effected in a biosafety level laboratory by emergent notification and specimen transport to the CDC Based on past experience, vaccination (with vaccinia, an orthopoxvirus closely related to variola) of smallpox-exposed persons within the first days after exposure may prevent the development of overt disease Although the vaccine has been used safely and successfully in even young infants, it has a relatively high rate of serious complications in certain patients Notably, fetal vaccinia and resultant fetal demise can occur when pregnant women are vaccinated Vaccinia gangrenosa, a frequently fatal complication, occurred when immunocompromised persons were inadvertently vaccinated Eczema vaccinatum may occur in those with pre-existing skin conditions and can be serious Myocarditis and pericarditis may occur A severe postvaccinal encephalitis was well known, albeit relatively rare, during the era of widespread vaccination, because this complication occurs only after primary vaccination, it would disproportionately affect pediatric patients Autoinoculation can occur when virus from the primary lesion arising at the site of vaccination is transferred by scratching or rubbing to other areas of the skin or to the eye To manage these complications, vaccinia immune globulin (VIG) should be available when undertaking a vaccination campaign VIG (0.6 mg/kg intramuscular [IM]) may be given to vaccine recipients who experience severe complications or to significantly immunocompromised individuals exposed to smallpox in whom vaccination would be unsafe Today, stocks of vaccine and VIG are controlled by the CDC There is also a nonreplicating smallpox vaccine (IMVAMUNE) for immune-compromised patients that is not yet FDA approved but is stocked by the CDC for emergency use Even a single case of smallpox occurring anywhere in the world today would represent a grave public health emergency A suspected case should thus prompt immediate notification and consultation with health authorities Strict airborne, droplet, and contact precautions should be instituted immediately for victims and should continue until all scabs have separated Decontamination of symptomatic patients is unnecessary Contacts must be observed closely for 17 days following their last potential exposure The development of fever during this period would be a cause for isolation Multiple victims would ideally be managed as a cohort at dedicated sites removed from conventional hospital facilities Botulism Background Botulism occurs as a result of exposure to one of eight botulinum neurotoxins (A through H) Only types A, B, E, and, rarely, F appear to cause human botulism in nature Botulinum toxin was included in the U.S biologic