PHWR Public Health Weekly Report

Major public health issues such as H1N1pdm09 in 2009, Middle East respiratory syndrome (MERS) outbreak in 2015, the coronavirus diseases 2019 (COVID-19) pandemic in 2020, and Mpox in 2022, have posed significant public health threats in Republic of Korea [1]. The risk of introduction of emerging infectious diseases remains high due to factors such as climate change, increased international exchange, and the increase in international travel. These conditions can lead to rapid spread, highlighting the importance of rapid and effective responses [2]. Since the MERS outbreak in 2015, the need to strengthen infection control and response capabilities within healthcare workers has become increasingly significant. The widespread economic and social disruptions caused by the COVID-19 pandemic have further emphasized the critical importance of these capabilities. Consequently, there is a growing demand for systematic educational programs aimed at enhancing the response of healthcare workers.

Since 2015, the Korea Disease Control and Prevention Agency (KDCA) has started supporting the National Medical Center to conduct a training program for healthcare workers in emerging and bioterrorism-related infectious disease response. To ensure the program’s sustainability and to establish a stable support base, the initiative transitioned to a private general subsidy project in 2022. The program aims to train healthcare workers and first responders from medical institutions to develop on-site response capabilities for emerging and bioterrorism-related infectious diseases, while enhancing their overall response capabilities. The program includes annual quality control measures, based on results from the previous year, to prepare for potential outbreaks of emerging and bioterrorism-related infectious diseases.

This paper aims to introduce the training programs for healthcare workers in emerging and bioterrorism-related infectious diseases in the years 2022 and 2023.

1. Project Implementation Framework

The training program for healthcare workers in emerging and bioterrorism-related infectious diseases is conducted by the National Medical Center’s Public Health and Medical Training Center, Supported by the KDCA. The Public Health and Medical Training Center, established under Article 20 of the Public Health and Medical Services Act, serves as a specialized institution for public health and medical education and training. The center recruits trainees, develops curricula in collaboration with internal and external experts, organizes faculty, and conducts training and evaluations. Post-training, satisfaction surveys and practical application evaluations are analyzed to continually improve the program (Figure 1).

Figure 1. Flowchart of training process
KDCA=Korea Disease Control and Prevention Agency; NMC=National Medical Center; PPE=personal protective equipment.

2. Participants

Participants were recruited from various institutions, including regional medical centers, Red Cross hospitals, hospitals with National Designated Isolation Unit wards, infectious disease hospitals, national university hospitals, public hospitals, private medical institutions, and first-response agencies (such as public health centers, quarantine stations, fire departments, and the military). Priority was given to healthcare workers from public medical institutions with designated isolation beds, considering regional and institutional diversity. The primary participants were healthcare workers, with some first responders also selected to enhance coordination with related organizations. In cases where the number of applicants exceeded the capacity, 1–2 participants per institution were selected to ensure equal opportunities. In 2022, 210 participants (42.4% of the applicants), including 14 medical doctors, 139 nurses, 2 medical technicians, 1 paramedic, and 54 others (firefighters, military personnel, public health center staff, etc.), completed the training. In 2023, 166 participants (29.5% of applicants), including 7 medical doctors, 127 nurses, 3 medical technicians, 5 paramedics, and 24 others, completed the training (Table 1). The sex distribution showed a higher proportion of female trainees (69.5% in 2022, 75.9% in 2023) compared to male trainees (30.5% in 2022, 24.1% in 2023). The majority of participants were in their 30s (50.0% in 2022, 47.0% in 2023), with most having 1 to 4 years of work experience (35.7% in 2022, 57.2% in 2023; Table 2).

Table 1 Training programs for emerging and bioterrorism-related infectious disease response healthcare workers

