ls -la /tmp/workspace/ 2>/dev/null || mkdir -p /tmp/workspace && echo "workspace ready"

mkdir -p /tmp/workspace/psm-tb-notes && cat > /tmp/workspace/psm-tb-notes/generate_pdf.py << 'PYEOF' from reportlab.lib.pagesizes import A4 from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.units import cm, mm from reportlab.lib import colors from reportlab.platypus import ( SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable, PageBreak, KeepTogether ) from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY from reportlab.pdfbase import pdfmetrics from reportlab.pdfbase.ttfonts import TTFont import os OUTPUT = "/tmp/workspace/psm-tb-notes/PSM_TB_Questions_11_to_20.pdf" doc = SimpleDocTemplate( OUTPUT, pagesize=A4, rightMargin=2*cm, leftMargin=2*cm, topMargin=2*cm, bottomMargin=2*cm, title="PSM Tuberculosis Notes Q11-Q20", author="Park's PSM - Homeopathic University Exam Notes" ) styles = getSampleStyleSheet() # Custom styles TEAL = colors.HexColor("#0D6E8A") DARK = colors.HexColor("#1a1a2e") LIGHT_TEAL = colors.HexColor("#E8F4F8") LIGHT_YELLOW = colors.HexColor("#FFFDE7") LIGHT_GREEN = colors.HexColor("#E8F5E9") ACCENT = colors.HexColor("#B71C1C") TABLE_HEADER = colors.HexColor("#0D6E8A") TABLE_STRIPE = colors.HexColor("#F0F8FC") cover_title = ParagraphStyle('CoverTitle', parent=styles['Title'], fontSize=24, textColor=TEAL, alignment=TA_CENTER, spaceAfter=6, leading=30, fontName='Helvetica-Bold') cover_sub = ParagraphStyle('CoverSub', parent=styles['Normal'], fontSize=13, textColor=DARK, alignment=TA_CENTER, spaceAfter=4, leading=18, fontName='Helvetica') cover_info = ParagraphStyle('CoverInfo', parent=styles['Normal'], fontSize=10, textColor=colors.grey, alignment=TA_CENTER, spaceAfter=3, leading=14, fontName='Helvetica-Oblique') h1 = ParagraphStyle('H1', parent=styles['Heading1'], fontSize=16, textColor=TEAL, spaceBefore=14, spaceAfter=6, fontName='Helvetica-Bold', borderPad=4, borderColor=TEAL, borderWidth=0, leading=20) h2 = ParagraphStyle('H2', parent=styles['Heading2'], fontSize=13, textColor=DARK, spaceBefore=10, spaceAfter=4, fontName='Helvetica-Bold', leading=16) h3 = ParagraphStyle('H3', parent=styles['Heading3'], fontSize=11, textColor=TEAL, spaceBefore=8, spaceAfter=3, fontName='Helvetica-Bold', leading=14) body = ParagraphStyle('Body', parent=styles['Normal'], fontSize=9.5, leading=14, spaceAfter=4, fontName='Helvetica', alignment=TA_JUSTIFY) bullet = ParagraphStyle('Bullet', parent=styles['Normal'], fontSize=9.5, leading=13, spaceAfter=2, fontName='Helvetica', leftIndent=14, bulletIndent=4) note_style = ParagraphStyle('Note', parent=styles['Normal'], fontSize=9, leading=13, spaceAfter=4, fontName='Helvetica-Oblique', textColor=ACCENT, borderPad=5, leftIndent=10) mnemonic_style = ParagraphStyle('Mnemonic', parent=styles['Normal'], fontSize=9.5, leading=14, spaceAfter=4, fontName='Helvetica-BoldOblique', textColor=colors.HexColor("#4A148C"), leftIndent=10) def qhead(num, title): return [ Spacer(1, 8), HRFlowable(width="100%", thickness=2, color=TEAL), Spacer(1, 4), Paragraph(f"Q.{num}. {title}", ParagraphStyle('QHead', parent=styles['Heading1'], fontSize=14, textColor=colors.white, spaceBefore=0, spaceAfter=0, fontName='Helvetica-Bold', backColor=TEAL, borderPad=6, leading=20)), Spacer(1, 6), ] def section(title): return [Paragraph(title, h2)] def subsection(title): return [Paragraph(title, h3)] def para(text): return [Paragraph(text, body)] def bul(items): return [Paragraph(f"&#8226; {i}", bullet) for i in items] def note(text): return [Paragraph(f"&#9432; {text}", note_style)] def make_table(headers, rows, col_widths=None, stripe=True): data = [headers] + rows if col_widths is None: n = len(headers) col_widths = [16*cm/n]*n ts = TableStyle([ ('BACKGROUND', (0,0), (-1,0), TABLE_HEADER), ('TEXTCOLOR', (0,0), (-1,0), colors.white), ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'), ('FONTSIZE', (0,0), (-1,0), 9), ('ALIGN', (0,0), (-1,0), 'CENTER'), ('VALIGN', (0,0), (-1,-1), 'MIDDLE'), ('FONTNAME', (0,1), (-1,-1), 'Helvetica'), ('FONTSIZE', (0,1), (-1,-1), 8.5), ('ROWBACKGROUNDS', (0,1), (-1,-1), [TABLE_STRIPE, colors.white] if stripe else [colors.white]), ('GRID', (0,0), (-1,-1), 0.4, colors.HexColor("#B0C4D8")), ('TOPPADDING', (0,0), (-1,-1), 3), ('BOTTOMPADDING', (0,0), (-1,-1), 3), ('LEFTPADDING', (0,0), (-1,-1), 5), ('RIGHTPADDING', (0,0), (-1,-1), 5), ('WORDWRAP', (0,0), (-1,-1), True), ]) t = Table([[Paragraph(str(c), ParagraphStyle('TC', fontName='Helvetica-Bold' if r==0 else 'Helvetica', fontSize=9 if r==0 else 8.5, textColor=colors.white if r==0 else DARK, leading=12, alignment=TA_CENTER if r==0 else TA_LEFT)) for c in row] for r, row in enumerate(data)], colWidths=col_widths) t.setStyle(ts) return [t, Spacer(1, 6)] story = [] # ── COVER PAGE ── story.append(Spacer(1, 3*cm)) story.append(Paragraph("PSM Study Notes", cover_sub)) story.append(Spacer(1, 