Abstract: On December 3, 2009, a respiratory therapist (Employee #1) working in the Emergency Department of the Alta Bates Summit Medical Center was exposed to a patient with bacterial meningitis. Employee #1 was hospitalized for 11 days with life-threatening bacterial meningitis starting on December 10, 2009, and he was released on December 21, 2009, from John Muir-Mt. Diablo Medical Center. The employer reported the hospitalization to Cal/OSHA on December 15, 2009. The employer failed to report the bacterial meningitis case in a timely manner to the local health authority (Alameda County Public Health Department) and to one (American Medical Response) of three other employers whose employees had been exposed to the meningitis case. Two employers (Oakland Police and Oakland Fire departments) were never notified by the employer, and an employee of the Oakland Police Department also contracted a secondary case of bacterial meningitis and was hospitalized for five days in a life-threatening condition. The employer did not conduct a required exposure analysis of its own employees for possible exposure to the meningitis case for seven days, until after the respiratory therapist had been hospitalized. The casual factors of the secondary cases of bacterial meningitis in the hospital employee and police officer include: the failure of the employees to use appropriate respiratory protection; the employer's failure to report the meningitis case in a timely manner to the local health authority and to other employers whose employees had been exposed to the index case; and the employer's failure to conduct a timely and complete exposure analysis of its own employees potentially exposed to the index case.