I serve as career commissioned officer -- now my rank is lieutenant colonel -- in ... Militare, that is a reference center and - according to the NATO evacuation ...
3rd Annual International Symposium on Biosecurity and Biosafety: Future Trends and Solutions Milan, October 12 – 14, 2011 Speech Defense Management in Case of Bio Outbreaks: The Italian Experience Francesco Urbano First of all let me thank professor Maria Rita Gismondo and the whole organizing committee for the kind invitation to speak in this prestigious symposium. Then, before getting to the main topic of my speech, the Italian Experience in Defense Management in Case of Bio Outbreaks, let me spend few words in order to introduce myself and explain the reasons of my interest in this topic. I serve as career commissioned officer -- now my rank is lieutenant colonel -- in the Italian Army medical Corps. In the last ten years, following the new geopolitical asset, the Italian Armed forces have dramatically changed. Very shortly, as in many other advanced countries, the end of the cold war and the emergence of new threats have led to a reshaping of the Italian military asset, the milestones of which have been first of all a numeric downsizing, accompanied by specialization (with the passage from a conscript army to a full professional model), and upgraded logistics to allow the forecasted employment in distant geographic areas with varied climatic, environmental, social and health conditions. To face the challenge of the new millennium, also military medical assistance changed his structure and function. In Italy the military medical assistance, having failed the many attempts to unification, on the German or French model, is still now split in four different medical services for the four Armed Forces. So Navy, Air Force and Carabinieri – our military police -- have their own separate medical services, with different structures and organizations: in all, they can rely on more than five hundred Physicians and one thousand and two hundred graduated nurse NCO. The largest medical service, not only from a numerical point of view, but also for the capillarity and the different skills owned, is the Army medical Corps. The army medical corps relays on about one thousand physicians and 5 hundred professional NCOs; its structure is quite complex and I’ll not bother you with its details. Of course the army medical corps is the oldest of the different Italian military medical services: it was born in the first half of the nineteenth century, and starting from its origins, one of its main interests has been the management of bio outbreaks.
Most of the papers by its founder Alessandro Riberi and by his followers, were on these matters. Thus we can firmly state that our experience in bio-outbreak management is about two hundred centuries old! I would only like to emphasize that the army medical corps can share with the other military medical services and with the civilian National health system, precious resources like the main high specialization military hospital in Rome, the Policlinico Militare, that is a reference center and - according to the NATO evacuation policy the role four structure for the strategic medical evacuation from all our overseas missions. We can also share a network of general practitioners widely spread in the country (every regiment/battalion has one or more medical officer with a surgery); such a privileged epidemiologic observatory has already shown its efficiency for the pandemic flu surveillance. Here you can see two examples of this military general practice: on the left when, as captain I was in charge of medical service in one parachutist regiment in Florence, and on the right when, as LTC, I was the chief of the Medical Center in Film city camp in Kosovo. We can also rely on a diffuse network of medical centers, former military hospitals, with labs e outpatient specialty clinics. All this complex structure is under the command of this headquarters, in Via Nomentana in rome, the Logistic Command medical branch, in which I work as chief of the preventive medicine section since 2006. And now to the main topics, The italian model of response to bio outbreaks. First of all I would like ti recall that naturally occurred epidemics have been the main historical drive for the establishment of Public Health Systems: notably in the renaissance Italy as reported in many historical essays, like the one by Cipolla or this here. Only in the second half of the ninetieth century were the pre-unitary health systems merged into a national one, and few remember that its mainframe was suggested by an army surgeon, Agostino Bertani. It would be of interest to recall the historical evolution of our National Health System, but we must limit ourselves to state that now Public Health in Italy is entrusted to our National Health Service, SSN, that it is Universal, funded by the general fiscality, regulated centrally, but managed by Regions, through Local Sanitary Units, ASL. Each ASL deals with both clinical and preventive medicine. The system has shown to be capable to face epidemics, granting good standards of efficacy, similar to the ones in other advanced countries.
