PHWR Public Health Weekly Report

The Korea Disease Control and Prevention Agency (KDCA) conducts annual training exercises for local governments (metropolitan and basic) and related organizations (disaster-related departments, fire departments, regional police agencies, military, local education offices, medical institutions, public health and environmental research institutes, quarantine stations, etc.) to enhance preparedness and response capabilities for public health emergencies caused by emerging and re-emerging infectious diseases. These simulation-based exercises, utilizing virtual scenarios, aim to assess the crisis management systems of local governments and strengthen the capabilities of first responders.

The training program began in 2004 as the first crisis management exercise for emerging infectious diseases.

Following the 2009 H1N1 influenza pandemic, concerns over the emergence of new public health crises and potential for their introduction into the country led to the establishment of crisis response training programs. Since 2010, these exercises have been conducted for public health personnel and relevant institutions at provincial and municipal levels to strengthen the response capabilities of frontline officials in crisis situations [1]. Currently, this training is carried out in its present form across 17 metropolitan and provincial governments, where relevant agencies gather to conduct joint exercises. The training programs for 2020 and 2021 were postponed owing to response efforts for coronavirus disease. The program resumed in 2022 at the same level as in previous years. However, in 2023, owing to budget constraints, the KDCA conducted centralized training sessions. In 2024, training was once again conducted at the provincial and municipal levels.

Over the past 5 years during which the training was conducted (2017, 2018, 2019, 2022, and 2023), the specific training themes varied annually but primarily focused on Middle East respiratory syndrome (MERS), avian influenza (AI), and Ebola virus disease (EVD). The training program was divided into practical exercises and discussion-based exercises, with detailed scenarios designed for each session. The evaluation metrics included four key indicators, along with a satisfaction survey consisting of ten questions (Table 1). Detailed information on the training themes and methodologies is provided in the following sections.

Table 1 Overview of Emerging and Re-emerging Infectious Disease Crisis Management Response Training in the past five years

Category		Year 2017	Year 2018	Year 2019	Year 2022	Year 2023
Training provinces and cities		16 provinces and cities (Sejong: joint training with Chungbuk).	16 provinces and cities (Sejong: joint training with Chungnam).	17 provinces and cities.	16 provinces and cities (Sejong: joint training with Chungnam).	Central (group training for 17 provinces and cities, including municipal and county governments).
Scenario	Training topics	Middle East respiratory syndrome. Ebola virus disease.	Middle East respiratory syndrome. Ebola virus disease. Avian influenza.	Middle East respiratory syndrome. Ebola virus disease. Avian influenza.	Simultaneous response to COVID-19 and Middle East respiratory syndrome. COVID-19. Monkeypox. Ebola virus disease. Avian influenza.	Avian influenza.
	Number of situations (questions)	Middle East respiratory syndrome. -. Practical training: standard scenario, 1–3 unexpected situations -. Discussion-based training: scenario-based situations 1–5. Ebola virus disease. -. Practical training: standard scenario, 1–4 unexpected situations. -. Discussion-based training: scenario-based situations 1–5.	Middle East respiratory syndrome. -. Practical training: 5 situations, 10 detailed scenarios. -. Discussion-based training: 8 questions. Ebola virus disease. -. Practical training: 4 situations, 9 detailed scenarios. -. Discussion-based training: 8 questions. Avian influenza. -. Practical training: 4 situations, 10 detailed scenarios. -. Discussion-based training: 9 questions.	Middle East respiratory syndrome. -. Practical training: 5 situations, 10 detailed scenarios. -. Discussion-based training: 8 questions. Ebola virus disease. -. Practical training: 4 situations, 9 detailed scenarios. -. Discussion-based training: 8 questions. Avian influenza. -. Practical training: 4 situations, 10 detailed scenarios. -. Discussion-based training: 9 questions.	Simultaneous response to COVID-19 and Middle East respiratory syndrome. -. Practical training: 5 situations, 10 detailed scenarios. -. Discussion-based training: 8 questions. COVID-19. -. Practical training: 2 situations, 4 detailed scenarios. -. Discussion-based training: 4 questions. Monkeypox. -. Discussion-based training: 4 situations, 14 detailed scenarios. Ebola virus disease. -. Practical training: 4 situations, 9 detailed scenarios. -. Discussion-based training: 8 questions. Avian influenza. -. Practical training: 4 situations, 10 detailed scenarios. -. Discussion-based training: 9 questions.	Avian influenza. -. Practical training: 4 situations, 10 detailed scenarios. -. Discussion-based training: 13 questions.
Evaluation criteria	Composition of evaluation items	Evaluation sheet: 4 items (training planning, training design, training implementation, training evaluation & feedback). Additional/deduction points: 8 items (maximum bonus points: 10, maximum deduction points: –10).	Evaluation sheet: 4 items (training planning, training design, training implementation, training evaluation & feedback). Additional/deduction points: 8 items (maximum bonus points: 10, maximum deduction points: –10).	Evaluation sheet: 4 items (training planning, training design, training implementation, training evaluation & feedback). Additional/deduction points: 8 items (maximum bonus points: 10, maximum deduction points: –10).	Evaluation sheet: 4 items (training planning, training design, training implementation, training evaluation & feedback). Additional/deduction points: 8 items (maximum bonus points: 10, maximum deduction points: –10).	Evaluation sheet: 3 items (training planning, training design, training implementation, training evaluation & feedback). Additional/deduction points: 5 items (maximum bonus points: 5, maximum deduction points: –5).
Satisfaction survey	Questionnaire composition	Composed of 4 items (pre-training lecture & training guidance, on-site training, tabletop training, training environment).	Composed of 10 questions (pre- and post-training knowledge assessment, pre- and post-training attitude assessment, training satisfaction assessment, demographic information).	Composed of 10 questions (pre- and post-training knowledge assessment, pre- and post-training attitude assessment, training satisfaction assessment, demographic information).	Composed of 10 questions (pre- and post-training knowledge assessment, pre- and post-training attitude assessment, training satisfaction assessment, demographic information).	Composed of 9 questions (pre- and post-training knowledge assessment, pre- and post-training attitude assessment, training satisfaction assessment, demographic information).

