful mother. She knew improperly cooked meat can carry E. coli, a microbe sometimes fatal to young children. So at Sizzler, the Kriefalls' buffet choices reflected caution: watermelon, cantaloupe, cheese, ham cubes, a meatball or two.

But on that night, the bacteria was hidden not in meat but in watermelon, an investigation concluded. A state health task force would determine that E. coli entered the restaurant in sealed packages of sirloin tips.

The USDA inspection stamp on the package read "XL Est. 86R" the code assigned to the Fort Morgan plant. Unopened packages of Excel beef in the restaurant's cooler would test positive for the same genetic strain of E. coli 0157 found in the bodies of Brianna Kriefall and other restaurant patrons.

Once loose in the restaurant's cramped kitchen, the task force found, the bacteria easily made the jump from raw meat to raw fruit. Health officials discovered that kitchen workers had violated the restaurant's rules by preparing watermelon and meat on the same counter top. A meat grinder used to convert steak trimmings into hamburger was located inches from the same counter, close enough to splatter juices on other foods.

The recycling of salad bar items over several days eventually exposed hundreds of people to the bacteria. The first symptoms surfaced on July 14, three days before the Kriefalls' dinner. By July 24, Milwaukee health officials were tracking an epidemic. Twenty-three victims were hospitalized. The intensive care unit at Milwaukee's Children's Hospital was already jammed with sufferers before medical investigators confirmed the cause of the illness and its source.

"I knew it was bad. I just didn't know how bad," recalled Judy Fortier, a Milwaukee mother whose oldest daughter, Carly, was among the most seriously ill. For days, Carly, 8, suffered painful bouts of bloody diarrhea so severe her intravenous line was moved to the bathroom so she could nap during the brief lulls between attacks. "She would lean against me," Fortier said, "and that's how she slept."

Like many other parents, Connie Kriefall assumed her children had picked up a summer virus when both came down with stomachaches on a Wednesday evening, two days after their meal at Sizzler.

By Friday, Chad had recovered, but Brianna's condition had taken a frightful turn. Severely dehydrated from diarrhea, she was admitted to the hospital the next morning.

For her parents, the next seven days unfolded with deepening horror. On Sunday, the family learned Brianna had developed a life-threatening complication. By Tuesday, doctors had begun dialysis to prop up the girl's failing kidneys. The normally bright, playful child had become nearly unresponsive, uttering only a single, mournful phrase for hours at a time.

"It was just 'Ow-wee, Mama, Ow-wee, Mama,' " Connie Kriefall recalled. "And those eyes. I'll never forget how she looked at me."

The crying would end abruptly. On Wednesday morning, Brianna was placed on a respirator after her heart briefly stopped beating. Finally, on Thursday, she suffered a catastrophic stroke and lapsed into a coma.

With all medical options exhausted, the Kriefalls decided to allow the doctors to disconnect Brianna's life support.

"Thursday night we both stayed up with her, and took turns crawling in bed with her, telling her how much we loved her and reading her stories," her mother said. "I couldn't hold her, and I wanted to hold her so bad. And her heart was racing all night her heart rate was so high."

On Friday, just before 7 a.m., Brianna's heart stopped.


The months since the Sizzler outbreak inevitably brought investigations and lawsuits, as both victims and governments tried to parcel out blame. An early casualty was the Sizzler restaurant on Layton Avenue, which was permanently closed.

Excel lawyers have maintained in court documents that the corporation was not at fault, since it had no control over Sizzler's food-handling practices.

"Excel is continuously seeking ways to eliminate or reduce food hazards," the statement said. "For the benefits of those efforts to reach the consumer, it is essential for food preparers to follow safe handling practices."

Pezze, the lawyer for the Sizzler franchise, said he had seen the USDA documents from the Excel plant and found the reports of fecal contamination surprising. "Obviously, if suppliers and producers could nip this problem in the bud, we wouldn't need to rely purely on preparers."

Industry trade groups and the USDA also argue that it is impossible to make meat germ-free, so consumers bear responsibility for using proper preparation techniques and fully cooking their food.

It's an argument that William Cannon, the Kriefalls' attorney, finds especially galling. The Kriefalls have joined other victims in a lawsuit that names Sizzler and Excel.

