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🫁 NTEP - NATIONAL TUBERCULOSIS ELIMINATION PROGRAMME

Park's Textbook of Preventive & Social Medicine, 28th Edition

Comprehensive High-Yield Chapter Summary

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📌 CHAPTER OVERVIEW - QUICK ORIENTATION

RNTCP → NTEP: The Revised National TB Control Programme (RNTCP) was renamed to National Tuberculosis Elimination Programme (NTEP) in 2020. The goal: Eliminate TB from India by 2025 (5 years ahead of the global 2030 SDG target).

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SECTION 1: TUBERCULOSIS - THE DISEASE

⭐ Definition

Tuberculosis is a specific infectious disease caused by Mycobacterium tuberculosis, primarily affecting the lungs (pulmonary TB). It can also affect the intestine, meninges, bones & joints, lymph glands, skin, and other tissues. "Bovine tuberculosis" is caused by M. bovis, communicable to humans.

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SECTION 2: PROBLEM STATEMENT

🔥 2A. WORLD

🔥 2B. INDIA

🔥 HIV - TB nexus: HIV is the most potent risk factor for progression of TB infection to disease. TB is the earliest and most common opportunistic infection in HIV.

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SECTION 3: EPIDEMIOLOGICAL INDICES 🔥

⭐ ARTI formula: ARTI of 1% = ~50 smear-positive cases per 1,00,000 population

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SECTION 4: DEFINITIONS OF TB CASES (Revised 2013) ⭐🔥

A. CASE DEFINITIONS

1. Classification by Bacteriological Status

2. Classification by Site of Disease

⚠ Confused concept: Miliary TB = classified as PTB (because lungs are involved). Tuberculous pleural effusion alone = EPTB. If both PTB and EPTB are present = classified as PTB.

3. Classification by History of Previous TB Treatment

4. Classification by Drug Resistance

⚠ Pre-XDR TB (new WHO 2021 definition): MDR/RR-TB + resistance to any fluoroquinolone. The XDR definition has been updated globally - worth noting for PG exams.

5. Classification by HIV Status

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SECTION 5: TREATMENT OUTCOME DEFINITIONS ⭐🔥

5A. For Drug-Sensitive TB (DS-TB)

🔥 Cohort = A group of TB patients registered for treatment during a specified time period - forms the DENOMINATOR for calculating outcomes.

5B. For RR-TB/MDR-TB/XDR-TB (Second-line treatment)

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SECTION 6: NATURAL HISTORY OF TUBERCULOSIS

6A. Agent Factors ⭐

┌──────────────────────────────────────────────────────────────┐
│  4 POPULATIONS OF TB BACILLI                                  │
│                                                              │
│  1. Large, actively dividing bacilli (EXTRACELLULAR)         │
│     → Killed by INH best                                     │
│                                                              │
│  2. Slow-growing / intermittently active bacilli             │
│     → Killed by Rifampicin                                   │
│                                                              │
│  3. Intracellular bacilli (inside macrophages)               │
│     → Killed by Pyrazinamide (acidic pH)                     │
│                                                              │
│  4. Dormant bacilli ("persisters")                           │
│     → Killed by extended therapy (Rifampicin + INH)          │
└──────────────────────────────────────────────────────────────┘

6B. Host Factors ⭐

6C. Social/Environmental Factors ⭐

• Overcrowding (most important social factor)
• Poor ventilation
• Low socioeconomic status / poverty
• Malnutrition
• Slum dwelling, migrant labourers
• Substance abuse (alcohol, drugs)

6D. Mode of Transmission ⭐

PRIMARY: Airborne (Respiratory droplet nuclei - WELLS DROPLETS)
         ↓
Droplet nuclei (1-5 µm) float in air for hours
         ↓
Inhaled by susceptible host
         ↓
Reach alveoli → Infection

OTHER (Rare):
- Ingestion (M. bovis from unpasteurized milk → intestinal TB)
- Skin inoculation (pathologist/lab worker - rare)
- Transplacental (congenital TB - very rare)

⭐ Infection occurs through inhalation of droplet nuclei (NOT droplets). Droplet nuclei are produced by coughing, sneezing, speaking, singing.