0.4*cm)) story.append(Paragraph("TUBERCULOSIS", cover_title)) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph("Questions 11 – 20", cover_title)) story.append(Spacer(1, 0.8*cm)) story.append(HRFlowable(width="70%", thickness=2, color=TEAL)) story.append(Spacer(1, 0.6*cm)) story.append(Paragraph("For Homeopathic University Examinations", cover_sub)) story.append(Spacer(1, 0.4*cm)) story.append(Paragraph("Based on Park's Textbook of Preventive and Social Medicine", cover_info)) story.append(Paragraph("NTEP / RNTCP Technical &amp; Operational Guidelines (2019)", cover_info)) story.append(Paragraph("WHO Global TB Report 2020", cover_info)) story.append(Spacer(1, 2*cm)) story.append(HRFlowable(width="40%", thickness=1, color=colors.grey)) story.append(Spacer(1, 0.4*cm)) story.append(Paragraph("Section C: Communicable Diseases – Tuberculosis", cover_info)) story.append(PageBreak()) # ─────────────────────────────────────────────────────────────────────── # Q11 – RISK FACTORS FOR TB # ─────────────────────────────────────────────────────────────────────── story += qhead(11, "Enumerate the Risk Factors for Tuberculosis") story += para("The risk of developing TB depends on: (1) probability of being infected, and (2) probability of progressing from infection to active disease.") story += section("A. Risk Factors for Getting Infected (Exposure Risk)") story += bul([ "Close contact with an infectious (smear-positive) TB case – most important", "Overcrowding – promotes droplet nuclei spread in enclosed spaces", "Poor ventilation – allows accumulation of droplet nuclei", "Urban slum dwelling – overcrowding + poor sanitation", "Health care settings – HCWs at high occupational risk", "Prisons, shelters, refugee camps – congregate settings", "High-prevalence communities and endemic areas", ]) story += section("B. Risk Factors for Progression (Infection → Active Disease)") story += subsection("(i) Biological Host Factors") story += make_table( ["Risk Factor", "Relative Risk (RR)"], [ ["HIV infection", "50–170x (single greatest risk factor)"], ["Silicosis", "~30x"], ["Renal failure / Dialysis", "10–25x"], ["Anti-TNF therapy (biologics for RA/IBD)", "5–25x"], ["Immunosuppressive drugs (steroids)", "5–7x"], ["Gastrectomy / Jejunoileal bypass", "~5x"], ["Diabetes mellitus", "2–3x"], ["Malnutrition", "2–3x"], ["Alcoholism", "3–4x"], ["Smoking", "2–3x"], ["Malignancies (lymphoma, leukemia)", "Increased"], ], col_widths=[11*cm, 5*cm] ) story += subsection("(ii) Age and Sex") story += bul([ "Males > Females (2:1 ratio) due to greater exposure and lifestyle factors", "Peak age: 15–45 years (economically productive group)", "High risk at extremes of age (infants, elderly)", "Children under 5 years develop severe disseminated TB", ]) story += subsection("(iii) Genetic Factors") story += bul([ "HLA-DR2 and HLA-DQB1 alleles associated with susceptibility", "Certain ethnic groups (Inuit, Aboriginal populations) have higher susceptibility", ]) story += subsection("(iv) Previous Treatment / Drug Resistance") story += bul([ "Inadequately treated TB → drug-resistant strains → higher disease burden", "Previously treated cases have higher risk of MDR-TB", ]) story += section("C. Social & Environmental Risk Factors") story += make_table( ["Factor", "Mechanism"], [ ["Poverty", "Overcrowding, malnutrition, poor access to healthcare"], ["Illiteracy", "Delayed diagnosis, poor treatment adherence"], ["Migration", "Spread from high to low incidence areas"], ["Season", "Winter overcrowding increases transmission"], ["Occupation", "Miners (silica), HCWs, teachers"], ], col_widths=[6*cm, 10*cm] ) story += section("D. Bacteriological Risk Factors") story += bul([ "Smear-positive pulmonary TB is most infectious", "High bacillary load = greater infectivity", "Drug-resistant strains (MDR-TB, XDR-TB) harder to treat", "Virulent strains (e.g. Beijing genotype) cause more severe disease", ]) story += [Paragraph("Mnemonic: HIDE MY SCARS", mnemonic_style)] story += bul(["H-HIV | I-Immunosuppression | D-Diabetes | E-Elderly", "M-Malnutrition | Y-Young children | S-Silicosis", "C-Close contact | A-Alcoholism | R-Renal failure | S-Social factors"]) story.append(PageBreak()) # ─────────────────────────────────────────────────────────────────────── # Q12 – EPIDEMIOLOGICAL INDICES # ─────────────────────────────────────────────────────────────────────── story += qhead(12, "Discuss the Epidemiological Indices of Tuberculosis") story += para("Epidemiological indices (parameters) are standardized measurements used to: quantify the TB burden in a community; plan and evaluate control programmes; and make international comparisons.") story += section("1. Incidence") story += para("Number of NEW and RECURRENT (relapse) episodes of TB (all forms) per year per 100,000 population. Best indicator of current transmission dynamics. India (2019): ~199/100,000.") story += section("2. Prevalence") story += para("Number of ALL TB cases (all forms) existing at a given point in time per 100,000 population. Best practical index to estimate case load in the community. Age-specific prevalence of smear-positive cases is the most relevant indicator. India (2019): ~271/100,000.") story += section("3. Mortality") story += para("Number of deaths caused by TB in HIV-negative people per 100,000 population per year. TB deaths in HIV-positive people are classified separately under HIV deaths (ICD-10). India (2019): ~36/100,000.") story += section("4. Case Fatality Rate") story += para("Risk of DEATH from TB among people with ACTIVE TB disease. Formula: (TB deaths ÷ TB cases) × 100. High case fatality = poor access to treatment.") story += section("5. Case Notification Rate (CNR)") story += para("Number of new and recurrent TB episodes notified to WHO for a given year, per 100,000 population. Reflects capacity of health services to detect and report TB. CNR < Incidence = under-detection.") story += section("6. Case Detection Rate (CDR)") story += para("(Number of notified new + relapse cases in a year ÷ Estimated incidence of such cases) × 100. WHO Target: ≥70%. CDR <70% suggests significant under-diagnosis.") story += section("7. Prevalence of Drug-Resistant Cases") story += para("Prevalence of patients excreting tubercle bacilli resistant to anti-TB drugs. Directly related to quality of chemotherapy programme. India (2019): 3.4% new cases, 11.5% previously treated cases had MDR/RR-TB.") story += section("8. Annual Risk of TB Infection (ARTI)") story += para("The probability of a person being newly infected with TB in a year. Rule of thumb: ARTI of 1% ≈ 50 new smear-positive cases per 100,000 per year. Declining ARTI = declining transmission. India ARTI: ~1.5% in high-burden areas.") story += make_table( ["Index", "What it Measures", "Unit"], [ ["Incidence", "New + relapse cases/year", "Per 100,000/year"], ["Prevalence", "All existing cases at a point", "Per 100,000"], ["Mortality", "Deaths from TB/year", "Per 100,000/year"], ["Case Fatality Rate", "Deaths among active TB cases", "Percentage (%)"], ["Case Notification Rate", "Cases reported to authorities", "Per 100,000/year"], ["Case Detection Rate", "Proportion of cases detected", "Percentage (%)"], ["Drug Resistance Prevalence", "Drug-resistant TB burden", "% of cases"], ["ARTI", "Annual transmission risk", "% per year"], ], col_widths=[5*cm, 7*cm, 4*cm] ) story.append(PageBreak()) # ─────────────────────────────────────────────────────────────────────── # Q13 – TREATMENT REGIMENS # ─────────────────────────────────────────────────────────────────────── story += qhead(13, "Enumerate Treatment Regimens of Newly Diagnosed, Previously Treated, and Drug-Resistant TB") story += section("First-Line Anti-TB Drug Abbreviations") story += make_table( ["Drug", "Abbreviation", "Type"], [ ["Isoniazid", "H", "Bactericidal"], ["Rifampicin", "R", "Bactericidal"], ["Pyrazinamide", "Z", "Bactericidal (sterilizing)"], ["Ethambutol", "E", "Bacteriostatic"], ["Streptomycin", "S", "Bactericidal (injectable)"], ], col_widths=[7*cm, 4*cm, 5*cm] ) story += section("A. Newly Diagnosed (Drug-Sensitive) TB — Regimen: 2HRZE / 4HR") story += make_table( ["Phase", "Duration", "Drugs", "Frequency"], [ ["Intensive Phase", "2 months", "H + R + Z + E (4 drugs)", "Daily"], ["Continuation Phase", "4 months", "H + R (2 drugs)", "Daily"], ], col_widths=[4*cm, 3.5*cm, 5*cm, 3.5*cm] ) story += para("Total duration = 6 months. All drugs given as Fixed Dose Combinations (FDCs). TB Meningitis/Bone TB: Continuation phase extended to 7 months (total 9 months). Streptomycin is contraindicated in pregnancy.") story += section("Weight-Based Dosing (Adult)") story += make_table( ["Weight", "Intensive Phase (HRZE) tablets", "Continuation Phase (HR) tablets"], [ ["25–39 kg", "2 tablets", "2 tablets"], ["40–54 kg", "3 tablets", "3 tablets"], ["55–69 kg", "4 tablets", "4 tablets"], ["≥70 kg", "5 tablets", "5 tablets"], ], col_widths=[5*cm, 5.5*cm, 5.5*cm] ) story += section("B. Previously Treated TB") story += para("Under NTEP (2019): Regimen 2HRZE/4HR (same as new cases). Old Category II regimen (with Streptomycin) has been DISCONTINUED. All previously treated cases must undergo Drug Susceptibility Testing (DST) first.") story += bul([ "If DST shows drug sensitivity → standard 2HRZE/4HR", "If DST shows resistance → treat as MDR-TB", "Types: Relapse, Treatment after loss to follow-up (TALF), Treatment failure", ]) story += section("C. Drug-Resistant TB") story += subsection("1. MDR-TB — Resistant to at least INH and Rifampicin") story += para("(a) Shorter MDR-TB Regimen (WHO 2022): BPaL — Bedaquiline + Pretomanid + Linezolid for 9 months total.") story += para("(b) Longer Regimen: 6–8 month intensive phase + 12–18 month continuation phase with second-line drugs.") story += make_table( ["WHO Group", "Drugs"], [ ["Group A (Priority)", "Levofloxacin/Moxifloxacin, Bedaquiline, Linezolid"], ["Group B", "Clofazimine, Cycloserine/Terizidone"], ["Group C", "Ethambutol, Delamanid, Pyrazinamide, Imipenem-cilastatin, Amikacin, Ethionamide, PAS"], ], col_widths=[5*cm, 11*cm] ) story += subsection("2. XDR-TB") story += para("Original Definition (2006): MDR-TB + resistance to any fluoroquinolone + at least one injectable second-line drug.") story += para("Revised Definition (2021): MDR/RR-TB + resistance to any fluoroquinolone + resistance to Bedaquiline or Linezolid.") story += para("Treatment: BPaL regimen (6–9 months); individualized regimens 18–24 months.") story.append(PageBreak()) # ─────────────────────────────────────────────────────────────────────── # Q14 – TREATMENT OUTCOMES, MDR & XDR # ─────────────────────────────────────────────────────────────────────── story += qhead(14, "Discuss Treatment Outcome Definitions, MDR and XDR") story += section("A. Treatment Outcome Definitions — Drug-Sensitive TB") story += make_table( ["Outcome", "Definition"], [ ["Cured", "Sputum smear/culture negative in last month AND at least one previous occasion"], ["Treatment Completed", "Completed treatment; no failure; but no record of smear/culture in last month"], ["Treatment Failed", "Sputum smear/culture POSITIVE at month 5 or later during treatment"], ["Died", "Died for any reason BEFORE starting or DURING treatment"], ["Lost to Follow-Up", "Treatment interrupted for ≥2 consecutive months"], ["Not Evaluated", "No treatment outcome assigned; includes transferred-out cases"], ["Treatment Success", "CURED + TREATMENT COMPLETED (combined indicator). WHO target: ≥85%)"], ], col_widths=[5*cm, 11*cm] ) story += section("B. Treatment Outcomes — MDR/RR/XDR-TB Patients") story += make_table( ["Outcome", "Definition"], [ ["Cured", "Completed treatment AND ≥3 consecutive negative cultures ≥30 days apart in final 12 months"], ["Treatment Completed", "Completed; does not meet criteria for cure (only 1–2 negative cultures)"], ["Treatment Failed", "Terminated or permanent regimen change ≥2 drugs due to lack of conversion/reversion/resistance/ADR"], ["Died", "Died for any reason during MDR-TB treatment"], ["Lost to Follow-Up", "Interrupted for ≥2 consecutive months"], ], col_widths=[5*cm, 11*cm] ) story += section("C. MDR-TB (Multi-Drug Resistant Tuberculosis)") story += para("Definition: TB caused by M. tuberculosis resistant to at least ISONIAZID (H) AND RIFAMPICIN (R) simultaneously, regardless of resistance to other drugs.") story += subsection("Causes of MDR-TB") story += bul([ "Primary MDR-TB: Infected with already resistant strain", "Acquired (Secondary) MDR-TB: Monotherapy, irregular treatment, subtherapeutic doses, poor quality drugs, treatment interruptions", ]) story += subsection("Diagnosis of MDR-TB") story += bul([ "CBNAAT (Xpert MTB/RIF): Detects TB DNA + Rifampicin resistance in ~2 hours — first-line test", "Line Probe Assay (LPA): Detects resistance to INH, RIF, FQs, injectable drugs", "Liquid culture (MGIT) + DST: Gold standard (takes 2–6 weeks)", ]) story += section("D. XDR-TB (Extensively Drug-Resistant TB)") story += para("Original (2006): MDR-TB + fluoroquinolone resistance + ≥1 injectable second-line drug resistance.") story += para("Revised (2021): MDR/RR-TB + fluoroquinolone resistance + Bedaquiline or Linezolid resistance.") story += note("Very limited treatment options; success rates <50%; major threat to global TB elimination.") story.append(PageBreak()) # ─────────────────────────────────────────────────────────────────────── # Q15 – HOMEOPATHIC PROPHYLAXIS & MANAGEMENT OF TB # ─────────────────────────────────────────────────────────────────────── story += qhead(15, "Homeopathic Prophylaxis and Management of Tuberculosis at the Community Level") story += section("Homeopathic Understanding of TB") story += bul([ "Miasm: Tubercular (Pseudo-psora) — intermediate between Psora and Sycosis", "Diathesis: Scrofulous/tubercular constitution", "Susceptibility: Lean, tall, fair, narrow chest; sensitive, emotional temperament", ]) story += section("A. Homeopathic Prophylaxis") story += subsection("Nosode Prophylaxis") story += make_table( ["Nosode", "Source", "Use"], [ ["Tuberculinum bovinum (Kent)", "Bovine TB cultures", "Prophylaxis, recurrent respiratory infections"], ["Bacillinum (Burnett)", "Macerated TB lung tissue", "Ring prophylaxis; contacts of TB patients"], ["Tuberculinum residuum", "TB residue", "Constitutional work"], ], col_widths=[5.5*cm, 5.5*cm, 5*cm] ) story += para("Dose for prophylaxis: 200C or 1M potency, single dose every 4–6 weeks.") story += section("B. Key Remedies in TB Management") story += make_table( ["Remedy", "Key Indications"], [ ["Phosphorus", "Pulmonary TB; tall, lean; rust-colored sputum; craving cold water; worse cold air; profuse sweating; hemorrhage"], ["Arsenicum iodatum", "Profuse