DoEpi: Exercises for Teaching Epidemiology and Computing, With a Framework for Creating New Exercises Programmed and Edited by Andrew G. Dean, MD, MPH Epidemiology Program Office Svati P. Shah Jeanetta Churchill, MS Klemm Analysis Group, Inc. The exercises and software are in the public domain and may be freely copied, translated, or distributed. Epidemiology Program Office Centers for Disease Control and Prevention (CDC) Atlanta, Georgia, U.S.A. CONTENTS What Is DoEpi? Origins of DoEpi Goals What Is a DoEpi Exercise? Choosing Exercises Using DoEpi Prerequisites Hardware and Software Requirements Installation Using Epi Info with DoEpi Computer Tasks Deleting Exercises Adding Exercises Making Your Own Exercise Printing the Handouts CME and CEU Credits Getting Technical Help or Sending Suggestions MODULES IN DOEPI: BACKGROUND What is DoEpi? Overview and history of Epi Info software for epidemiology EPIDEMIC INVESTIGATIONS Postoperative Rhodococcus: Infection after open-heart surgery Oswego Church Supper: Gastroenteritis following a church supper Toxic Shellfish Poisoning: Deaths in a tropical country RESEARCH STUDY OC Use and Ovarian Cancer: Oral contraceptives and cancer risk ADVANCED EPI INFO PROGRAMMING Planning a Program or System: Steps in planning computerization Programming the Epi Info Menu: Setting up a new system Programming Data Input: Questionnaires and check file programs Programming Data Output: Advanced data management and analysis PUBLIC HEALTH SURVEILLANCE Paralytic Illness in Ababo: Setting up a surveillance system in Africa Surveillance Request: Computerizing an existing system Refugee Camp Nutrition: Nutritional measurements in disasters U.S. State Case Surveillance: How one complex system is programmed INSTRUCTOR'S MODULE Making a new exercise ORIGINS OF DOEPI: Computer-assisted instruction (CAI) has advanced beyond the stage of experimentation to play a central role in medical education. For many years, the Centers for Disease Control and Prevention (CDC) has used epidemic simulations in paper format for instructing Epidemic Intelligence Service Officers. The epidemiologic exercises used in the annual Epidemiologic Intelligence Service course are one of CDC's premier products, often used and emulated in schools of public health for teaching epidemiology. A number of these exercises are particularly well suited for adaptation to CAI and for teaching epidemiology, statistics, and computing in an integrated way. Interactive computer exercises in epidemiology have been combined with the teaching of Epi Info, CDC's public domain software system for epidemiologic computing, so that both epidemiologic tasks and the computing tools to perform them are included in the exercises. DoEpi exercises contain text, images, questions, hints, access to Epi Info, and in cases where they may be needed, files to print out student materials. They can thus be distributed in electronic form, over the Internet, or on floppy disks, without the need for an accompanying manual. GOALS OF DOEPI: The overall goals of DoEpi are: 1. To provide a series of computer-based education modules for use by the CDC and the worldwide epidemiologic community 2. To encourage others to develop new exercises by providing a framework for module preparation 3. To promote the use of practical exercises from the real world in teaching epidemiology 4. To integrate the teaching of epidemiologic computing with the teaching of epidemiology WHAT IS A DOEPI EXERCISE? Most DoEpi modules consist of scenarios from real public-health events: for example, a foodborne outbreak, consultation on computerization of a surveillance system, or an outbreak of hospital-acquired infections. Each problem is presented with text and photographs, and data files are included, if appropriate. Names and locations may be changed to protect confidentiality, but the overall facts are true to life. The exercise is divided into manageable pieces, with questions to prompt the student and "Hints" to be used after the student (or class) has attempted to solve the problem. The Hints may contain answers to the exercise, correct computer results, or other material. Photographs are in low-resolution format to accommodate older screen displays, conserve disk space, and facilitate distribution over the Internet. CHOOSING EXERCISES: Most exercises contain a combination of epidemiologic questions for discussion and computer exercises to be done in Epi Info. The table of contents makes it easy to focus on one or the other, and classes and individuals may choose to emphasize either epidemiology or computing. Each exercise begins with "Learning Objectives" that give an idea of the contents of the exercise. The first few exercises on the menu provide introductory to intermediate materials for both epidemiology and Epi Info. The Advanced Epi Info Programming exercises, particularly the last three, are designed for those who have used Epi Info