PHWR Public Health Weekly Report

Emerging and bioterrorism-related infectious diseases pose a significant threat to national and public health systems, necessitating effective preparedness and rapid response. The coronavirus disease 2019 pandemic has highlighted the importance of structured training programs for healthcare workers. These programs reportedly contribute to improving knowledge, attitudes, and skills, ultimately strengthening infectious disease response capabilities [1].

The incidence of infectious disease outbreaks, including avian influenza, Middle East Respiratory Syndrome, and Mpox, has been progressively increasing, emphasizing the need for continuous training and functional exercises for healthcare personnel to reinforce the public health emergency response system [2,-4]. Additionally, recent bioterrorism threats, such as unknown international postal packages in 2023 and North Korea’s balloon-borne biological agent threats in 2024, have further increased the need to train healthcare workers in emerging and bioterrorism-related infectious disease responses.

In response, the Korea Disease Control and Prevention Agency (KDCA) has been systematically implementing a training program for healthcare workers. The objective of this study was to analyze the implementation outcomes of the 2024 training program and propose directions for improvement.

1. Implementation Framework

The 2024 training program for healthcare workers responding to emerging and bioterrorism-related infectious diseases was organized by the KDCA and executed by the Public Healthcare Training Center, National Medical Center, which is responsible for developing, operating, and evaluating the program. The program was implemented in collaboration with internal and external experts to ensure its validity and effectiveness. The experts provided consultations on curriculum design and content development and analyzed the post-training evaluation results to propose areas for improvement (Figure 1).

Figure 1. Implementation framework for training programs
KDCA=Korea Disease Control and Prevention Agency; NMC= National Medical Center.

Participants were primarily recruited from healthcare institutions, including regional public hospitals, Red Cross hospitals, nationally designated isolation facilities, infectious disease hospitals, and private healthcare institutions. Additionally, first responders from the military, fire departments, public health centers, and quarantine stations were included. The program was conducted from January 1 to December 31, 2024.

2. Training Curriculum

The 2024 training curriculum was developed based on an evaluation of the 2023 program. The 2023 training program received 238% more applications than the number of available slots; however, only 30.1% of applicants completed the training, indicating that training opportunities were highly limited. Additionally, there was a strong demand for more hands-on, practice-based training, highlighting the need for program expansion. To address these issues, the 2024 curriculum was restructured to include three basic courses focused on infectious disease response exercises and four advanced courses based on problem-solving. The total number of training sessions was increased from 10 to 13 to improve accessibility and provide more practical training opportunities [5].

To accommodate this high demand, the duration of training was shortened, and the number of participants and sessions was increased. In particular, a one-day training format was introduced for physicians to enhance participation rates. Furthermore, new tabletop and functional exercises were incorporated, enabling trainees to experience real-life infectious disease response scenarios and develop practical skills.

To further enhance practical learning, a virtual reality (VR)-based personal protective equipment (PPE) donning and doffing simulation was introduced into a competency enhancement course for emerging infectious disease responses. This allowed the trainees to practice repeatedly in a controlled, immersive environment that resembled real-world infectious disease response scenarios. Tabletop and functional exercises were integrated to strengthen practical skills in strategic planning, patient transport, and isolation ward operations, thereby equipping trainees with the ability to respond rapidly and systematically to infectious disease outbreaks (Figure 2).

Figure 2. Training activities in the healthcare workers training program for emerging and bioterrorism-related infectious disease response
(A) Virtual reality-based personal protective equipment donning and doffing training. (B) Functional exercise for emerging infectious disease response.

3. Training Evaluation

Training effectiveness was assessed using Kirkpatrick’s four-level training evaluation model, focusing on Levels 1 (training satisfaction) and 2 (learning assessment). Training satisfaction was evaluated across all seven courses using a five-point Likert scale to assess lecture content, instructors, training support, and overall satisfaction. Learning outcomes were measured by assessing learning efficacy, practical efficacy, and knowledge improvement through pre- and post-training evaluations [6].

Learning efficacy and practical efficacy were measured using structured questionnaires consisting of eight and five items, respectively, rated on a five-point Likert scale. Knowledge improvement was assessed using a written test comprising 20 items, with identical questions administered before and after the training.

1. Participant Characteristics Analysis

The 2024 training program for specialists in emerging and bioterrorism-related infectious disease response recruited 224 participants, received 572 applications, and was completed by 231 individuals. The completion rate was 93.3% for the basic training course and 120.2% for the advanced training course. The higher completion rate of the advanced course is attributable to its one-day format, which posed fewer scheduling conflicts for participants. In contrast, the basic course, conducted over one to two nights, showed a relatively lower completion rate due to frequent absences arising from work-related constraints. To accommodate the high demand, the advanced course conducted in the latter half of the year was implemented by enrolling participants in excess of the initially planned quota (Table 1). Among the participants, 82.7% were female, and the majority were in their 30s (42.4%). Participants were predominantly affiliated with public healthcare institutions (39.8%), followed by private institutions (21.6%) and regional public hospitals (18.2%). Regarding occupation, nurses, physicians, and paramedics accounted for 78.8%, 9.5%, and 2.6% of participants, respectively. Overall, 42.9% of participants had 1–4 years of experience in infectious disease responses (Table 2).

