South Carolina public health officials gravely mishandled a tuberculosis (TB) outbreak at a rural elementary school, said the director of the state's largest public health agency on Tuesday, and four people have been fired. According to the Wall Street Journal, a series of failures throughout the testing and notification system led to the exposure of hundreds of people to the disease, including some 465 children who were only tested three months after they were exposed.

The Associated Press quoted Department of Health Environmental Control (DHEC) Director Catherine Templeton as saying, "DHEC screwed this up. I'm sort of as indignant and angry about it as anybody else. It's not how I run the railroad. It's why they were fired."

A reported 53 children were infected with TB, including 10 who were infected with the active form of the disease -- which requires a lengthy and exacting treatment regimen with strong antibiotic medication. A number of DHEC employees have been fired or suspended over the outbreak, including three local DHEC nurses and the head of the state agency dedicated to fighting TB.

In March, the three nurses, who are suing the state to regain their positions, became concerned when the janitor from Greenwood County's Ninety-Six Primary School went to the hospital with symptoms of acute respiratory distress. The hospital notified the local DHEC team that he tested positive for the active form of the disease.

The nurses opened an investigation, visiting the sick custodian at home and notifying the state supervisors in the city of Columbia. The nurses tested school staff and repeatedly requested permission to notify parents and begin testing schoolchildren, but never got the go-ahead from the state, according to their attorneys.

A spokesperson for Templeton said that the state director learned about the outbreak and the stalled testing and notification process when she visited Greenwood County on another, unrelated matter on May 20. Her office said that she immediately began an investigation. Ultimately the state was forced to call in the Centers for Disease Control and Prevention (CDC) to help bring the situation under control.

On Thursday, Templeton released a statement saying that the local nurses did not react quickly enough nor did they do enough to raise the alarm and catch their supervisors' attention in a time of crisis.

"The investigation did not begin in a timely manner, the public-health protocols were ignored, and the conclusions from the investigation were nonsensical," she said, adding that the nurses "could have obtained the authority they needed to properly conduct the investigation by contacting me."

Templeton told the AP that the director of the state's TB agency in Columbia was also fired due to her sluggish response to the crisis.

"They all shared this lethargy," she said.

Testing of schoolchildren, their families and other contacts began on May 31, twelve weeks after the school janitor was diagnosed. Templeton told the AP that the investigation is ongoing and that more firings are possible. In addition to the fired nurses, suits against the state have been filed by the families of several children affected by the outbreak.

The Journal reported that the janitor who was the originally infected patient has remained uncooperative throughout the investigation. He refused to be quarantined and resisted the recommended medical treatment. He is currently being detained in a high security medical facility, said the DHEC.

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