Infection Control Failure

Communications Failure Blamed in Tuberculosis Case

Published in TB and Outbreaks Week, March 30th, 1998

St. Louis, Missouri, health officials said a communications breakdown in a disorganized city health department allowed a patient with infectious tuberculosis (TB) to fall through the cracks of the system without treatment.

An AIDS patient with drug-resistant TB remained untreated and infectious for about two months while being seen at four different medical facilities, the St. Louis chief health officer acknowledged.

During part of that time, city and state officials exchanged telephone calls discussing whether to count the patient as a new case or as the recurrence of a previous infection. But no one bothered to ensure the man, 50, was receiving...

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Source: TB and Outbreaks Week (1998-03-30)

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