Table 1 Training enrollment and completion status

Category	Recruitment trainees	Application	Completion trainees	Completion rate
Total	224	572	231	103.1
Basic courses
Capacity building for emerging infectious diseases response	80	190	76	95.0
Capacity building for bioterrorism-related infectious disease response	40	112	34	85.0
Field exploration program	20	69	20	100.0
Advanced courses
Emerging infectious disease course for physicians	12	20	14	116.7
Emerging infectious disease course for managers	20	39	26	130.0
Tabletop exercise for emerging infectious disease response	40	120	47	117.5
Functional exercise for emerging infectious disease response	12	22	14	116.7

Values are presented as number of participants or percentage..

Table 2 General characteristics of trainees

Category	Total	Capacity building for emerging infectious diseases response	Capacity building for bioterrorism-related infectious disease response	Field exploration program	Emerging infectious disease course for physicians	Emerging infectious disease course for managers	Tabletop exercise for emerging infectious disease response	Functional exercise for emerging infectious disease response
Sex
Male	40 (17.3)	12 (15.8)	5 (14.7)	3 (15.0)	9 (64.3)	7 (26.9)	3 (6.4)	1 (7.1)
Female	191 (82.7)	64 (84.2)	29 (85.3)	17 (85.0)	5 (35.7)	19 (73.1)	44 (93.6)	13 (92.9)
Age (yr)
19–29	35 (15.2)	13 (17.1)	9 (26.5)	2 (10.0)	1 (7.1)	3 (11.5)	5 (10.6)	2 (14.3)
30–39	98 (42.4)	32 (42.1)	14 (41.2)	8 (40.0)	10 (71.4)	7 (26.9)	20 (42.6)	7 (50.0)
40–49	64 (27.7)	17 (22.4)	8 (23.5)	7 (35.0)	1 (7.1)	9 (34.6)	17 (36.2)	5 (35.7)
≥50	34 (14.7)	14 (18.4)	3 (8.8)	3 (15.0)	2 (14.3)	7 (26.9)	5 (10.6)	0 (0.0)
Institution
Regional public hospitals	42 (18.2)	19 (25.0)	4 (11.8)	1 (5.0)	3 (21.4)	8 (30.8)	6 (12.8)	1 (7.1)
Public healthcare institutions	92 (39.8)	33 (43.4)	22 (64.7)	8 (40.0)	4 (28.6)	5 (19.2)	15 (31.9)	5 (35.7)
Private healthcare institutions	50 (21.6)	8 (10.5)	2 (5.9)	4 (20.0)	0 (0.0)	3 (11.5)	25 (53.2)	8 (57.1)
Others (military, fire department, public health centers, etc.)	47 (20.3)	16 (21.1)	6 (17.6)	7 (35.0)	7 (50.0)	10 (38.5)	1 (2.1)	0 (0.0)
Occupation
Physicians	22 (9.5)	3 (3.9)	3 (8.8)	1 (5.0)	14 (100.0)	1 (3.8)	0 (0.0)	0 (0.0)
Nurses	182 (78.8)	60 (78.9)	31 (91.2)	17 (85.0)	0 (0.0)	16 (61.5)	45 (95.7)	13 (92.9)
Paramedics	6 (2.6)	1 (1.3)	0 (0.0)	1 (5.0)	0 (0.0)	1 (3.8)	2 (4.3)	1 (7.1)
Others (administration, researchers, etc.)	21 (9.1)	12 (15.8)	0 (0.0)	1 (5.0)	0 (0.0)	8 (30.8)	0 (0.0)	0 (0.0)
Work experience (yr)
<1	34 (14.7)	16 (21.1)	10 (29.4)	0 (0.0)	1 (7.1)	2 (7.7)	3 (6.4)	2 (14.3)
1–4	99 (42.9)	29 (38.2)	13 (38.2)	2 (10.0)	11 (78.6)	11 (42.3)	26 (55.3)	7 (50.0)
5–9	41 (17.7)	12 (15.8)	3 (8.8)	2 (10.0)	0 (0.0)	5 (19.2)	15 (31.9)	4 (28.6)
10–14	21 (9.1)	6 (7.9)	4 (11.8)	5 (25.0)	2 (14.3)	3 (11.5)	1 (2.1)	0 (0.0)
≥15	36 (15.6)	13 (17.1)	4 (11.8)	11 (55.0)	0 (0.0)	5 (19.2)	2 (4.3)	1 (7.1)

Values are presented as number of participants (%)..