Untested, because untried, is the efficacy towards intentional biological attacks like the ones in the slide, that you know well. After the peak of interest in 2001, the threat of bioterrorism is now considered just one of the diverse risks facing our society and endangering public health. Without major investments, the effort has been to integrate existing resources, to implement tight links among national and supranational agencies and to make plans for their most efficient involvement in case of need. In Italy, the mainstay for the response to a biological attack is represented by the public health system, entrusted to our national health service (S.S.N), centrally coordinated but put into action by the Regions. Local Sanitary Unites are responsible for the use of allotted resources in all aspects of health care; so they are also in charge of protecting and promoting public health; each has a section or department of preventive medicine that deals with hygiene and public health: epidemiology, health promotion and education, food control, veterinary surveillance, and environment protection. Other agencies cooperate in the protection of public health, either at the regional level, like the ARPAs (Agenzie Regionale di Protezione Ambientale Regional Environment Protection Agencies) or supra-regional, like the 10 IZPSs (Istituti Zooprofilattici Sperimentali - Experimental Zoo Prophylactic Institutes). In time, several kinds of emergencies they have driven the establishment of the present system to cope with them, mainly based on DC, Difesa Civile (Civil Defense), and PC, Protezione Civile (Civil Protection). At present, in Italy, DC is conceived as a hierarchy of diverse structures which are coordinated to respond to intentional threats, including bioterrorism, which endanger the population. intelligence services should assess the risks of such threats. the chain of command has vertex structures at ministerial level, and provincial prefects who coordinate the efforts of municipal entities. personnel and facilities may be drawn from the SSN, the Civil Protection structures, the military apparatus, the Red Cross and volunteer NGOs. DC can activate emergency operational rooms at various levels and it may emanate and enforce regulations. PC a national department, at the highest ministerial level, has the mission to foresee, prevent and manage extraordinary events that might endanger the population. PC is not directly aimed to face bioterrorism, but its structures may be called upon by the Civil Defense in order to activate an integrated response. PC is diffuse on the territory, and it can rely on over 300.000 variously trained volunteers and on all the facilities available to public institutions; PC formalizes the steps to be taken to the various ends of the mission. In particular, it links the various functions, in order to delimit the scenarios and to answer the questions ‘who does what, where and when?’ So in the event of a disaster the role of the military has become subsidiary to that of the organizations whose mission is the defense and protection of the civilians.
However most of knowledge about disaster and mass casualties that could follow an intentional bio-outbreak, is owned by the military apparatus: the army codified a doctrine about mass casualties. According to this doctrine Armed forces, used to face war and all the other conditions characterized by mass casualties, can rely on all you need to face disasters, like organized manpower with a clear chain of command, mobility, logistics specialized units as medical ones and engineering ones. However the specific threat posed by biological agents [and chemical or nuclear weapons] dictates that the military apparatus be ready to face it, so it maintains specialized units for NBC defense, and a national center for research and for the specific training. One particular unit, the 7th Regiment ‘Cremona’, is fully dedicated to NBC defense; the regiment has specialized units for the delimitation of the affected area and for the decontamination of people and of materials. Regarding the biological hazards, it is equipped with a mobile laboratory capable of molecular detection of biological agents, and of isolator tents and ambulances. The NBC defense center runs courses for the personnel of all the armed forces, the national and local police corps, the Italian Red Cross, the firemen, the S.S.N., the railway and port authorities. The center, which participates to international working groups, develops policies, procedures and guidelines for the integrated response to NBCR emergencies. In addition to these units, in relation to the early detection of biological warfare agents, we must remind the role of the medical and veterinarian military research center, in Rome, which labs has of classical and molecular microbiology with Biosafety level 3 containment standards, and can deploy mobile diagnostic teams. As you have seen yesterday a limited capacity for the safe aerial transport of highly contagious patients is guaranteed by the Air Force, with a number of aircraft transit isolators which, along with specially trained and equipped teams, on several occasions have been used for civilian missions. In conclusion the emerging threat of emerging infectious diseases and of bioterrorism has shown the need for a change in the education curricula of sanitary professions and for specific training of first line operators. Specific courses have been activated by universities and other bodies, but attendance has been limited by the lack of ad hoc funds. Bioterrorism was not contemplated in the university core curricula and standard textbooks, which have started to mention it in the editions after 2002. So most of our physicians have had to rely on continuous medical education. Many medical societies have included sessions on bioterrorism (and other biological
emergencies) in their national congresses; some have set up study groups of experts and fostered the establishment of early warning systems and laboratories networks. The CME offer has been consistent, but its fruition has been hampered by the lack of public funding.