thick irritating discharge; emaciation despite eating; night sweats"], ["Calcarea carbonica", "Scrofulous child; fat, fair, flabby; cold damp sweats; swollen glands; craving eggs"], ["Stannum metallicum", "Exhaustive cough; large quantities of greenish mucus; extreme weakness"], ["Drosera rotundifolia", "Spasmodic suffocating cough; holds chest; laryngeal TB"], ["Bacillinum", "Family history of TB; recurrent respiratory infections; chronic cough"], ["Silicea", "Scrofulous constitution; suppurative tendencies; night sweats; slow healer"], ["Lycopodium", "Right-sided lung; 4–8 PM aggravation; liver involvement"], ["Kali carbonicum", "Lower right lung; stitching pains; 3 AM aggravation"], ], col_widths=[5*cm, 11*cm] ) story += section("C. Community-Level Implementation") story += bul([ "Survey community to identify TB prevalence", "Screen contacts of known TB cases", "Identify susceptible individuals (immunocompromised, malnourished, children)", "Administer prophylactic nosodes (Tuberculinum/Bacillinum 200C/1M) to close contacts", "Constitutional treatment for high-risk individuals", "Nutritional counseling to improve host resistance", "Hygiene education: ventilation, covering cough, no spitting", "Coordinate with NTEP — ensure ATT for bacteriologically confirmed cases", ]) story += note("IMPORTANT: In active bacteriologically confirmed TB, NTEP/DOTS treatment is MANDATORY. Homeopathy plays a complementary/supportive role and must NOT replace anti-TB chemotherapy.") story.append(PageBreak()) # ─────────────────────────────────────────────────────────────────────── # Q16 – NTEP # ─────────────────────────────────────────────────────────────────────── story += qhead(16, "Discuss the National Tuberculosis Elimination Programme (NTEP)") story += section("Background") story += bul([ "RNTCP launched in 1997; fully operational across India by 2006", "Renamed NTEP in 2020 — reflects India's goal of eliminating TB by 2025", "Elimination target: <1 case per million population per year", ]) story += section("Vision: TB-Free India — Reaching the last patient") story += section("Four Pillars of NSP 2017–2025: DETECT – TREAT – PREVENT – BUILD") story += make_table( ["Pillar", "Objective"], [ ["DETECT", "Early case finding; reach all TB patients including private sector"], ["TREAT", "Universal access to quality treatment; prevent drug resistance"], ["PREVENT", "Scale up TB Preventive Therapy; infection control"], ["BUILD", "Strengthen health systems; enabling environment"], ], col_widths=[4*cm, 12*cm] ) story += section("Key Features of NTEP") story += bul([ "Free Diagnosis and Treatment: All TB diagnosis & treatment completely free", "Universal Drug Susceptibility Testing (UDST): ALL patients tested before starting treatment", "CBNAAT (Xpert MTB/RIF) as primary diagnostic tool for all presumptive TB", "Daily Fixed-Dose Combination (FDC) Regimen — replaced old thrice-weekly intermittent regimen", "NIKSHAY Portal: IT-based real-time TB notification and monitoring system", "NIKSHAY Poshan Yojana: Monthly nutritional support of ₹500/month to all TB patients", "Active Case Finding (ACF): Door-to-door surveys in high-risk areas", "TB Preventive Therapy (TPT): INH for HIV+, child contacts <5 yrs, immunocompromised", "Mandatory Private Sector Notification under Epidemic Diseases Act", ]) story += section("NTEP Structure") story += make_table( ["Level", "Unit", "Functions"], [ ["National", "Central TB Division (CTD), New Delhi", "Policy, training, supply chain"], ["State", "State TB Cell", "Coordination, monitoring"], ["District", "District TB Centre (DTC)", "Programme management"], ["Sub-district", "TB Unit (TU)", "Case-finding, referral"], ["Peripheral", "Designated Microscopy Centre (DMC)", "Sputum microscopy, diagnosis"], ["Community", "ASHA, ANM, DOT provider", "DOTS, patient follow-up"], ], col_widths=[3.5*cm, 6*cm, 6.5*cm] ) story += section("NSP 2017–2025 Targets") story += make_table( ["Indicator", "2020 Target", "2023 Target", "2025 Target"], [ ["Case notification rate", "175/100,000", "225/100,000", "290/100,000"], ["Treatment success rate", "88%", "90%", "90%"], ["TB mortality reduction (vs 2015)", "75%", "90%", "—"], ], col_widths=[7*cm, 3*cm, 3*cm, 3*cm] ) story.append(PageBreak()) # ─────────────────────────────────────────────────────────────────────── # Q17 – DOTS # ─────────────────────────────────────────────────────────────────────── story += qhead(17, "Describe Directly Observed Treatment (DOTS)") story += section("Full Form: Directly Observed Treatment, Short Course") story += para("DOTS is a STRATEGY to ensure cure by providing the most effective medicines and confirming that they are taken. It is the ONLY strategy documented to be effective worldwide on a programme basis. (Park's PSM)") story += section("Five Core Components of DOTS") story += make_table( ["Component", "Description"], [ ["1. Political