before and are familiar with the Epi Info Manual. The INFO item on the main DoEpi Menu leads to a KEY WORD INDEX, which allows selecting a topic (e.g., ANTHROPOMETRY) to display the names of exercises that focus on that topic. PREREQUISITES: BACKGROUND There is no prerequisite for this introductory material. EPIDEMIC INVESTIGATIONS and RESEARCH STUDY Some knowledge of epidemiology and study design is assumed. A brief introduction to Epi Info, based on the "Epi Info, Version 6," section of WHAT IS EPI INFO or on reading Chapters 2 and 5 of the Version 6 manual, will be helpful for the computer tasks. ADVANCED EPI INFO PROGRAMMING No background is assumed for the Planning exercise, other than some experience in the use of computers. The other three exercises are quite advanced and assume an intermediate level of skill with Epi Info and familiarity with the Epi Info Manual. PUBLIC HEALTH SURVEILLANCE These exercises progress from elementary to advanced skills in computing. Some acquaintance with surveillance concepts will be useful, but is not required. INSTRUCTOR'S MODULE Making a new exercise requires skill and care in text editing and an instructor's viewpoint in devising an exercise. Customizing a new exercise may require knowledge of DOS batch files and commands and of Epi Info programming, but this is not necessary for all types of exercises. USING DOEPI: DoEpi can be used in a variety of ways in a classroom setting. An instructor may choose to intersperse the computer exercises with more traditional lectures. Within an exercise, an instructor may use all or only a few of the materials and may substitute locally available material at any point. Alternatively, a class of students may work through the exercises at their own pace, alone or in small groups, with the entire group coming together at the end for discussion. The exercises can also be used individually by motivated students, particularly in isolated areas where classes are not available. Such use is most suitable for students with some epidemiologic background and computer experience. The exercises provided do not represent a curriculum, since the "ADVANCED EPI INFO" exercises are addressed to a somewhat different audience--those likely to teach Epi Info use, for example--than are the epidemiologic exercises. The hypertext format allows a class or individual to focus more heavily on computing or on epidemiology if desired. HARDWARE AND SOFTWARE REQUIREMENTS: DoEpi consists of DOS programs built around Epi Info. It requires that Epi Info be installed on the same computer or Local Area Network (LAN) as DoEpi. The programs will run on a 286 computer with 640 K of random access memory in DOS or in a DOS window under Microsoft Windows or Windows95. About 12 megabytes of hard disk space is required for full installation, in addition to the 10 megabytes for a full version of Epi Info. Instructions for installation on a LAN are contained in a file called README.LAN. INSTALLATION: Several types of DoEpi installation are offered in the INSTALL program. If you have enough disk space (about 12 megabytes), run the INSTALL program and choose FULL INSTALLATION when you are prompted to select the type of installation you want. If you install an exercise you do not need, you may delete it at any time (see "Deleting Exericises" topic.) If you wish to add exercises after an installation has been completed, you may also do so at any time (see "Adding Exercises" topic.) The Full Installation of DoEpi includes all exercise modules available from CDC, including the Instructor's module. A Partial Installation of DoEpi includes only those exercises that you specify during the installation and certain core modules. The Student Installation loads all but the Instructor's module. HOW TO INSTALL DOEPI: INSTALLATION FROM DISKETTES: To install DoEpi from diskettes, run the program INSTALL.EXE by typing INSTALL, after logging onto the appropriate floppy diskette drive (e.g., "A:"). Then follow the instructions on the screen. HOW TO INSTALL DOEPI: INSTALLATION FROM THE INTERNET: DoEpi is available on the internet for free download. Go the the Epi Info web site at http://www.cdc.gov/epo/epi/epiinfo.htm and click on "Software" to go to the DoEpi page. Follow directions on the screen to download the software. To install DoEpi from a downloaded copy: 1. Download the software into an existing temporary directory on the hard drive of your computer - e.g., C:\TEMP\INSTALL - the temporary directory should not be called DOEPI. Alternatively, you may download onto a floppy diskette. 2. Unpack the compressed files by typing the first part of the file name at the DOS prompt (in the temporary directory) or by clicking on the file name in your windows File Manager. 3. Type INSTALL at the DOS prompt (in the temporary directory) or click on INSTALL.EXE in your windows File Manager. 