6E. Incubation Period

• Primary infection to tuberculin positivity: 4-12 weeks (usually 6-8 weeks)
• Interval from infection to disease: Months to years (lifelong risk of reactivation)

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SECTION 7: THE CONTROL OF TUBERCULOSIS

7A. Case-Finding ⭐🔥

Three Pillars of Case-Finding:

┌─────────────────────────────────────────┐
│  a. PASSIVE CASE FINDING                │
│  Patient presents with symptoms         │
│  → Health facility investigates         │
│  (Most common method in NTEP)           │
│                                         │
│  b. ACTIVE CASE FINDING (ACF)           │
│  Health system goes to community        │
│  → Screen households, high-risk groups  │
│                                         │
│  c. INTENSIFIED CASE FINDING (ICF)      │
│  Active screening in special settings   │
│  (prisons, mines, slums, TB contacts)   │
└─────────────────────────────────────────┘

Who to Screen (Vulnerable/High-Risk Groups):

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SECTION 8: CASE-FINDING TOOLS / DIAGNOSIS ⭐🔥

8A. Sputum Collection

• Suspected PTB: Submit 2 sputum samples
• Day 1: On-the-spot (spot) sample at the facility
• Day 2: Early morning sample (most bacteria-rich)
• If patient from long distance or risk of default: 2 spot specimens with 1 hour gap

8B. Ziehl-Neelsen (ZN) Staining - AFB ⭐

🔥 AFB = Red/Pink bacilli against Blue background

8C. Slide Reporting (at 1000X) 🔥

⚠ Note the SWITCH in denominator: 1+ and Scanty use "per 100 fields"; 2+ and 3+ use "per single field"

8D. False Positives & Negatives of Sputum Smear

• Carryover contamination in lab
• Non-tuberculous mycobacteria (NTM)
• Nocardia species (weakly acid-fast)

• <10,000 bacilli/mL needed for smear positivity
• Poor sample quality (saliva, not sputum)
• Inadequate decolorization
• Extrapulmonary TB

8E. Fluorescence Microscopy 🔥

• Uses auramine-rhodamine stain
• AFB appear yellow-orange/gold on dark background
• More sensitive than ZN (can examine at lower magnification - 200-400X)
• LED fluorescence microscopy = cheaper, more practical; WHO-endorsed replacement for conventional fluorescent microscopy

8F. Rapid Diagnostic Tools ⭐🔥

🔥 NTEP endorsed diagnostics order:

1. NAAT (Xpert/TrueNat) - initial test
2. FL-LPA (First-Line LPA) if NAAT positive
3. SL-LPA if MDR/RR-TB confirmed
4. Liquid culture + DST for confirmation/extended DST

8G. Radiography

• Chest X-ray: supportive tool (not confirmatory)
• Classic findings: Upper lobe infiltrates, cavitation, nodules
• Used when: symptoms present but smear/NAAT negative; EPTB evaluation
• NOT recommended as primary screening tool for all suspected PTB

8H. Tuberculin Skin Test (TST / Mantoux Test) ⭐

Classification of Positive TST:

⭐ In India (National Programme): ≥10 mm = positive for contact investigation; ≥5 mm = positive in HIV

• HIV/immunosuppression (most important)
• Recent TB infection (<8-10 weeks - "window period")
• Overwhelming TB (miliary/meningitis)
• Malnutrition
• Viral infections (measles, influenza)
• Corticosteroids, immunosuppressants
• Improper technique

• BCG vaccination (up to 15 mm; usually fades over time)
• NTM infection
• Improper reading

🔥 Two-step testing: Used for baseline TST in healthcare workers. If 1st TST negative, repeat in 1-3 weeks. A positive 2nd test = "boosted" reaction (not new infection). Done to avoid falsely attributing a "boosted" reaction to occupational exposure.

8I. TB-IGRA (Interferon Gamma Release Assay) 🔥

⚠ IGRAs cannot distinguish active TB from latent TB infection (LTBI) - same as TST.

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SECTION 9: ANTI-TUBERCULOSIS DRUGS ⭐🔥

9A. First-Line Drugs

🔥 Mnemonic for 1st line drugs: "RIPE" (or "HRZE") H - Isoniazid | R - Rifampicin | Z - Pyrazinamide | E - Ethambutol | S - Streptomycin

⚠ Hepatotoxic drugs: All of H, R, Z (not E or S primarily). If hepatotoxicity occurs, stop all 3. Can use S+E temporarily.

9B. Second-Line Drugs

9C. Bedaquiline (BDQ) 🔥

• Class: Diarylquinoline (NEW class)
• Mechanism: Inhibits mycobacterial ATP synthase
• Type: Bactericidal
• Half-life: Extended - persists up to 5.5 months after stopping
• Key side effect: QTc prolongation (cardiac arrhythmia = contraindication)
• Eligible patients: MDR/RR-TB + FQ or SLI resistance; XDR-TB; Treatment failure

• Age ≥18 years
• Pregnancy = CONTRAINDICATION
• Cardiac arrhythmia = CONTRAINDICATION
• Must use non-hormonal contraception during treatment

9D. Delamanid (DLM) 🔥

• Class: Nitroimidazole (new)
• Mechanism: Inhibits synthesis of methoxymycolic acid and ketomycolic acid (mycobacterial cell wall)
• Type: Bactericidal
• Also inhibits respiration (like metronidazole - nitroimidazole class)
• Duration: 24 weeks

