Factors contributing to the cause of a community outbreak of tuberculosis.

The diagnosis of pulmonary tuberculosis (TB) in a nursery teacher led to a total of 282 adults and children being screened for TB, and 67 of these contracted the condition. Latent and active factors mitigated against earlier diagnosis of the disease during the multiple contacts by the teacher with the healthcare system over 18 months. A series of barely inter-linked events meant that the system failed the patient and consequently the contacts who contracted the disease. The system errors were widespread and render possible a similar occurrence elsewhere.