Clinical Infectious Diseases    2001;32:1580-1588
© 2001 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2001/3211-0011$03.00

User's Guide to Tuberculosis Resources on the Internet

Midori Kato-Maeda and Peter M. Small

Division of Infectious Diseases and Geographic Medicine, Department of Medicine Stanford Medical School University, Stanford, California

Received 20 November 2000; electronically published 30 April 2001.

     Reprints or correspondence: Dr. Peter M. Small, 300 Pasteur Dr., Grant Building S 143, Medical Center, Stanford University, Stanford, CA 94305 (peter@molepi.stanford.edu).

     The Internet is connecting an unknown number of computer networks worldwide, and as such, contains vast amounts of information dedicated to tuberculosis (TB). However, it is impossible to know the total number of Web pages or the type of information available. Currently, to find the proverbial needle in this haystack, several different search engines may be used to find specific information. These engines do keyword searches against databases that vary in size, frequency of update, and search capability. Depending on which engine is used, searches will result in a list of Web categories, Web sites, or Web pages; the number of matches will differ dramatically. For example, the number of matches resulting from a query that used the word "tuberculosis" in the search engine Alta Vista produced 124,870 Web pages (110,315 in June 2000) while Infoseek yielded only 30,845. For someone looking for the answer to a specific question, the magnitude and variability of search results can be daunting.

     The purpose of this article is to provide a starting point and central location, known as a portal, for a number of common uses of the Internet related to TB. In this study, we reviewed and included Web pages that we, as infectious disease physicians, considered most useful. An on-line version of this information can be found at http://molepi.stanford.edu, which will link to the desired Web page. Because most users go to the Internet with specific uses in mind, we classified the Web pages according to users' needs.

     We included the following topics related to TB: scientific information; epidemiologic data; comprehensive literature for laypeople; recommendations, guidelines, and decision-making algorithms for the management of TB; research databases; research groups; resources for research, teaching material, and training; and information about regulatory action.

METHODS

     To find a relatively comprehensive list of relevant Web pages, we searched for the word "tuberculosis" with Netscape and Explorer browsers by means of the following search engines: Netscape, Yahoo, Alta Vista, and Looksmart. When these sites had links to other Web site, we also reviewed them. We evaluated Web pages until we found sites that adequately addressed the question posed. We analyzed the resulting sites by use of published recommendation for Internet medical data quality (the availability of a source responsible for the Web site, reliability, and free information, as well as the user-friendliness of the Web page) [1].

RESULTS AND DISCUSSION

     Where can I find scientific information?     Table 1 lists sites that deal with scientific information. One of the best sites for accessing the TB literature is PubMed, a search tool that identifies literature citations and links to full-text journals at Web sites of participating publishers. Medscape has a search tool that also accesses peer-reviewed medical information articles, but it also includes conference summaries, treatment updates, clinical management modules, practice guidelines, and textbooks. An excellent way to rapidly review recent publications about TB in the scientific and lay press is Current TB News. This Web page is located on the Johns Hopkins Center for Tuberculosis Research Web site and contains a weekly summary prepared by the Center of Disease Control and Prevention (CDC) of key scientific articles and lay media reports on TB, HIV, AIDS, and other sexually transmitted diseases. The Division of Tuberculosis Elimination of the CDC also has a Web page that allows access to their TB-related articles, fact sheets, guidelines, and other publications. "The Connections," published by CDC National Prevention Information Network, is a Web page that provides scientific information about the relationship between HIV, sexually transmitted diseases, and TB. The National Institute of Allergy and Infectious Diseases (NIAID) publishes fact sheets and brochures related to TB research and opportunities. One of many medical journals that publish research about TB is the official monthly publication of the American Thoracic Society. Also, the International Union against Tuberculosis and Lung Diseases (IUATLD) publishes a monthly journal, with a more international focus on TB research (including free access to some full-text articles). The World Health Organization (WHO) has a searchable Web page that lists their documents, books, articles, and other publications by subject.

     Where can I find epidemiologic data?     Table 2 outlines sites that provide epidemiologic data. The best source for current data about the epidemiology of TB in the United States are the CDC Web sites. These sites include Morbidity and Mortality Weekly Report, a publication containing epidemiological data about a number of reportable diseases (including TB) collected by every state health department in United States. Some of this information is also provided as PowerPoint (Microsoft) computer images, which can be downloaded and used in electronic slide presentations. For global epidemiologic data, the Global Tuberculosis Control Report of the WHO contains information about TB epidemiology and treatment outcomes collected by national control programs. The reports from 1998, 1999, and 2000 are available on the Internet. The WHO has 2 surveillance reports of global drug resistance of TB, which includes the frequency of resistant TB in different parts of the world. Clinicians may find this data useful to assess an immigrant's risk of being infected with drug-resistant TB.

     Where can I find comprehensive literature for laypeople?     Table 3 lists sites geared to the lay audience. The Web sites of the CDC, as well as many teaching hospitals and state TB control programs, host Web pages written in a simple and didactic format for laypeople. Some of them have information written in languages other than English. We include addresses for the Web pages from the CDC and the American Lung Association, which have lists of frequently asked questions, and the Web page from Columbia University, which contains a Spanish-language section.

