The notion of DC has changed in time and it has given rise to a variety of models. 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. National (secret) intelligence services, in collaboration with the ones of other countries or organizations, should assess the risks of such threats.

The chain of command for DC 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 PC 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.

The Law 225/1992 (24 February 1992) [17] has established a national department, at the highest ministerial level, with the mission to foresee, prevent, and manage extraordinary events that might endanger the population; Italy’s PC is not directly aimed to face bioterrorism, but its structures may be called upon by the DC in order to activate an integrated response.

The organization of 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 follows the so called “Augustus method”, which formalizes the steps to be taken to the various ends of the mission. In particular, it links the various functions, in order to define the scenarios and to answer the questions “Who does what, where and when?” [10].

The idea that biological agents can be used as weapons dates back to pre-history [32]. In modern times several states have invested a lot for the study and development of biological weapons. There have been international agreements to ban them, which have not deterred some states, notably Japan, to use them, and others, notably the two superpowers, to prepare huge stockpiles of deadly, “weaponized” biological agents.

Italy had adhered to the Geneva Protocol of 1925, prohibiting the use in war of chemical or bacteriological methods of warfare. At the time, and until World War II, some experts were engaged in literature searches on the matter of the potential use of biological agents, and a limited amount of research was done on it. Contrary to a recent libel asserting a heavy involvement of the fascist regime in biological warfare [7], it is proven by documents from the British National Archives that the allies had investigated Italy’s activities in the field and concluded that they were very limited in scope, lightly financed, and naively conducted [3].

Rather than an active actor, Italy appears to have been the victim of an insidious kind of biological warfare, the attack by the Germans to the reclamation system of marshy lands in the Pontine area, with the introduction of salty waters to favour the breeding of Anopheles labranchiae. There followed an upsurge of malaria cases, which lasted for years after the end of the war [28].

Worldwide, the concept of bioterrorism is recent, as it only emerged in the 1990s of the past century. A PubMed search for the word finds nothing until 1996, when a paper was published in JAMA [31]. An editorial of 1997 recognized the unpreparedness of society to face bioterrorism, and pleaded for more attention to the threat [35], while the six papers of 1998 stressed its relevance to public health. Figure 13.2shows how the number of papers on bioterrorism rose at first slowly, and then peaked on account of the anthrax mailings following the Twin Tower attack of 11 September 2001.

In fact, the surge of scientific interest on bioterrorism was an immediate consequence of the new geopolitical asset of the world, with the end of the superpower bipolar influence, which had been based on atomic deterrence. Biological agents were thus considered to be attractive by “rogue states” and by non-governmental groups, on account of their favourable cost/effects ratios, which allowed their economic development as weapons of mass destruction or their use as a frightening means of terrorism, capable, with a modest effort, of disrupting entire societies.

The emerging threat has been amplified by the media coverage, which has indulged in apocalyptic worst case scenarios. This in turn has had paradoxical effects, like the hoarding and subsequent shortage of ciprofloxacin in the entire USA, followed by a rise in the stock values of its manufacturer.

The media storm swept through the world. The anthrax scare hit the headlines and enticed the phenomenon of fake alarms: over a period of a few weeks in Italy alone there were hundreds of such alarms. Measures had to be taken immediately: A task force of experts was set up and a guideline for their management was hastily drawn. In short, the guideline instructed for a minimal and safe handling of suspicious specimens by first line operators; the heat inactivation of the material, and its referral to the national anthrax reference centre at the IZS of Foggia, where in due course the material was analyzed by PCR [8, 9, 11, 12].

Immediately after the peak of the anthrax scare, societies everywhere realized that they were unprepared to face bioterrorism. The more affluent ones allocated enormous amounts of money and implemented programmes for the early warning of biological attacks, for research on selected agents, for educating laymen and professionals, in short, for preparing for the worst. The less affluent ones, like Italy, took advantage of the growing knowledge on the threat and followed as they could.

On the judiciary side, the emergence has brought about an updating of the penal laws against the associations with the scope of terrorism in general (Law of 15 December 2001) [15], while the old penal code, Article 438, states: “Anyone who causes an epidemic through the spread of germs is punished with life imprisonment”, and Article 430 states “Anyone who poisons water or substances intended for food, before they are paid or distributed for consumption, is punished with imprisonment of not less than fifteen years. If the fact is followed by death it is punished with life imprisonment”. There are several other provisions for criminal offences which may occur in bioterrorism activities, and it may be recalled that in Italy all crimes must be prosecuted. Actually, this is the main difference in the response to natural epidemics and the bioterrorism threat.

Before the anthrax scare we had to face a series of other biological emergencies, like the HIV pandemic and the Bovine Spongiform Encephalopathy. Each found Italy unprepared, and each had some strengthening effect on Italy’s public health system. In particular, there was a renewed interest in infectious diseases (ID), a branch of medicine that had appeared to be superseded by antibiotics. Ad hocinvestments led to the opening of many ID units, many more MDs embraced the specialty, and there was a flowering of mathematical models of epidemic spread. In general, these emergencies favoured the transfer into the health system of modern communication technologies.

In the last decade the SARS pandemic (2003) demonstrated the value of real time networks and of international collaboration: in a matter of weeks after the isolation of the agent by Carlo Urbani, the virus was fully characterized as a novel Coronavirus and PCR methods allowed for its detection. Italy reacted with health checks of incoming international flights, and guidelines for caring and isolating patients at two selected ID hospitals, located in the cities near Italy’s two main airline hubs, where the Spallanzani Hospital (Rome) and the Sacco Hospital (Milan) are equipped with negative pressure isolation rooms, BSL-4 laboratories, and isolator ambulances and stretchers. Both are national reference centres for bio-emergency.

An urgent decree funded the establishment of a national centre for disease prevention and control, CCM, with the mission to prevent and control sanitary emergencies due to bioterrorism or incumbent epidemics [16].

In 2006 there was the first Italian report, in birds, of the highly pathogenic H5N1 influenza virus which had lingered since the 1990s in the Far East and had reached Turkey, East Europe, and Great Britain, with a number of serious human infections. The bird flu led to a stringent veterinary surveillance and to a network of dedicated laboratories. Italy followed the lead of the WHO 2005 pandemic preparedness plan, and adopted its own [25], which dictated that all Regions had to prepare similar plans, coordinating the efforts of the various agencies involved. At the central level, measures were taken as to the purchase of vaccines and antivirals, with post factumpolitical controversies.

On the regulatory side, the national committee for biosafety, biotechnology and life sciences, under the patronage of the prime minister office, has drafted a code of conduct for biosafety [26] which stresses the importance of education and of strict adherence to caution in the handling of select agents.

The council of regional health assessors has agreed on a list of diseases deserving extreme surveillance and control, regardless of whether they occur naturally or maliciously. The list includes smallpox, botulism, plague, tularemia, multiple viral hemorrhagic fevers, yellow fever, Marburg virus disease, cholera, and any other quarantinable diseases considered by international authorities.

Other kinds of emergencies, like the garbage disposal crisis of Naples, the Aquila earthquake, the waves of clandestine immigrants and the recent global economic crisis have distracted from the threat of bioterrorism, which is now to be considered just one of the possible, albeit improbable, catastrophic events, for which the foundation has been laid for an integrated response. The fact that the word “bioterrorism” is not present in the national plan for health [21] nor in the national plan for prevention 2010–2012 [23] attests that it is no longer considered a priority.