|
 |
|||
Department of Agriculture and Food Systems
|
||||
|
||||
|
|
|||
Department of Agriculture and Food Systems
|
||||
|
||||
|
|
Agribusiness Review - Vol. 3 - 1995Paper 5 Business risks from food poisoning in food processing: The Garibaldi case.This case is published with permission from The Advertiser, Adelaide, Sylvia Kriven IntroductionWorkers at the Garibaldi Smallgoods factory had seen it before. Company director and man-in-charge of production, Mr Luciano Marchi, was on the rampage. Through the factory floor, checking boning bins and equipment, chiding workers if they were unhygienic or wasteful; he was feared but he was respected and in some cases, liked. He had plenty to do. The place was humming. Not as much as in previous years when workers had plenty of overtime and the economy was moving; or when his co-founding partner Mr Mario Vallorani worked regularly, before he became ill. But there were plenty of orders from supermarket chains, pizza franchises and small, continental delicatessens, stocking up on metwursts and salamis and smallgoods for Christmas last year. Sure, there had been hitches but nothing unusual for a factory that serviced hundreds of clients not only in South Australia but also in Victoria, Tasmania and the Northern Territory. Machines sometimes broke down. At Garibaldi, a robot filler used to put sausage meat in skins went on the blink for days. But production went on, turning frozen and chilled meat into smallgoods. The meat was boned on the premises but also imported and, last year; a new supplier had sent mutton from Victoria. Mutton was the source meat for Garibaldi 1 s metwursts, which claimed a sizeable part of South Australia's metwurst market. Of course, mutton was not the only meat being wheeled into the factory production area every day. There was beef for salami and pork fat, to blend with the other meats, and bins of old off cuts and returned goods, which would be reworked into a cooked product called salami cotto, or in other circles, pizza topping. Sometime workers would notice the meat was off. Sometimes, it was green, slimy and smelly. They would tell a supervisor, who would tell a director and the shipment would be sent back, although some workers swear these were never returned but instead were used. Out of the room where the meats were blended, spices added and the mixture filled into skins making them recognisable as sausage, were places where uncooked smallgoods fermented and matured. This process was vital. Fermentation is another name for an unholy war between good and bad bacteria that naturally live in meat. The idea is to help good bacteria win, by keeping the meat mix at certain temperatures and dropping the pH or acid/alkaline level to set levels within the first 24 hours. There are millions of bacteria on even the slightest sliver of meat and if they are not cooked and the conditions are right, plenty of moisture and nutrients - they thrive, some doubling their numbers literally in half-hours. Knowing how to handle bacteria is an ancient art dating back to when European peasants were left with the cheapest cuts of meat and needed to preserve them for long bleak winters. They learned by trial and error to make metwurst and salamis in wooden vats. Each batch was brewed until it looked and smelt right and then tipped out and filled into casings made from emptied animal intestines. But the vats were not sanitised and instead, a little mixture was left as 'back slop' to start fermentation in the next lot. The danger was the war between bacteria in the earlier batch could be won by potentially fatal E.Coli bacteria. If this happened, these would dominate subsequent batches, which would not set properly or would later sweat or smell and look funny in their sausage casings. Those ignorant enough to persist in making sausage with bad batches for too long, got sick or died. The Garibaldi factory didn't use wooden vats any more, although they, like most smallgoods makers, once did. No one has, since laws changed 15 or 50 years ago, when stainless steel vats were introduced. These are easier to clean, and keep sanitised but the irony is, they don't harbour those good bacteria that used to flourish in the vats of well-made metwursts. Instead, manufacturers now use artificial starter cultures. Mr Lou Marchi heard about starter cultures while he was working at Tibaldi Smallgoods in Victoria. Tibaldi was implicated in a salmonella outbreak in 1982 and when he and Mr Vallorani set up the precursor company to Garibaldi, L&M Smallgoods, in 1971, the men experimented with starter culture then, for a while. He was reminded of the importance of good fermentation and other techniques to make safe smallgoods in 1991, when a Port Pirie bride and 1 (#) of her guests became ill with food poisoning, after a reception where Garibaldi salami was served. After that incident, Mr Lou Marchi and his trusted financial controller, Mr Neville Mead, attended a conference with Health Commission officials, including communicable disease unit head, Dr Scott Cameron, food scientist Mr Chris Murray, and others from the local council and Meat Hygiene Authority. It was made clear the best way to run a smallgoods factory was to have a quality assurance program - that if end-product specifications were consistently met, there would be no problem. The group also discussed properly coding and labelling batches, not only because it was illegal not to but because it would make it possible to trace back ingredients in any particular batch of smallgoods. Epidemic signals new public health problem