These findings indicate a high demand for training on emerging and bioterrorism-related infectious disease responses, particularly among nurses and healthcare professionals affiliated with public medical institutions. The high participation rate suggests the necessity for continuous education and the development of specialized training programs.

2. Training Satisfaction Analysis

Training satisfaction was evaluated based on four categories using a five-point scale: lecture content, instructors, training support, and overall satisfaction (Figure 3). Satisfaction with lecture content, which assessed lecture topics, difficulty level, and teaching methods, received a rating of 4.7 for advanced courses and 4.6 for basic courses. Instructor satisfaction, which measured instructor expertise and effectiveness in content delivery, was rated 4.9 and 4.7 for the advanced and basic courses, respectively. Moreover, satisfaction with training support, which covered the educational environment, course administration, and practical training preparedness, was rated 4.7 and 4.5 for advanced and basic courses, respectively.

Figure 3. Training satisfaction evaluation in the healthcare workers training program for emerging and bioterrorism-related infectious disease response

Overall, the advanced courses received higher satisfaction ratings than the basic courses (4.7 vs. 4.6, respectively), which can be attributed to the use of real-world infectious disease response scenarios, including tabletop and functional exercises, thereby enhancing practical applicability.

3. Training Effectiveness Analysis

Training effectiveness was assessed through learning efficacy, practical efficacy, and knowledge improvement, evaluated before and after training using a ten-point scale (Figure 4).

Figure 4. Training outcome analysis for capacity building for emerging infectious diseases response
(A) Pre- and post-training comparison of educational outcomes. (B) Educational outcome improvement rate (%).

Learning efficacy, which included assessments of infectious disease characteristics, infection control principles, PPE donning and doffing procedures, and the ability to develop and implement response strategies, increased from 6.1 before training to 9.0 after training, representing a 48.7% improvement. Notably, the greatest improvement was observed in the knowledge of PPE donning and doffing procedures and the ability to establish and implement infectious disease response strategies.

Practical efficacy, which included competency in donning and doffing Level C PPE and using powered air-purifying respirators (PAPR), improved from 4.5 before training to 9.1 after training, indicating a 102.2% improvement. The greatest improvement was noted in confidence in Level C PPE and PAPR donning and doffing, supporting the effectiveness of functional exercises and VR-based simulation learning.

Knowledge improvement, as assessed through a written test comprising 20 questions on infectious disease characteristics, infection control principles, and response systems, increased from 6.3 before training to 7.2 after training, reflecting a 10.2% improvement.

The training program for healthcare workers in emerging and bioterrorism-related infectious disease responses was structured into basic and advanced courses to enhance their skills and develop specialized expertise. Compared with the training sessions and trainees recorded in 2023, the number of training sessions increased from 10 to 13, while the number of trainees increased from 166 to 231 in 2024. However, only 40.3% of applicants could participate despite this expansion, indicating that training opportunities remain limited.

To address this growing demand, the 2025 curriculum has been adjusted by extending the training duration and increasing the number of sessions. To facilitate hands-on practice without restrictions of time and location, instructional videos for donning and doffing Level C PPE were developed, and a blended learning approach combining online and offline training was introduced to enhance proficiency through repetitive learning. In addition, a same-day PPE training module was newly incorporated into the basic curriculum to improve the course completion rate. Simulation-based training, combined with online learning, is an effective approach for enhancing infectious disease response capabilities, particularly in PPE donning and doffing, as well as functional exercises, which are essential for infection prevention among healthcare workers [7,8].

The program integrated practical training methodologies and participatory learning techniques, significantly improving the competencies of trainees. Functional exercises conducted in realistic hospital settings under simulated outbreak conditions received high satisfaction ratings and exhibited robust real-world applicability. These exercises addressed gaps in conventional training programs by strengthening practical response skills and were recognized by the domestic media as a key component in infectious disease preparedness. In addition, a tailored training program reflecting the characteristics of various healthcare professions and institutions was newly introduced, aiming to strengthen practical competencies that can be applied in real-world healthcare settings.

To further enhance the expertise and effectiveness of this training program, increased funding and improvements in the educational infrastructure are essential. A systematic training framework incorporating regular evaluations and feedback is required to ensure continuous enhancement. Moving forward, the KDCA will continue to expand training opportunities by integrating core competencies essential for real-world infectious disease responses and improving training tools and methodologies, thereby ensuring a structured and effective training system for healthcare workers.

Ethics Statement: Not applicable.

Funding Source: None.

Acknowledgments: None.

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

Author Contributions: Conceptualization: HJH, BIK. Data curation: HJH. Project administration: HJH, BIK, SGY. Supervision: BIK, SGY. Writing – original draft: HJH. Writing – review & editing: HJH, BIK, SGY.