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SECTION 10: TREATMENT REGIMENS ⭐🔥

10A. DOTS (Directly Observed Treatment, Short Course)

⭐ DOTS = The hallmark strategy of RNTCP/NTEP. Five elements:

1. Political commitment
2. Case detection by quality sputum smear microscopy
3. Short-course chemotherapy under direct observation
4. Regular drug supply
5. Standardized recording and reporting

🔥 Current NTEP: Switched from thrice-weekly (3x/week) to DAILY DOSE regimen (introduced via NTEP 2019 guidelines)

10B. Two-Phase Chemotherapy

┌─────────────────────────────────────────────────────────────┐
│  INTENSIVE PHASE (IP)                                       │
│  - Multiple drugs to kill actively dividing bacilli         │
│  - Rapid sputum conversion                                  │
│  - Duration: 2 months                                       │
│                                                             │
│  CONTINUATION PHASE (CP)                                    │
│  - Fewer drugs to kill remaining/dormant bacilli            │
│  - Prevent relapse                                          │
│  - Duration: 4 months (DS-TB)                               │
└─────────────────────────────────────────────────────────────┘

10C. Management of Drug-Sensitive TB (DS-TB) - 2019 Guidelines ⭐🔥

Standard Regimen: 2HRZE + 4HR (Daily)

🔥 If smear positive at end of IP: Do NOT extend IP; do NAAT/Xpert; proceed with CP and investigate for DR-TB.

Pre-treatment Counselling & Evaluation (for DS-TB):

• Baseline weight, height
• Baseline liver function (if risk factors)
• Baseline visual acuity (for Ethambutol)
• HIV testing
• Diabetes screening
• Nikshay registration (mandatory - online patient tracking)

10D. FDCs (Fixed-Dose Combinations) 🔥

FDCs = Multiple drugs in a single tablet; reduces pill burden, improves adherence, prevents selective drug use.

• Prevents monotherapy (inadvertent)
• Improves adherence
• Reduces risk of drug resistance development
• Easier drug supply management

• Intensive phase: HRZE (75mg/150mg/400mg/275mg)
• Continuation phase: HR (75mg/150mg) or HRE (75mg/150mg/275mg)

10E. Adult Daily Dose (Weight-Based) 🔥

10F. Paediatric TB Treatment

• Regimen: 2HRZE + 4HR (same structure as adults)
• Dispersible FDC tablets used for children
• Weight bands: 4-7 kg, 8-11 kg, 12-15 kg, 16-24 kg, 25-29 kg, 30-39 kg
• Pyridoxine: 10 mg/day for ALL children on INH-containing therapy

🔥 Nikshay entry: Mandatory for all TB patients; treatment card must be opened; all events from notification to outcome recorded digitally.

10G. Follow-up of Treatment

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SECTION 11: MANAGEMENT OF DRUG-RESISTANT TB (DR-TB) 🔥

11A. DR-TB Guidelines 2019 (PMDT - Programmatic Management of Drug-resistant TB)

Drug Groups for MDR-TB (WHO revised grouping):

11B. Standard MDR-TB Regimens

┌─────────────────────────────────────────────────────────┐
│  1. SHORTER MDR-TB REGIMEN                              │
│     9-12 months                                         │
│     IP (4-6 mo): Bdq + Mfx/Lfx + Cfz + Z + E + H + Eto│
│     CP (5 mo): Mfx/Lfx + Cfz + Z + E                   │
│                                                         │
│  2. ALL-ORAL LONGER MDR-TB REGIMEN                      │
│     18-20 months                                        │
│     IP (6-8 mo): Bdq + Lfx/Mfx + Lzd + Cfz (+/- Cs)   │
│     CP (10 mo): Lfx/Mfx + Cfz + Lzd/Cs                 │
│                                                         │
│  3. ALL-ORAL H MONO-POLY DR-TB REGIMEN                  │
│     6 months: Lfx + R + Z + E                           │
└─────────────────────────────────────────────────────────┘

🔥 KEY: Injectable agents (Kanamycin, Amikacin) have been largely PHASED OUT from MDR-TB regimens in favor of all-oral regimens (WHO 2019 update).