COVID-19=coronavirus disease 2019..

This manuscript is based on the “2024 Report on the Crisis Management Response Training for Emerging and Re-emerging Infectious Disease” [2].

1. Participating Organizations and Their Roles

The KDCA oversaw the training program by developing and distributing training operation guidelines, exercise-based training scenarios, discussion-based training scenarios, and evaluation indicators to metropolitan municipalities. The Regional Disease Response Centers under the KDCA provided technical support for training programs within their respective jurisdictions. Their responsibilities included supporting the development of municipal training scenarios, conducting training for municipal training coordinators, reviewing municipal training plans, offering on-site consultations, and conducting training evaluations. As the primary entities responsible for training, the metropolitan municipalities developed and executed training plans and submitted the training results to the KDCA. The Regional Centers for Infectious Disease Control and Prevention supported the practical operations and manpower needs of the municipal training programs. Public health centers (at the basic municipal level) and related organizations (departments) participated in the training sessions.

2. Training Themes

The training themes were selected based on the likelihood of occurrence, social impact, and economic consequences of emerging and re-emerging infectious diseases. The training utilized three standardized manuals covering the MERS, AI, and EVD. The KDCA provided these three infectious disease training manuals in advance. Each provincial or municipal government selected one of the three manuals based on its specific circumstances and developed a corresponding training plan. Additionally, scenarios were adapted to reflect the local response conditions of each region to enhance the relevance and effectiveness of the exercises.

3. Training Components

The training program consisted of five main components: educational lectures on infectious diseases; exercise-based training; discussion-based training; practical training on donning and doffing personal protective equipment (PPE); and a comprehensive review, followed by a closing session. The training began with educational lectures that covered epidemiological characteristics and guidelines related to the infectious disease topics of the sessions. Exercise-based training focused on the initial responses to suspected cases. Activities included reporting and responding to travelers from high-risk countries, conducting epidemiological investigations, managing suspected patients, and handling contacts. These activities were conducted using O/X quizzes and role-playing exercises. Discussion-based training was designed to develop response strategies for crises. It covered scenarios such as the patient occurrences, additional confirmed cases, and post-situation measures. The practical training session on donning and doffing PPE involved lectures or demonstrations tailored to the infectious disease being addressed (Level C or Level D PPE), followed by hands-on practice.

4. Training Evaluation

The training evaluation comprised three main components: an institutional assessment of each provincial and municipal government, an individual assessment of trainees, and a satisfaction survey. The institutional evaluation examined the adequacy and thoroughness of the training planning and design by each regional government. It also assessed the level of participation, appropriateness of training implementation, publicity efforts, and effectiveness of the evaluation and feedback processes. Individual evaluations measured the extent to which trainees improved their knowledge and response capabilities before and after the training, as well as any changes in their attitudes toward crisis response. The satisfaction survey collected feedback from the trainees on their overall experience with the training program. For individual assessment, participants completed surveys before and after the training to measure their progress and evaluate the effectiveness of the training in enhancing their knowledge and preparedness.

