BACKGROUND: Overcrowded emergency departments (EDs) are used by undiagnosed tuberculosis (TB) patients. TB infection control measures are seldom prioritized, making EDs potential foci of unrecognised nosocomial transmission. OBJECTIVE: To quantify TB infection risk among health care workers in an ED in a high TB-burden setting, Lima, Peru, and to evaluate TB infection control measures. METHODS: Consenting ED staff were tested for TB infection at baseline and after 1 year using the QuantiFERON-TB Gold In-Tube (QFT-G). In parallel, sputum for TB culture was requested from patients spending >2 h in the ED, irrespective of presenting complaint. Infection control measures were documented and room ventilation measured. RESULTS: Over 1 year, there were 2246 TB patient-hours of exposure in the ED from 153 different patients. At baseline, 56% of the 70 staff recruited were QFT-G-positive; 27 of 31 baseline-negatives consented to follow-up after 1 year, and eight (30%, all clinical staff) tested positive. Annual incidence of infection was 1730 per 100,000 population. TB infection control measures were sub-optimal, with no patient screening, no isolation rooms, inadequate ventilation and sporadic respirator use. CONCLUSIONS: ED staff were exposed to an unexpectedly large TB burden in the workplace, resulting in a high rate of TB infection. TB infection control should be prioritized in EDs, especially in high-prevalence settings.