commitment", "Sustained government funding and priority for TB control"], ["2. Quality-assured bacteriology", "Sputum microscopy, culture, CBNAAT for reliable diagnosis"], ["3. Standardized supervised treatment", "Patient swallows drugs in front of a trained observer"], ["4. Uninterrupted drug supply", "Regular supply of quality-assured anti-TB drugs in patient-wise boxes"], ["5. Recording and reporting", "Standardized documentation; systematic evaluation of treatment outcomes"], ], col_widths=[6*cm, 10*cm] ) story += section("How DOTS Works") story += subsection("Intensive Phase (First 2 months):") story += bul([ "DOT provider watches patient swallow EVERY dose", "Ensures 4 drugs (HRZE) are taken correctly", "Patient attends DOTS centre or DOT provider visits patient's home", ]) story += subsection("Continuation Phase (Next 4 months):") story += bul([ "Patient given medicine for 1 WEEK at a time in a multiblister combipack", "First dose of each week swallowed in front of DOT provider", "Empty combipack returned when collecting next week's supply (compliance check)", "Drugs provided in patient-wise boxes with sufficient shelf-life", ]) story += section("DOT Provider (Anyone trained and accountable)") story += bul([ "ASHA (Accredited Social Health Activist) — most commonly used in rural India", "Health worker at the DOTS centre", "Pharmacist or community volunteer", "Family member — less preferred; only if trained and accountable", "Private practitioner (under Public-Private Mix)", ]) story += section("Advantages of DOTS") story += bul([ "Prevents development of drug resistance (ensures complete and regular treatment)", "Ensures treatment adherence — reduces default/loss to follow-up", "Allows early detection of treatment failure", "Cost-effective — prevents expensive MDR-TB development", "Cure rates >85% in programme settings", "Patients treated at HOME (domiciliary treatment) — avoids hospitalization", ]) story += section("Limitations of DOTS") story += bul([ "Requires daily travel to DOTS centre by patient", "Stigma — attending DOTS centre reveals TB status", "Dependence on DOT provider availability and accountability", "Difficult in mobile/migrant populations", "Does not address social determinants of TB", ]) story += section("DOTS Plus") story += para("Extension of DOTS principles to manage MDR-TB patients with second-line drugs under direct observation at specialized DR-TB centres.") story.append(PageBreak()) # ─────────────────────────────────────────────────────────────────────── # Q18 – RNTCP # ─────────────────────────────────────────────────────────────────────── story += qhead(18, "Discuss the Revised National Tuberculosis Control Programme (RNTCP)") story += section("Historical Background") story += make_table( ["Year", "Milestone"], [ ["1962", "National TB Programme (NTP) launched — district-based, focused on chemotherapy"], ["1992", "Joint WHO-World Bank review revealed NTP failures (cure rate only ~30%)"], ["1993", "RNTCP pilot launched in 2 districts"], ["1997", "RNTCP Phase I launched nationally"], ["2006", "Nationwide coverage achieved across India"], ["2012", "DOTS-Plus for MDR-TB rolled out nationwide"], ["2017", "NSP 2017–2025 launched; Universal DST introduced"], ["2020", "RNTCP renamed NTEP"], ], col_widths=[2.5*cm, 13.5*cm] ) story += section("Why NTP Failed (Reasons for Revision)") story += bul([ "Low cure rates (~30% vs >85% under RNTCP)", "No directly observed treatment — patients self-administered drugs irregularly", "Intermittent drug supply — frequent stock-outs", "Inadequate diagnosis — only clinical, no sputum microscopy emphasis", "Poor recording and reporting systems", "Over-reliance on hospitalization (costly, insufficient beds)", "No standardized treatment regimens", ]) story += section("Key Features of RNTCP") story += subsection("1. Diagnosis") story += bul([ "Sputum smear microscopy as primary diagnostic tool (free)", "Designated Microscopy Centres (DMCs) at every PHC/CHC level", "2 sputum samples (spot + early morning) examined", "Graded reporting: Scanty, 1+, 2+, 3+", ]) story += subsection("2. Standardized Treatment Regimens (Original RNTCP — Thrice Weekly Intermittent)") story += para("Category I (New Smear Positive / Seriously Ill Smear Negative): 2H₃R₃Z₃E₃ / 4H₃R₃") story += para("Category II (Previously Treated): 2H₃R₃Z₃E₃S₃ / 1H₃R₃Z₃E₃ / 5H₃R₃E₃") story += note("Note: The thrice-weekly intermittent regimen has been REPLACED by daily FDC regimen under NTEP (2019).") story += subsection("3. Recording and Reporting") story += make_table( ["Register", "Purpose"], [ ["TB Register", "All TB cases registered at TU level"], ["Laboratory Register", "All sputum examinations recorded"], ["Referral/Transfer Form", "Movement of patients between centres"], ["Quarterly Reports", "Case notifications, treatment outcomes"], ["NIKSHAY (IT portal)", "Real-time online