The 2024 training was conducted between July and September, following the individual schedules set by each provincial and municipal government. Sixteen metropolitan and provincial governments participated in the program. Notably, this was the first time training was conducted without financial support from the central government.

1. Training Topics

MERS training was conducted in three metropolitan municipalities, AI training in 11 metropolitan municipalities, and EVD training in two metropolitan municipalities.

2. Composition of Trainees

In total, 1,334 individuals from approximately 480 institutions participated in the training. Participating organizations included local governments (metropolitan and basic municipalities), regional infectious disease management centers, and related institutions and departments, such as quarantine stations, public health laboratories, the Animal and Plant Quarantine Agency, fire services, police, military, the Ministry of Justice, education offices, and medical institutions. The training evaluation involved the Emerging Infectious Disease Response Division of the KDCA and its Regional Disease Response Centers.

Of all the trainees, 759 completed both the pre- and post-training surveys, and 592 (78.0%) were women. Participants in their 30s accounted for the largest group 287 (37.8%), followed by those in their 40s (27.9%) and 50s (21.2%) (Table 2). By occupation, 475 (62.6%) trainees were staff from metropolitan municipalities and public health centers, followed by education (3.4%), diagnostic testing and firefighting (3.0%), and police service (2.4%). Participants from other occupations (22.4%) included personnel from medical institutions, animal quarantine, disaster management, and administrative and immigration departments (Table 2).

Table 2 General characteristics of 2024 trainees

Category	Total (n=759)	Percentage (%)
Sex
Male	167	22.0
Female	592	78.0
Age (yr)
19–29	97	12.8
30–39	287	37.8
40–49	212	27.9
50–59	161	21.2
60+	2	0.3
Occupation
Infectious disease response (city/province, health center)	475	62.6
Diagnostic testing	23	3.0
Quarantine	15	2.0
Education	26	3.4
Firefighting	23	3.0
Police	18	2.4
Military	9	1.2
Othersa)	170	22.4

^a)Others include medical institutions, animal quarantine departments, disaster response departments, administrative departments, and immigration management departments..

In terms of overall work experience, 479 participants (63%) had less than 2 years of experience, while 623 (82.1%) had less than 2 years of experience working in infectious diseases. In addition, 445 participants (58.6%) participated in this type of training for the first time (Table 3).

Table 3 Work experience of 2024 trainees

Category	Total (n=759)	Percentage (%)
Work experience at current institution (yr)
<1	147	19.3
1–2	332	43.7
3–5	106	14.0
6–10	75	9.9
11–15	32	4.2
16–20	27	3.6
21+	40	5.3
Experience in infectious disease-related work (yr)
None	95	12.5
<1	205	27.0
1–2	323	42.6
3–5	85	11.2
6–10	41	5.4
11–15	3	0.4
16–20	7	0.9
21+	0	0.0

3. Evaluation of Trainees’ Knowledge Improvement Rate

To assess the trainees’ knowledge acquisition, a multiple-choice questionnaire consisting of 10 questions, covering key concepts related to the three training scenarios on infectious diseases, was employed. Trainees responded to the same set of questions before and after the training to measure improvements in their knowledge. The overall knowledge improvement rate among all the trainees was 14.1%. When analyzed according to disease category, improvement rates were 10.9% for MERS, 11.1% for AI, and 37.0% for EVD. These results indicate that the trainees’ understanding of each infectious disease topic improved after training (Table 4).

Table 4 Knowledge improvement rate assessment of 2024 trainees

Category	Total (n)	Averagea)		Improvement rate (%)b)	p-value
		Pre-training	Post-training
Overall	759	7.2±2.1	8.3±1.6	14.1	<0.001
Middle East respiratory syndrome	127	7.4±2.1	8.3±1.4	10.9	<0.001
Avian influenza	525	7.6±2.0	8.4±1.6	11.1	<0.001
Ebola virus disease	107	5.4±1.7	7.4±1.6	37.0	<0.001

^a)Mean score±standard deviation. ^b)Improvement rate (%): {(post-training score–pre-training score)/pre-training score}×100..

4. Evaluation of Trainee Satisfaction

Based on a 5-point scale, the average trainee satisfaction score was 4.5, indicating a high overall level of satisfaction with the training program.

5. Training Evaluation according to Metropolitan Municipality

The highest total score was recorded in Ulsan Metropolitan City with 104 points, whereas Daejeon Metropolitan City scored the lowest score in the second training session (60 points). The average score across 16 metropolitan municipalities was 93.2 points. However, as the evaluators and number of evaluators varied between municipalities, direct comparisons of scores among municipalities were not appropriate. Therefore, these scores were used for purposes only.

