Learning From Major Incidents Cadbury Salmonella Outbreak

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Learning From Major IncidentsCadbury Salmonella
Outbreak

• Nick Lowe
• Food Safety Team Leader
• Birmingham City Council

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Introduction

• Cadbury Chocolate Making
• Initial Stage
• Preliminary Investigations
• Main Investigation
• Discussion Points Home Authority Perspective

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Cadbury

• Multi National food company
• Number of sites in UK
• Chocolate making, chocolate products
• Supply of goods to other manufacturers
• Head office in Birmingham (Bournville)

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COCOA BEANS
MILK
SUGAR
COCOA LIQUOR
CHIRK
MARLBROOK
3RD PARTY SALES
COCOA POWDER
CRUMB
BOURNVILLE
COCOA BUTTER
CHOCOLATE PRODUCTS
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Initial Stage

• June 2006
• FSA notified us of Product Withdrawal
• National Increase in Salmonella Montevideo
• S. Montevideo found in Cadbury products
• Suggestion that Cadbury were aware of Salmonella
  but still distributed product.

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Questions

• How could this happen?
• Explanation for release of product
• Lack of notification, liaison
• Any on-going problems?
• Have all the affected products been identified,
  could others be involved?

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Preliminary Investigation - Process

• Crumb arrives in tankers from Marlbrook, sample
  taken prior to departure
• Emptied into one silo
• Manufactured into product within 24 hours
• Affected crumb/chocolate distributed throughout
  the factory

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What went wrong?

• S. Montevideo found in crumb at Marlbrook
• Later attributed to a leaking drainpipe
• When result obtained crumb already made into
  chocolate product.
• No positive release of crumb

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What went wrong?

• What happened if Salmonella found in crumb or
  liquid chocolate
• ve/-ve, ve/ve
• Increase in end product sampling
• 2 per line per shift
• 4 per line per shift 100 increase
• From 52 samples to 104
• 300 tonnes of chocolate produced
• 60,000,000 50g bars

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What went wrong?

• S. Montevideo in end product
• Most Probable Number (MPN)
• Mike Pusey report 2003
• BCCCA
• Microbiological risk analysis for the biscuit,
  cake, chocolate and confectionary industry.

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Key Questions

• Validity of MPN?
• Validity of ve/-ve, ve/ve?
• Interpretation of Pusey Report?
• Role of Campden Chorleywood?
• Lack of notification?

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Nagging Question

• What prompted the introduction of the MPN policy?
• 3 Salmonella incidences between April 2002 and
  January 2003
• All product disposed of
• Internal Report Wells Report

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Nagging Question

• Project Ivan
• Project Jade (Somerdale)
• What about A-H?

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• May 03 S. Montevideo CDM 49g MPN release
  of product
• Jan 04 - S. Montevideo in crumb, no source
  identified, release of product
• March 04 - S. Carmel CDM 49g MPN release of
  product
• June 04 - S. Montevideo in crumb, no source
  identified, release of product
• Jan 05 Project Alex, Salmonella in crumb,
  release of product

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• March 05 Project Becks, S. Carmel in double
  decker, MPN release of product
• April 05 Project Charlie, S. Carmel in drinking
  chocolate, MPN release of product
• April 05 Project Donald, S. Carmel in double
  decker, MPN release of product
• April 05 Project Eden, S. Brackenridge in
  double decker with nuts, MPN release of product

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• May 05 Project Flash, S. Brackenridge in Curly
  Wurly, MPN release of product
• June 05 Project Gomez, S. Brookfield in CDM
  buttons MPN release of product
• Oct 05 Project Hector, S. Bonariensis in Curly
  Wurly, MPN release of product

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Main Investigation

• Five key areas of investigation
• What evidence do we need?
• How are we going to get it?
• What have we achieved?

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Project Campden

• Advice/instruction given to Cadbury by Campden
  about Salmonella
• MPN procedure appropriateness
• Copies of notes of meetings, reports, letters,
  e-mails
• Microbiological results going back to 2002

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Project Campden

• Search under warrant
• Seizure of records, including computer records
• Statements from key personnel

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Project Probable

• ACMSF nominated witness
• Salmonella/MPN/any other relevant discussion
• ACMSF minutes to be introduced

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Project Probable

• Interview with Professor Hunter
• MPN suitable for homogenous spread of bacteria
• Not suitable for Salmonella, chocolate
• ve/-ve, ve/ve discredited
• Misinterpretation of Pusey Report

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Project HPA

• Expert Witnesses outbreak, chocolate samples
• Introduction of epidemiological evidence
• Contact with Campden/FSA
• Reference to published guidance

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Project HPA

• Interview with 4 key witnesses at Colindale
• PFGE, gel plates, DNA match

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Project OB Cases

• Identify OB cases
• Witness statements from OB cases
• Identification via HPA
• Visit and interview witnesses

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Project Cadbury

• Company details
• Introduction of MPN
• Consultation
• Challenge
• PACE interview
• Refused

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Joint Working

• Routine outbreak meetings
• Clear roles set
• FSA recall
• Herefordshire hygiene at Marlbrook
• Birmingham corporate decision making
• HPA epidemiological investigation, distribution
  of samples, outbreak control team
• ACMSF expert opinion

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Health Protection Agency

• Essential support for investigation
• Joint visits
• Key witnesses epidemiological evidence, expert
  opinion, counter Cadburys expert witness
• Contact with cases

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Health Protection Agency

• Access to patient information
• Medical confidentiality