Garibaldi was not prosecuted over the {19911 out break, and the commission accepted assurances from its directors they would set up a quality control program and upgrade their processes. The commission never followed this up, although Dr Cameron did co-author an article about the lessons learned for a medical bulletin on communicable diseases. The wedding incident prompted Garibaldi to hire a microbiologist. Dr Stuart Andrews, who had met Mr Lou Marchi's son and fellow director, Mr Philip Marchi, while Philip was studying for a science (food) technicians certificate. Mr Philip Marchi did some of the 'hands-on testing' Dr Andrews needed for his various briefs - to test starter cultures for future use at the factory, microbiological testing of end products and preparation of 'specifications' for metwurst. But Dr Andrews couldn't come up with specifications. It seemed to him, Garibaldi had no control over its processes. He recommended a comprehensive quality assurance program. A system with some pre-set control criteria to follow so any deviance would indicate a problem. "Critical control points" had to be identified and then procedures put in place to monitor them, he said. Mr Lou Marchi never really read the report. English was his second language to Italian and reading English took time. But he had listened to the others talk about it and had discussed it. He later was to say perhaps he may not have taken Dr Andrews recommendations "seriously enough". But Philip Marchi and Neville Mead read the report. And although Mr Mead later said a program had to be postponed until the company was in a better financial position, Garibaldi did attempt some improvements, including development of a flow chart on making metwurst. But this did not prevent a major health crisis in South Australia, causing the death of one four year old child, and the hospitalisation of 24 others, most of whom required dialysis. The cause of the child's death, according to the Coroner Wayne Chivell, was the result of eating Garibaldi metwurst, believed to embody E.Coli 0111. E.Coli 0111 is a special gut bacterium which produces a potent toxin called Shiga-like toxin. It is a rod-shaped bacterium two microns long. It is commonly found in the intestines of livestock and so, potentially, can contaminate meat during the slaughter process. Human infection is caused usually by eating contaminated meat or dairy products which haven't been adequately cooked or processed. Once in the intestines the organism multiplies producing a toxin and causing diarrhoea. The toxin is also absorbed into the bloodstream and attacks the kidney and cells lining the small blood vessels, resulting in Haemolytic Uraemic Syndrome (HUS). In defending Garibaldi Smallgoods before the coroner, Mr Philip Marchi, a director, maintained that contaminated meat and not his company's process was behind the epidemic. "My personal opinion from having reviewed the test result is that our meat source is the cause of the situation which forced our company into liquidation," he said. Mr Marchi told the inquest he stopped production and dispatch of metwurst the day the South Australian Health Commission called him to say it suspected Garibaldi products in the HUS outbreak. The company was invited to attend a subsequent press conference but declined because it had no information on which to base any answers. In his statement, Mr Marchi said he and financial controller Mr Neville Mead attended a meeting with commission officers the next day and asked them for help in the company's investigation. "We were told our request would be complied with in two weeks' time but despite subsequent requests, nothing written has been received to date," he said. Another meeting was held on January 25 and Mr Marchi said he had the impression one senior commission officer had "made up his mind we were at fault". Adverse publicity coupled with the child's death had "such a pronounced effect on the business" the company had no alternative but to go into liquidation. This case raises many questions about responsibility, specifically: whether manufacturers or suppliers are responsible,
AppendixEpidemic chronology of eventsMinister for Health, Dr Michael Armitage, said today that Opposition attempts to score political points over the tragic death of a child from HUS was despicable. December 31The first case of IJUS disease is hospitalised (normally two a year, no cause for any public health concerns). History seemed to indicate New South Wales source of infection. January 16Second and third case reported. Public officers become involved. Public Health officials believe epidemic may occur and intensive investigations begin. Extensive data started to be collected on each patient but not enough information can be gleaned from children to pin-point a single common source of infection (water, food, other). Initial common ingredient appears to be fritz [a form of pre-cooked meat sausage eaten cold, Ed .]