Category	2022							2023
	Recruit-ment	Applica-tion	Comple-tion	Public medical institutions	Private medical institutions	First response agencies		Recruit-ment	Applica-tion	Comple-tion	Public medical institutions	Private medical institutions	First response agencies
Total	210	495	210	123	7	80		162	549	166	90	30	46
Basic courses
Capacity building for emerging infectious diseases response	112	240	113	68	2	43		64	246	64	38	6	20
Capacity building for bioterrorism-related infectious disease response	28	142	38	18	0	20		32	173	40	19	6	15
Field exploration program	14	57	14	9	0	5		18	55	17	7	4	6
Advanced courses
Advanced course for emergency departmenta),b)	14	13	12	8	1	3		16	18	13	12	1	0
Advanced course for nursesa)	14	22	15	11	0	4		-	-	-	-	-	-
Advanced course for nurses doctora)	14	9	6	5	1	0		-	-	-	-	-	-
Instructor training coursea)	14	12	12	4	3	5		-	-	-	-	-	-
Simulation training courseb)	-	-	-	-	-	-		16	22	17	8	9	0
Expert courseb)	-	-	-	-	-	-		16	35	15	6	4	5

Units: number of participants. ^a)2022 Training courses. ^b)2023 Training courses..

Table 2 General characteristics of trainees

Category	2022 (n=210)	2023 (n=166)
Sex
Male	64 (30.5)	40 (24.1)
Female	146 (69.5)	126 (75.9)
Age (yr)
19–29	57 (27.1)	35 (21.1)
30–39	105 (50.0)	78 (47.0)
40–49	33 (15.7)	40 (24.1)
≥50	15 (7.1)	13 (7.8)
Work experience (yr)
<1	26 (12.4)	34 (20.5)
1–4	75 (35.7)	95 (57.2)
5–9	53 (25.2)	25 (15.1)
10–14	18 (8.6)	8 (4.8)
≥15	38 (18.1)	4 (2.4)

Unit: number (%)..

3. Programs

The training programs are divided into a basic education component, which focuses on practical responses to infectious diseases, and an advanced problem-solving education component. The training is conducted by specialized faculty, including medical professionals from the National Medical Center and professors from medical and nursing schools. In 2022, the program consisted of 15 sessions across 7 courses, and in 2023, it comprised 10 sessions across 6 courses [3,4]. The basic education component includes three common courses: capacity building for emerging infectious diseases, capacity building for bioterrorism, and a field exploration program. The first day of the capacity building course involves theoretical education; the second day includes practical training on donning and doffing personal protective equipment (PPE), and the third day concludes with evaluations. The field exploration program involves visits to relevant institutions.

On the first day of the capacity building for emerging infectious diseases course, theoretical education covers general topics on infectious diseases (types, characteristics, latest trends), the characteristics and transmission routes of emerging infectious diseases, basic principles of infection control for different individuals (patients, transporters, healthcare workers), and understanding the national response system during infectious disease outbreaks. The capacity building for the bioterrorism course covers laws related to bioterrorism, types of bioterrorism, the characteristics of bioterrorism-related pathogens and infectious diseases, diagnosis, treatment methods, bioterrorism response systems, and response strategies for different types of bioterrorism.

On the second day, the practical training includes educating participants on the types and functions of PPE, principles of donning and doffing, and precautions. The training involves a demonstration by one instructor, with another instructor explaining the process, including the use of gloves, overshoes, masks, detached hoods, goggles, face shields, and full-body protective suits. In the capacity building for emerging infectious diseases course, participants practice donning and doffing Level C PPE to familiarize themselves with the process, while the capacity building for bioterrorism course includes training on the specifications of bioterrorism-related protective equipment and the donning and doffing of fully sealed biological and chemical protective suits (Level A). Both courses include practical exercises in groups of 6–8, which simulate scenarios such as patient occurrence and death, followed by discussions and feedback on problem areas and improvement plans from the instructors.

On the third day, evaluations for the capacity building for emerging infectious diseases course includes written tests, practical tests on donning and doffing PPE, and satisfaction surveys. The bioterrorism capacity building course also includes satisfaction surveys. The field exploration program, introduced in 2022, involves visits to the KDCA emergency operation center, the National Institute of Health, hospitals with nationally designated, Incheon Airport quarantine station, public health centers, and other government and regional medical institutions. These visits enhance participants’ understanding of the integrated work processes of these institutions and allow sharing of experiences of managing infectious disease cases.

The advanced courses in 2022 included four courses tailored to specific job categories (emergency room, nurses, medical doctors), including a training of trainers course. In 2023, the advanced courses consisted of an advanced course for emergency rooms, a simulation training course for emerging infectious diseases, and an expert training course. While the content and participants vary by course, advanced education sessions focus on moving beyond simple practical training to include simulation exercises and debriefing sessions. These sessions involve discussing resource allocation, establishing patient management strategies, and simulating scenarios of emerging infectious disease cases in healthcare settings. The debriefing sessions help identify issues and improvements, thereby strengthening participants’ systematic response capabilities (Figure 2).