"They have blamed other people for not catching their mistakes, but the blame starts with them," Cannon said of Excel. "They knew or should have known they were sending out meat that contained this bacteria. And that there was a substantial risk that somebody, somewhere, in America would end up eating this meat."

But others find more disturbing the government's ineffectiveness in responding to chronic lapses at plants such as Excel's. It's a problem nearly as old as meat inspection itself, said Carol Tucker Foreman, the assistant secretary for food and consumer services in the Carter administration.

"There is almost no notion of shutting down a plant for failing to meet standards," said Foreman, now a distinguished senior fellow at the Washington-based Food Policy Institute. "The regulations help ensure that plants stay just above the level that requires sanctions."

USDA officials are promising change. After devoting three years to implementing HACCP, the agency is beginning an extensive review to determine how the system can be improved.

Congressional supporters of stronger food safety protections say they will press again this year for a law giving meat inspectors more effective enforcement tools, including the power to impose civil fines and order mandatory meat recalls. But after similar legislation failed in the last three sessions, backers acknowledge their prospects are far from certain.

"The American people would be shocked," said Sen. Tom Harkin, an Iowa Democrat and sponsor of several previous bills, "to learn that the USDA does not have the fundamental authority to protect public health."

Anger and Grief

The memorial card for Brianna Kriefall is a collage of things the little girl liked best: Barney and Barbies, dancing and Dr. Seuss, the little watering can that was Brianna's delight on summer days when the flowers were in bloom. The card's verse is written in a child's words.

"Mom and Dad, don't cry that I didn't stay," it begins. "I know you'll be lonesome for me for a while, but time heals all wounds and again you will smile."

For now, though, the promise of healing seems a hollow one. At the Kriefalls' neatly kept home in middle-class South Milwaukee, every day brings searing reminders. Pictures of Brianna adorn almost every wall. The little girl's room and toys remain just as she left them. Their son Chad, now 2, asks about his sister and sometimes loses patience with his parents' explanations. "'Nana come home now!'" he wails.

For Connie Kriefall, just knowing that Brianna's ordeal might have been prevented fires emotions too intense for words. Like her son's, the mother's grief is tinged with an anger she suspects is beyond healing.

"They need to be aware that this has completely destroyed our lives," she says in a whisper. "Our daughter was a miracle child we waited eight years for. And now she's gone, and we'll never get her back."

2001 The Washington Post Company

-- Swissrose (, April 09, 2001


Powerful article.

"Nothing likely to carry E. coli." Actually, more and more we see non- meat food vehicles...including sprouts, other fruits and vegetables, unpasteurized cider and other unpasteurized fruit juice. Sometimes the problem stems from cross-contamination ("A meat grinder used to convert steak trimmings into hamburger was located inches from the same counter, close enough to splatter juices on other foods.") Other times, the pathogen is introduced earlier in preparation...including at the level of the farmer's field or during transport: the organisms get onto the outer skin of the fruit, then are introduced into the fruit's flesh when the fruit is cut.

Other ways E.coli and related organisms can be spread is through person-to-person contact (dirty hands after using toilet, changing diapers, etc) and through other fecal contact (petting zoos are an emerging problem). See for some factsheets.

"But others find more disturbing the government's ineffectiveness in responding to chronic lapses at plants such as Excel's." Agreed. ""The American people would be shocked," said Sen. Tom Harkin, an Iowa Democrat and sponsor of several previous bills, "to learn that the USDA does not have the fundamental authority to protect public health." Indeed, this has long appalled those of us on the human health end of things.

"At line speeds of more than 300 cattle per hour, things frequently go wrong. Organs tear and spill their contents. Fecal matter is smeared and splattered." Here's a big part of the problem (but far from the only problem). At these speeds, the workers and the meat both suffer horribly. Contrast this with the care that, for example, I use when I kill, gut and butcher my own meat (venison). Completely different.

"After what I've seen," Viadero said in an interview, "if my hamburgers don't look like hockey pucks, I don't eat them." Not bad advice. Doesn't prevent cross-contamination in the kitchen, unfortunately.

-- Andre Weltman, M.D. (, April 09, 2001.

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