4. Follow the installation instructions as they appear on the screen. MAKING INSTALLABLE COPIES OF DOEPI ON DISKETTE FROM THE DOWNLOADED FILES: DoEpi files from the Internet are in compressed self-expanding executable form, as DOEPI1.EXE, DOEPI2.EXE, and DOEPI3.EXE. To expand each and place the installation files on diskettes, either download them directly onto diskette from the internet, or: 1. Insert a blank, formatted 1.4 megabyte diskette into the floppy disk drive. 2. Log onto the appropriate floppy diskette drive (e.g., "A:"), and run a DOEPI file (e.g., by typing "C:\TEMP\DOEPI1", if the file is in C:\TEMP). This will place the installation files on the diskette (or in a hard-drive directory if you first log on to that directory). 3. Using two more diskettes, repeat this process for DOEPI2 and DOEPI3. USING EPI INFO WITH DOEPI: DoEpi computer tasks automatically call up Epi Info when required and return the student to DoEpi after the task has been performed. To do the computer exercises in DoEpi, you must have installed Epi Info Version 6.04 or later (earlier versions may work, but have not been tested with DoEpi). You must also have the location of Epi Info specified in the DOS computer PATH. When you installed Epi Info, you were asked if you wished to have the location of Epi Info added to the PATH in AUTOEXEC.BAT file automatically. If you answered "Y" for yes, the PATH statement should already be correct. If you are not sure, you can check on the PATH from the DOS prompt by typing PATH; you should see something like: PATH C:\;C:\EPI6;etc. If "\EPI6;" is present, then the path is set; if not, you can edit the AUTOEXEC.BAT, usually found in the root directory (e.g., C:\AUTOEXEC.BAT), so that its PATH statement contains the location of \EPI6. Do this carefully, recognizing that a semicolon separates items in the PATH. After changing the PATH in AUTOEXEC.BAT, you must reboot (restart) the computer before the PATH takes effect. As you do the exercises, you will notice that many contain computer tasks -- practical exercises in computing. Computer tasks vary in format between exercises. In the Rhodococcus module, for example, computer tasks require that you do statistical calculations in STATCALC, make a questionnaire in EPED, and enter data in ENTER, starting with the EPI6 menu. The only help provided during these operations is from instructions that can be printed from the files provided. In later exercises, after you have learned to use the EPI6 menu and to use ENTER and EPED, the computer tasks will move directly to the Epi Info ANALYSIS program, since the focus is on analytic tasks and you should no longer need to practice navigating to ANALYSIS through the EPI6 menu. In Oswego Church Supper, for example, data from 75 questionnaires has already been entered, and the tasks jump directly into tutorials in ANALYSIS rather than to the Epi Info menu. CLEANUP Each exercise has a menu entry called CLEANUP. This option removes files that are copied to the working directory, a necessary step in working with DoEpi on a Local Area Network, where users are generally prevented from writing to or saving files in the program directories. When you run an exercise, the necessary files are copied to directory from which you run DoEpi. They can be removed by invoking the CLEANUP option on the menu. Since CLEANUP removes only specified files, it will not delete files that you have created and named yourself. DELETING EXERCISES: Each exercise is housed in a subdirectory of its own under the \DOEPI directory. After installation, you may decide to delete an exercise if you have disk space constraints, or you may decide to keep only those exercises that meet specific needs. To delete an exercise, you must delete the entire subdirectory. To delete the KAMP exercise, for example, log into the \DOEPI directory in DOS, type DELETE KAMP (or DELETE KAMP\*.*) and respond "Y" to the question that appears. Then type RMDIR KAMP to remove the now empty directory. On newer DOS systems, typing DELTREE KAMP will erase files and remove the directory with one command, but be careful, as "DELTREE" is a powerful command! After deleting an exercise subdirectory, the name of the exercise will continue to appear in the main DoEpi menu "Exercises" list unless you delete the corresponding MENUITEM from the file DOEPI.MNU. ADDING EXERCISES: After partial installation or when new DoEpi modules become available, use the INSTALL program to add additional modules. Each new exercise will be installed in a separate subdirectory under \DOEPI that INSTALL creates. Exercises that are created locally with the Instructor's module may need special installation that creates a subdirectory and copies the appropriate files. The Instructor should provide instructions for locally created modules. The instructor's module provides a semi-automated setup for a new exercise, saving much of the labor of inserting file names, topic headings, and hypertext controls when an exercise is being