. January 17Sought information from Australian Paediatric Surveillance Unit on numbers of HUS cases notified from around Australia. Answer: 7 in last six months. Fourth case notified. Meeting held between Public Health officials, Institute of Medical and Veterinary Science (IMVS). Agricultural Department, and Women's and Children's Hospital (WCH). Water eliminated as possible source. Food more likely as source. IMVS to letter drop 700 surgeries alerting (general practice doctors) GP's. Samples of HUS victims from homes taken. Questionnaire for interviewing victims drafted. Fourth case notified. January 18Health Departments and communicable disease network notified nationally by this time. MI pathology laboratories informed and asked to send specimens to WCH for special testing. Minister informed. GP's informed. Fifth and sixth cases notified. January 19Calls from GP's about possible cases. Laboratory confirmation of E.Coli was responsible for HUS. Special testing facilities set up at IMVS for testing food samples. IMVS testing various meat samples including Garibaldi garlic metwurst. Fifth case (South Australian source) found in NSW. Seventh and eighth cases notified. Information suggesting some victims had consumed large quantities of fritz, burgers, metwurst and hot dogs. January 20AlI major hospitals asked to check whether other cases may be mis-diagnosed and actually HUS. Press Release issued warning of symptoms and warned source likely to be a meat product and said meat should be cooked properly. Asked GP's for prompt notification. January 22Fritz still most likely suspect. Still uncertain whether this is a coincidence or the actual source of contamination. 12.40 p.m. WCH suggest connection made by two families of eating same brand of metwurst. 1 .3Opm IMVS say blind testing showed Garibaldi sample proved positive. Fritz samples prove negative. 1.35 p.m. Parents interviewed by Public Health officials again. Asked if Garibaldi rang any bells. Asked where it had been bought so it could be confirmed that was what was bought. Initial media coverage targeting processed meats. Another sample of Garibaldi metwurst was in process of being tested and could confirm new lead next day (Monday). (Test process takes three days.) January 23Brand names checked with histories of victims. IMVS confirm second sample of metwurst has toxin late morning. Garibaldi is notified of link with their product. Garibaldi ceases production of all metwurst. No further metwurst has been manufactured. Media Conference is called at 3.3Opm with Acting Minister Lucas in which Garibaldi is named and particular batch of metwurst specified. Garibaldi inspection of premises indicates no product left and prohibition not required. Request for immediate recall of specified metwurst. Garibaldi officially indicates they are moving to remove the product from sale and agree to recall by means of phone and visits, as well as by advertisement in The Advertiser. January 24Local Government notified of public health concerns and naming of Garibaldi and specific metwurst. Local Government organises official notices. At same time Garibaldi contacts distribution outlets. Public Health officials meet with Garibaldi. Tenth case hospitalised. Local Government notified of public health concerns and naming of Garibaldi and specific metwurst. Local Government organises official notices. At same time Garibaldi contacts distribution outlets. Public Health officials meet with Garibaldi. Tenth case hospitalised. January 25Communicable diseases national network tele-conference. Health Commission informs Local Government to ensure specified metwurst is removed from local retail outlets. Samples taken of metwurst from a variety of manufacturers for testing. January 27Inspection of Garibaldi's premises. Request for all information regarding meat sources, quality assurance procedures and production procedures, ingredients etc. Garibaldi refuses until legal advice was sought. January 30Public Health officials concerns raised that not all products removed from retail outlets. Follow up letter sent to local councils advising them to ensure inspection [of] retail premises. Further inquiry made regarding Garibaldi's okay to release information. Garibaldi says still getting advice. January 31Garibaldi asks for and gets meeting with Garibaldi lawyers and Public Health Officials. Agree to supply information to SALIC only if request made in writing. February 18.30 am four-year-old child dies from 'HUS in WCH. Notification of 20th 'HUS case. All cases so far have been from ingestion of contaminated material prior to or on date of public announcement pinpointing Garibaldi source. Press Conferences by WCH and Minister for Health. Garibaldi provides some of requested information. IMVS results of testing of sample of meat which was claimed by Garibaldi was used in contaminated batch of metwurst proves positive for E.Coli responsible for 'HUS epidemic. February 2Garibaldi instigates recall of all metwurst products. Continuing investigations
|
top of page
|
Contact the University : Disclaimer & Copyright : Privacy : Accessibility |
|
Date Created: 03 June 2005 |
The University of Melbourne ABN: 84 002 705 224 
|
![The University of Melbourne [logo]](/template-assets-custom/images/custom_logo_crest_comb.gif){kind=logo}