notification and monitoring"], ], col_widths=[6*cm, 10*cm] ) story += section("RNTCP Programme Indicators") story += make_table( ["Indicator", "RNTCP Target"], [ ["Case detection rate", "≥70%"], ["Treatment success rate", "≥85% (new cases)"], ["Sputum conversion rate at 2 months", "≥80%"], ["Default rate", "<10%"], ["Failure rate", "<5%"], ], col_widths=[10*cm, 6*cm] ) story.append(PageBreak()) # ─────────────────────────────────────────────────────────────────────── # Q19 – DIAGNOSIS UNDER RNTCP/NTEP # ─────────────────────────────────────────────────────────────────────── story += qhead(19, "Discuss the Diagnosis of Tuberculosis Under RNTCP/NTEP") story += section("Step 1: Identify Presumptive TB") story += para("A person with COUGH ≥2 weeks OR any other symptoms/signs suggestive of TB (fever, weight loss, night sweats, hemoptysis) is defined as Presumptive TB (previously called 'TB suspect').") story += section("Step 2: Diagnostic Algorithm (NTEP 2019)") story += subsection("SMEAR POSITIVE → CBNAAT") story += bul([ "Not at risk of DR → Microscopically confirmed TB → Start Drug-Sensitive Treatment", "At risk of DR → CBNAAT → RIF-Resistant → DR-TB Referral; RIF-Sensitive → Drug-Sensitive Treatment", ]) story += subsection("BOTH SMEARS NEGATIVE → Chest X-Ray") story += bul([ "X-Ray suggestive → CBNAAT on 2nd sample", "CBNAAT positive (MTB detected, RIF-sensitive) → Drug-Sensitive TB", "CBNAAT negative → Clinical evaluation → Clinically Diagnosed TB if strong suspicion", ]) story += section("Diagnostic Tools in Detail") story += subsection("1. Sputum Smear Microscopy") story += make_table( ["Method", "Features", "Sensitivity", "Specificity"], [ ["ZN Staining", "Standard; bacteria stain red on blue background", "40–60%", ">95%"], ["LEDFM", "Fluorescent dye; bacteria glow under LED/UV light; faster", "55–70%", ">95%"], ], col_widths=[4*cm, 6.5*cm, 2.5*cm, 3*cm] ) story += subsection("Grading of Smear Results") story += make_table( ["Grade", "Bacilli seen per field"], [ ["Scanty", "1–9 bacilli per 100 fields"], ["1+", "10–99 per 100 fields"], ["2+", "1–10 per field in 50 fields"], ["3+", ">10 per field in 20 fields"], ], col_widths=[3*cm, 13*cm] ) story += subsection("2. CBNAAT (Xpert MTB/RIF) — Most Important Test in NTEP") story += bul([ "Simultaneously detects M. tuberculosis DNA AND Rifampicin resistance in ~2 hours", "Sensitivity: 88% (smear+), 68% (smear–)", "First-line test for: HIV+, children, previously treated, smear-negative, EPTB", ]) story += subsection("3. Line Probe Assay (LPA)") story += bul([ "First-line LPA (FL-LPA): Detects resistance to INH and RIF", "Second-line LPA (SL-LPA): Detects fluoroquinolone and injectable drug resistance", "Used for RR-TB cases confirmed by CBNAAT; XDR-TB workup", ]) story += subsection("4. Culture and DST") story += bul([ "Solid media (LJ medium): Gold standard — takes 6–8 weeks", "Liquid culture (MGIT): Takes 2–3 weeks; more sensitive; used for second-line DST", ]) story += subsection("5. Tuberculin Skin Test (Mantoux Test)") story += para("0.1 mL of 2 TU (PPD RT-23) injected intradermally. Read at 48–72 hours. Induration (NOT erythema) measured in mm transversely.") story += make_table( ["Category", "Positive if Induration ≥"], [ ["HIV-positive persons", "5 mm"], ["Close contacts of confirmed TB", "5 mm"], ["General population (BCG given)", "10 mm"], ], col_widths=[10*cm, 6*cm] ) story += subsection("6. New Diagnostic Tests") story += make_table( ["Test", "Use"], [ ["TrueNat MTB", "Rapid molecular test; portable, battery-operated; WHO-endorsed"], ["IGRAs (QuantiFERON-TB Gold, T-SPOT.TB)", "Latent TB diagnosis; blood-based; not affected by BCG vaccination"], ["Urine LAM", "Rapid test for HIV-positive severely ill patients"], ], col_widths=[6.5*cm, 9.5*cm] ) story += section("Classification of TB Cases Under NTEP") story += subsection("Based on Bacteriology:") story += bul([ "Bacteriologically Confirmed TB: Positive by smear, culture, or WHO-approved rapid test", "Clinically Diagnosed TB: Not bacteriologically confirmed; diagnosed by clinician on symptoms + CXR/histology", ]) story += subsection("Based on Anatomical Site:") story += bul([ "Pulmonary TB (PTB): Lung parenchyma or tracheobronchial tree", "Extrapulmonary TB (EPTB): Lymph nodes, pleura, abdomen, joints, meninges, genitourinary", ]) story.append(PageBreak()) # ─────────────────────────────────────────────────────────────────────── # Q20 – TB/HIV RELATIONSHIP # ─────────────────────────────────────────────────────────────────────── story += qhead(20, "Discuss the Relationship of Tuberculosis and HIV/AIDS") story += section("Introduction — The 'Deadly Duo'") story += para("TB and HIV are the 'deadly duo' — each accelerates the other's progression. HIV is the SINGLE MOST POWERFUL risk factor for TB, increasing risk by 50–170 times. TB is the LEADING CAUSE OF DEATH in HIV-positive persons worldwide.") story += section("Epidemiological Link") story += bul([ "Globally (2019): 8.2% of all TB patients were HIV-positive", "India (2019): 6.2% of new TB cases are HIV co-infected", "South-East Asia and Sub-Saharan Africa bear the highest TB/HIV burden", "One infectious TB patient can infect 10–15 persons/year", ]) story += section("How HIV Causes TB") story += para("HIV destroys CD4+ T lymphocytes (helper T cells) essential for macrophage activation, granuloma formation, and cell-mediated immunity (CMI) against intracellular pathogens.") story += make_table( ["CD4 Count", "Clinical Presentation"], [ [">350 cells/µL", "Increased risk of primary TB — typical presentation"], ["200–350 cells/µL", "Classical TB with atypical features"], ["<200 cells/µL", "Severe immunosuppression → Disseminated/Miliary TB, extrapulmonary TB"], ["<50 cells/µL", "TB bacteremia; no granuloma formation possible"], ], col_widths=[5*cm, 11*cm] ) story += section("Clinical Features Comparison") story += make_table( ["Feature", "HIV-Negative TB", "HIV-Positive TB"], [ ["Cough", "Productive, blood-tinged", "May be minimal"], ["Cavitation on CXR", "Common", "Less common (esp. low CD4)"], ["Smear positivity", "~50–60%", "Lower: 30–40% smear-negative"], ["Extrapulmonary TB", "~10–15%", "30–50%"], ["Miliary TB", "Uncommon", "Common"], ["Mantoux test", "Usually positive", "Often NEGATIVE (anergy)"], ["X-ray appearance", "Upper lobe cavitation", "Atypical: lower lobe, diffuse infiltrates"], ], col_widths=[5*cm, 5.5*cm, 5.5*cm] ) story += section("Management of TB/HIV Co-infection (NTEP Guidelines)") story += subsection("Diagnosis:") story += bul([ "ALL TB patients must be offered HIV testing (PICT)", "ALL HIV patients screened for TB at EVERY visit", "CBNAAT preferred (higher sensitivity in HIV-positive)", "Urine LAM test for severely ill HIV patients with CD4 <100", ]) story += subsection("Treatment Sequence:") story += bul([ "START ATT (Anti-TB Treatment) FIRST", "Start ART within 2–8 WEEKS of starting ATT (regardless of CD4 count)", "Exception: TB Meningitis → start ART at 8 weeks (earlier ART increases IRIS risk in CNS TB)", ]) story += subsection("Preferred ART Regimen with TB Treatment:") story += para("Tenofovir (TDF) + Lamivudine (3TC) + Efavirenz (EFV) — Efavirenz preferred over Nevirapine; less interaction with Rifampicin.") story += note("Rifampicin induces CYP450 enzymes → reduces levels of Protease Inhibitors — AVOID PIs with Rifampicin-containing regimens.") story += section("Three I's for TB/HIV (WHO Strategy)") story += make_table( ["'I'", "Full Name", "Action"], [ ["Intensified CF", "Intensified TB Case Finding", "Screen all HIV patients for TB at every visit; screen all TB patients for HIV"], ["IPT", "Isoniazid Preventive Therapy", "Offer INH (300 mg daily × 6 months) to all HIV+ persons without active TB"], ["IC", "Infection Control", "Implement TB infection control in all healthcare settings especially HIV care facilities"], ], col_widths=[2*cm, 5*cm, 9*cm] ) story += section("IRIS — Immune Reconstitution Inflammatory Syndrome") story += para("Definition: Worsening of TB symptoms after initiation of ART in TB/HIV co-infected patients, due to recovering immune response attacking TB antigens.") story += make_table( ["Type", "Description"], [ ["Paradoxical IRIS", "Patient deteriorates after starting ART despite ongoing ATT"], ["Unmasking IRIS", "Previously subclinical TB revealed after ART starts"], ], col_widths=[5*cm, 11*cm] ) story += subsection("Management of IRIS:") story += bul([ "Continue BOTH ATT and ART — do NOT stop either", "NSAIDs for mild cases", "Corticosteroids (Prednisolone) for severe cases", ]) story += section("Summary: Key Points TB/HIV Relationship") story += bul([ "HIV = single most important risk factor for TB (50–170x increased risk)", "TB = leading cause of death in HIV-positive persons", "Atypical presentations common; smear negative, extrapulmonary TB more frequent", "All TB patients: offer HIV testing; all HIV patients: screen for TB", "Start ATT first, then ART within 2–8 weeks", "Use Efavirenz-based ART (compatible with Rifampicin)", "Three I's strategy: Intensified CF + IPT + Infection Control", ]) # ── FOOTER / REFERENCE ── story.append(Spacer(1, 1*cm)) story.append(HRFlowable(width="100%", thickness=1, color=TEAL)) story.append(Spacer(1, 0.3*cm)) story.append(Paragraph( "Reference: Park's Textbook of Preventive and Social Medicine (K. Park) | " "NTEP/RNTCP Technical and Operational Guidelines (2019) | " "WHO Global TB Report (2020)", ParagraphStyle('Ref', parent=styles['Normal'], fontSize=8, textColor=colors.grey, alignment=TA_CENTER, fontName='Helvetica-Oblique', leading=12) )) # ── BUILD ── doc.build(story) print(f"PDF generated: {OUTPUT}") PYEOF echo "Script written"

cd /tmp/workspace/psm-tb-notes && python generate_pdf.py 2>&1

ls -lh /tmp/workspace/psm-tb-notes/PSM_TB_Questions_11_to_20.pdf