     Where can I find recommendations, guidelines, and decision-making algorithms for management of TB?     Table 4 lists sites for recommendations and guidelines. The single best source of information for clinicians faced with clinically related TB questions is the CDC Major Tuberculosis Guidelines Web site. This includes an extremely helpful and up-to-date list of recommendations, guidelines, and algorithms for TB management in the United States. The American Thoracic Society and CDC publication that defines diagnostic standards and classification of TB in adults and children is also available on-line as a downloadable .pdf file [2]. This is particularly valuable in that it outlines strategies for diagnosing TB in different populations and a classification of TB based on pathogenesis. Another helpful Web page from the CDC contains the current recommendations for diagnosing and treating TB infection, a major focus of the current effort to eliminate TB in the United States. This site contains the details of these recommendations and is the authoritative source for background information on which the current recommendations are based. The CDC also has recommendations for the management of TB in foreign-born patients, recommendations for those coinfected with HIV and Mycobacterium tuberculosis, and a Web page about interactions between antiretroviral and antituberculous drugs. Additionally, there are recommendations for the use of BCG vaccine in the United States.

     Where can I find research databases?     Table 5 provides Web site addresses for TB research databases. Sequencing of the M. tuberculosis genome was a watershed in TB research and its utility is greatly increased by its easy accessibility via the Internet. The Sanger Center Web site contains the sequence of the standard laboratory strain of M. tuberculosis H37Rv, a list of the 3924 identified genes, and bioinformatic tools for its analysis [3]. The Institute of Genome Research Web site contains the sequence of a recent clinical isolate (CDC1551) [4] and additional bioinformatic tools. TubercuList from the Pasteur Institute is a Web page with nucleotide information linked to annotations and functional assignments. The National Institutes of Health (NIH) has a Web site, Entrez-PubMed, that provides integrated access to biomedical literature and nucleotide and protein sequences.

     Where can I find research groups interested in TB?     Table 6 lists sites that deal with research groups interested in TB. The Internet is one way to identify and contact groups interested in TB research. The WHO has a Web page with their research and development agenda for TB focused primarily on health policy, systems, and services. The Global Forum for Health Research is interested in policy research to improve the efficacy of current strategies, to develop new tools to control TB, and to do research to provide knowledge needed for the design of better interventions. The Trudeau Institute is an independent research Institute interested in the human immune response against cancer and infectious diseases, including TB. The Trudeau Institute Web site includes available educational programs and opportunities for research. Several universities around United States and TB control programs have TB research groups. The Stanford Center for Tuberculosis Research is focused on the integration of molecular and conventional epidemiology to study transmission dynamics and pathogenesis of TB. Their Web site contains research interests, research summaries, and free software that may be used for the analysis of TB DNA fingerprints and DNA microarray data. The Atlanta Tuberculosis Prevention Coalition promotes the collaboration and coordination of groups involved in the management and care of TB patients in the state of Georgia. They also promote the development of new approaches for the management of patients and high-risk population as well as strategies for education of patients and health care workers. The Sequella Global Tuberculosis Foundation is interested in applied research to identify and develop products to control TB. One of their main topics is the identification, development, and field testing of anti-TB vaccines. The NIAID Tuberculosis Antimicrobial Acquisition and Coordinating Facility is a program for the acquisition and screening of TB drugs. It was established to provide free screen compounds and to encourage development of anti-TB drugs. The Tuberculosis Research Center, Chennai (India), has performed several clinical trials to evaluate chemotherapy and vaccines. Action TB is a multinational initiative funded and coordinated by Glaxo Wellcome Group Research, together with scientists from United Kingdom, South Africa, Canada, and United States. Their main objective is to develop new anti-TB drugs.

     Where can I find resources for research, teaching, and training?     Table 7 lists resources for teaching and research. A very useful Web site is GrantsNet, supported by the Howard Hughes Medical Institute and the American Association for the Advancement of Science. This site contains a tool that allows investigators to search for grants by using different criteria such as the type of training (e.g., undergraduate, master, and postdoctoral fellow), the area of interest (e.g., biology, genetics, and epidemiology), or the application deadline. In United States, the NIH is the largest source of biomedical research funding. They have a specific Web page for TB that lists their research interests and available resources. The NIH also has a Web page with both general and TB-specific guides to grants and fellowship programs. The Wellcome Trust Foundation offers grants for research in the history of medicine, biomedical ethics, public understanding of science, and other biomedical topics. This foundation is currently supporting research on the pathogenesis and immunology of TB. Among the Internet TB training materials, we included CDC self-study modules designed for health care workers working in the management of TB patients. The Francis J. Curry National Tuberculosis Center is one of the model TB centers funded by CDC to provide training about TB control. The National Tuberculosis Center of New Jersey Medical School is another academic institution that has a Web page with a calendar of training courses and conferences about TB. Similar types of information can be found on the IUATLD and CDC Web pages. Tuberculosis.Net from Montefore Medical Center also has a Web page containing teaching material about TB.

     Where can I find information about regulatory action?     Table 8 lists sites about regulatory action. The CDC has a Web page providing contact information for each of the 50 state TB control offices that also lists the control programs, regulatory actions, epidemiology, and surveillance data. An important issue in TB control is the protection of the health care workers against this infection. Information relevant to this topic is provided by the TB regulatory protection program in health care facilities. A separate site has guidelines for settings with limited health care resources. Finally, we include 2 Web pages from the WHO related to the current strategy for the global control of TB. The first one is the TB handbook, which contains the general principles and practical approaches for TB control. The second provides details about Direct Observed Therapy short courses, the current global public health strategy for controlling TB.

COMMENTS

     Any attempt to identify the "best" TB-related Web sites is doomed to fail. The number of sites is immense, their scope is vast, and their content is perpetually changing. Furthermore, the needs of Internet users are diverse, and sites that meet the needs of one user may be irrelevant to the next. However, these limitations should not deter the busy clinician, patient, or investigator from making use of the Internet as a primary source of information. The sites identified here will serve as a starting point for answering a wide variety of questions. But using the Internet simply to answer a specific question overlooks its true utility as an avenue that connects the worlds of TB management and research. We encourage the reader to stroll leisurely down this avenue and revel in the unanticipated discoveries.