Figure 2. Training curriculum
(A) Theoretical education. (B) Level C donning and doffing. (C) Level A donning and doffing. (D) Practical exercise in suspected patient transportation. (E) Table top exercise. (F) Practical assessments.

4. Evaluation

The training evaluation primarily focused on the capacity building for emerging infectious diseases course, utilizing the first three stages of Kirkpatrick’s four-level evaluation model (Reaction, Learning, Behavior, and Results) (Table 3) [5]. The Reaction stage assesses participants’ reactions to the course, including the appropriateness of the content, the competency of the instructors, and overall satisfaction, through surveys conducted after the course. In 2022, 84.0% of participants indicated that the course content was appropriate, and 79.2% felt it was helpful for their actual work. In 2023, these figures were 82.8% and 75.0%, respectively. The instructors received high satisfaction ratings, with 88.7% in 2022 and 81.3% in 2023 indicating overall satisfaction.

Table 3 Evaluation results of the emerging infectious disease response capacity building course

Category	2022	2023	Evaluation method
Level 1: Reaction
Training topics	84.0	82.8	Satisfaction survey
Training content	79.2	75.0
Instructors	88.7	81.3
Level 2: Theoretical learning
Academic achievement	22.2	20.0	Pre and post evaluation
Knowledge improvement	57.4	48.1
Level 2: Practical learninga)
PPE donning and doffing	26.5	23.4	Checklist
Level 3: Behaviorb)
Training satisfaction	77.1	-	Post training evaluation
Workplace application	82.8	-

Units: %. PPE=personal protective equipment. ^a)Re-examination rate. ^b)2023 Evaluation in progress..

The Learning stage evaluates improvements in knowledge, skills, and attitudes through a combination of theoretical and practical assessments. The theoretical assessments are based on questions prepared by the instructors, with fewer than 20 questions selected to match the difficulty level of the participants. They are conducted before and after the training. The level of improvement in knowledge regarding emerging infectious diseases was 22.2% in 2022 and 20.0% in 2023. The achievement rate in practical skills increased by 57.4% in 2022 and 48.1% in 2023. Practical assessments for donning and doffing PPE involve a checklist of 66 items, requiring participants to perform at least 90% correctly and checking for exposure using ultraviolet-sensitive materials. Participants who did not meet the criteria were given up to three retests. The results showed that 26.5% of the participants in 2022 and 23.4% in 2023 did not pass the initial assessment, but ultimately, all participants passed the practical evaluation.

The Behavior stage assesses the practical application of the training content in the participants’ workplaces, at a certain period after the course, evaluating satisfaction, core competency application, practical application, and case studies. A practical application evaluation conducted within 10 months after completing the capacity building for emerging infectious diseases course in 2022 revealed that 77.1% of participants were very satisfied with the training, and 82.8% could apply the content to their work to a large extent. In particular, the core competency of donning and doffing PPE was utilized in institutional training or shared with colleagues.

Continuous improvement of the training program is made based on participant satisfaction evaluations and feedback from advisory committee assessments.

The appropriate combination of theoretical and practical training in the programs for healthcare workers in emerging and bioterrorism-related infectious diseases aims to enhance the basic infectious disease response capabilities of healthcare workers and first responders. Simulation training is included to strengthen participants’ practical response capabilities. The high level of practical application of the training content in the participants’ actual workplaces indicates the effectiveness of the training programs. However, the demand for training exceeds the available opportunities, with only an average of 36.0% of applicants in 2022 and 2023 were selected. This highlights the need for continuous program implementation and an increase in the number of participants through investment. The KDCA plans to continue provide educational opportunities for healthcare workers in emerging and bioterrorism-related infectious diseases as strengthening response capacity of healthcare workers is critical.

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, YAO, IHK, SGY. Data curation: HJH, YJK. Formal analysis: SHL. Project administration: HJH, YJK, HSK. Resources: HSK, EMP. Supervision: SGY. Validation: YAO, IHK. Visualization: YJK, EMP, SHL. Writing – original draft: HJH. Writing – review & editing: YAO, HSK, IHK, SGY.