created. The set-up process then becomes mostly one of editing and pasting appropriate text into the framework provided, leaving the author free to pursue the creative work of developing the questions, hints, correct answers, and goals and objectives for the exercise. Materials for graphics can be scanned locally or sent to a photo store for conversion to the Kodak CD-ROM format. This method of digitization is widely available at minimal cost. Software for reducing the resolution and number of colors is widely available; instructions are provided in the Instructor's module. The DoEpi framework is designed so that teachers of epidemiology and/or computing can produce exercises based on their own materials. DoEpi is intended to be a toolbox for teachers of epidemiology worldwide. PRINTING MATERIALS: DoEpi is designed to be, as much as possible, a paperless system. For some computer exercises, however, printed instruction are necessary, unless another computer or projector in the same room is displaying the Computer Task while you do the exercise. DoEpi, therefore, provides files for printing. Some exercise modules contain several files that may be printed and used as class materials. To copy files to a directory for printing from your own favorite word processor, use the PRINT MATERIALS choice on the main DoEpi menu. Choose PRINTING INSTRUCTIONS to read how to set up for printing. If you prefer to use EPED for printing, use the .TXT files and read them from EPED in the \DOEPI directory or after copying them to another directory. CME AND CEU CREDITS: Continuing Medical Education (CME) Credit: The Centers for Disease Control and Prevention (CDC) is accredited by the Accreditation Council for Continuing Medical Education to sponsor Continuing Medical Education (CME) for physicians. The Centers for Disease Control and Prevention (CDC) designates this continuing education activity for up to 42 credit hours in Category 1 of the Physician's Recognition Award of the American Medical Association, as listed in the table below. Continuing Education Units (CEU) Credit: This program has been structured following the International Association for Continuing Education and Training (IACET) Criteria and Guidelines and therefore is awarding Continuing Education Units (CEU's). The Centers for Disease Control and Prevention (CDC) will award up to 4.2 CEU's to each participant who successfully completes this training, as listed in the table below. The CEU is an internationally recognized unit designed to provide a record of an individual's continuing education accomplishments. Credit will be recorded and a certificate provided on receipt of examination results and a completed evaluation for the exercise. To receive either type of credit, complete both the examination and the evaluation at the end of an exercise, and, from the same screen, prepare materials to send to CDC. A blank certificate and a data file will be created, and you will be given a chance to save the certificate to a convenient drive and directory from which to send it to CDC. Initially, the file is called SENDTO.CDC, but if you have several such files you may want to give them different names. The SENDTO.CDC file(s), possibly renamed, should be sent to CDC, using one of the following methods of transmission (the first being preferred): 1. As attachments to an E-mail message, addressed to EPIINFO@CDC1.CDC.GOV The Subject of the E-mail should be "CME" or "CEU". 2. In the body of an E-mail, addressed as above 3. After printing on paper, send by FAX to (404) 639-0841 4. After printing on paper, send by mail, dog sled, or personal messenger to the address on the certificate. NUMBER OF CME OR CEU CREDITS ALLOWED PER EXERCISE EXERCISE CME Credits CEU Credits Rhodococcus 6.0 0.6 Oswego 3.5 0.35 Toxic 1.7 0.2 Shellfish Oral 2.3 0.2 Contraceptive Use Planning 4 0.4 a system* Input 3.7 0.4 Output 4.0 0.4 Menus 3.3 0.3 Surveillance 1.9 0.2 Consultation Ababo 2.5 0.25 Kamp 3.2 0.3 State 6.2 0.6 surveillance system ------------------------------------------------------- Total (Maximum) 42 4.2 *CME awarded only if a plan is constructed for a public health or biomedical system GETTING TECHNICAL HELP OR SENDING SUGGESTIONS: We hope you enjoy DoEpi. Please feel free to e-mail, post, or telephone your questions, comments, and suggestions about DoEpi... Technical Support: E-mail: EpiInfo@CDC1.CDC.GOV U.S. Telephone (404) 639-0840 Comments and Suggestions to: Svati Shah ZGA5@CDC.GOV or Andrew G. Dean, MD, MPH Epidemiology Program Office M/S C-08 Centers for Disease Control and Prevention 1600 Clifton Rd. NE Atlanta, GA 30333 Join the Epi Info E-mail Discussion Group by sending a message with the words, "Subscribe epi-info," to listserv@listserv.cdc.gov Visit the Epi Info Web site at HTTP://WWW.CDC.GOV/, under "Products and Publications" and then "Epi Info and Epi Map". Or go directly to the site at URL http://www.cdc.gov/epo/epi/epiinfo.htm