6. Suggestions for Training Improvement

The participants suggested several improvements, including extending the training schedule, providing budget support for training, developing scenarios tailored to related organizations, and allocating time to share experiences in the infectious disease response.

The evaluators provided additional feedback, such as the need to extend the time allocated for discussion-based training, improve strategies to increase survey participation rates, enhance the capabilities of team leaders, restructure lectures and scenarios to improve understanding among related organizations, and strengthen the ongoing capacity of metropolitan municipalities.

Emerging and Re-emerging Infectious Disease Crisis Management Response Training is designed to enhance the ability of local governments (both metropolitan and municipal) to respond to public health emergencies. Additionally, the training serves as an opportunity to clarify and share the roles of relevant infectious disease response agencies within each province and municipality while also strengthening inter-agency cooperation.

The 2024 training program was the first to be conducted at the provincial and municipal levels without any financial support from the central government. Overall, the training was successfully conducted and achieved the intended objectives. Several key insights and considerations emerged from this program.

1. Necessity for Stable and Continuous Annual Operation of the Emerging and Re-emerging Infectious Disease Crisis Management Training

By 2024, Emerging and Re-emerging Infectious Disease Crisis Management Training comprised 1,334 participants from approximately 480 institutions. This remains the only training program specifically designed to enhance the infectious disease response capabilities of local governments.

The 2024 training revealed that a high proportion of participants (82.1%) had less than 2 years of experience working in infectious disease-related roles, and 58.6% were participating in this training for the first time. Given the prevalence of low levels of work experience and the likelihood of frequent staff changes, it is essential to maintain consistent response capabilities through annual training sessions.

Furthermore, the current training curriculum, which includes lectures on infectious disease theory, exercise-based training to practice procedures based on guidelines, discussion-based training to coordinate with related organizations, and practical sessions on donning and doffing PPE, must be continuously sustained to ensure preparedness.

2. Improvement Plans for Future Training Based on 2024 Results

As continuous capacity building at the frontline level is essential, securing a dedicated training budget is a prerequisite. However, as central government funding may not be available by 2025, it is crucial to prepare alternative measures. To alleviate the burden on local governments, training efficiency should be improved by selectively applying the evaluation criteria.

A key area for improvement is the simplification of the evaluation criteria. Currently, there are 16 main evaluation categories, each with detailed subitems. Rather than designing training primarily for evaluation purposes, the focus should shift toward assessing only the actual execution of training on the designated day. This approach would allow provincial and municipal training coordinators to streamline their preparation processes and focus more effectively on implementing practical training programs.

Furthermore, as highlighted in the feedback, it is essential to improve the training, allocate sufficient discussion time, and ensure effective interagency communication. Given the participation of numerous relevant institutions, new training scenarios should be developed to increase involvement. In addition to public health centers, which traditionally take the lead in responding to emerging infectious diseases, training should provide time for relevant agencies to discuss the anticipated challenges in their response efforts.

To strengthen interagency cooperation, changes should be made to the program to optimize discussion-based training sessions. Currently, participants engage in discussions on eight key questions over approximately 90 minutes to develop response strategies. To enhance focus and engagement, the number of discussion points was reduced to six and discussion duration was adjusted to approximately 60 minutes. This change was aimed at creating a more structured and concentrated discussion format, allowing for more productive and in-depth exchanges between agencies.

Emerging infectious diseases require coordinated responses and collaboration among multiple relevant agencies. Therefore, the continuous implementation and improvement of Emerging and Re-Emerging Infectious Disease Crisis Management Response Training program is essential for strengthening the response capabilities of local governments. Moving forward, efforts will continue to ensure that training implementation, feedback collection, and the identification of vulnerabilities will contribute to refining future training programs. Additionally, local governments should be encouraged to actively reflect on training outcomes, incorporate identified weaknesses, and apply these insights to enhance the design and execution of the next year’s training program.

Ethics Statement: Not applicable.

Funding Source: None.

Acknowledgments: None.

Conflict of Interest: The authors have no conflicts of interest to declare.

Author Contributions: Conceptualization: EMP, IHK, SGY. Data curation: EMP. Formal analysis: EMP, IHK. Methodology: EMP, IHK. Project administration: EMP. Supervision: SGY. Validation: IHK. Visualization: EMP. Writing – original draft: EMP. Writing – review & editing: HJH, IHK, SGY.