11C. Inclusion/Exclusion Criteria for Bdq/Dlm

• MDR/RR-TB with resistance to FQ or SLI
• XDR-TB
• Treatment failure of MDR-TB

• Pregnancy
• Cardiac arrhythmia / prolonged QTc
• Age <18 years (Bdq)
• Severe hepatic impairment

11D. Pretreatment Evaluation for DR-TB

• NAAT + FL-LPA + SL-LPA + LC DST
• ECG (QTc baseline - for Bdq/Dlm)
• Audiometry (for SLI use)
• Renal function tests
• Liver function tests
• Eye examination
• HIV testing + CD4 count
• Pregnancy test in women of reproductive age

11E. Health Education for DR-TB Patients

• Nature of disease, treatment duration, importance of adherence
• Common side effects and what to do
• Treatment is FREE under NTEP
• Social support available (NIKSHAY POSHAN YOJANA - ₹500/month incentive)
• No stigma, isolation not needed
• Importance of infection control at home

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SECTION 12: NTEP PROGRAMME STRUCTURE ⭐🔥

12A. NTEP Key Features

12B. NSP 2017-2025: "FIND, TREAT, PREVENT, BUILD" 🔥

┌──────────────────────────────────────────────────────────┐
│  NSP 2017-2025 PILLARS:                                  │
│                                                          │
│  F - FIND: Universal access to early diagnosis           │
│  T - TREAT: Effective treatment with support             │
│  P - PREVENT: TB preventive therapy + infection control  │
│  B - BUILD: Health system, research & accountability     │
└──────────────────────────────────────────────────────────┘

12C. NTEP Organogram (Organizational Structure)

NATIONAL LEVEL
Central TB Division (CTD), MoHFW, New Delhi
         ↓
STATE LEVEL
State TB Cell (STC) → headed by State TB Officer (STO)
         ↓
DISTRICT LEVEL
District TB Centre (DTC) → headed by District TB Officer (DTO)
         ↓
SUB-DISTRICT/BLOCK LEVEL
Tuberculosis Unit (TU) → headed by Senior Treatment Supervisor (STS)
Each TU covers population of 2.5 lakh (rural) / 4 lakh (urban)
         ↓
PERIPHERAL/MICROSCOPY LEVEL
Designated Microscopy Centre (DMC)
Each DMC covers population of 1 lakh (rural) / 50,000 (urban)
         ↓
VILLAGE/COMMUNITY LEVEL
ASHA, ANM, Multipurpose Health Worker
Treatment Supporter (for DOTS)

🔥 TU = Tuberculosis Unit (basic programmatic unit of NTEP)

12D. Key Programme Indicators

12E. NIKSHAY - IT Platform 🔥

• Nikshay = National TB Information System (web-based)
• Mandatory registration of ALL TB patients (public + private)
• Real-time tracking from notification to outcome
• Used for Nikshay Poshan Yojana (nutritional support)
• All events: diagnosis, treatment start, follow-up, outcome - recorded on Nikshay

12F. Nikshay Poshan Yojana ⭐

• Direct Benefit Transfer (DBT): ₹500/month to TB patient's bank account
• Duration: Throughout treatment duration
• Purpose: Nutritional support to improve treatment outcomes

12G. TB Preventive Treatment (TPT) 🔥

Latent TB Infection (LTBI) treatment to prevent progression to active disease

• Household contacts <5 yrs of bacteriologically-confirmed PTB (regardless of TST)
• HIV-positive patients (PLHIV)
• All children under 6 years who are contacts
• TST/IGRA positive individuals in high-risk groups

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SECTION 13: BCG VACCINATION ⭐🔥

⚠ BCG does NOT prevent infection - it prevents progression to severe/disseminated disease. This is why TB persists even in BCG-vaccinated populations.

🔥 BCG scar appears 2-4 weeks after injection; signifies successful vaccination (not universally required as proof of immunity).

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SECTION 14: PREVENTION LEVELS IN TB ⭐

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SECTION 15: INFECTION CONTROL IN TB ⭐

AIRBORNE INFECTION CONTROL HIERARCHY:

┌──────────────────────────────────────────────────────┐
│  1. ADMINISTRATIVE CONTROLS (MOST IMPORTANT)         │
│     - Fast-track TB suspects                         │
│     - Separate infectious patients                   │
│     - Cough etiquette, respiratory hygiene           │
│     - TB in healthcare workers screening              │
│                                                      │
│  2. ENVIRONMENTAL CONTROLS                           │
│     - Natural ventilation (open windows)             │
│     - Mechanical ventilation (exhaust fans)          │
│     - UV germicidal irradiation (UVGI)               │
│     - Negative pressure rooms                        │
│                                                      │
│  3. PERSONAL PROTECTIVE EQUIPMENT (PPE)              │
│     - N95 respirators for HCW in high-risk areas     │
│     - Surgical masks for TB patients (prevent        │
│       dispersal of large droplets)                   │
└──────────────────────────────────────────────────────┘

🔥 N95 respirators protect the wearer (HCW); surgical masks protect others from the patient's secretions.

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📊 KEY STATISTICS RAPID REFERENCE TABLE

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🧠 MNEMONICS

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⚠ FREQUENTLY CONFUSED CONCEPTS

1. DOTS vs NTEP: DOTS is a strategy; NTEP is the programme
2. RNTCP vs NTEP: Same programme, renamed in 2020
3. Smear-negative PTB vs EPTB: Both can be clinically diagnosed - not the same
4. Miliary TB classification: PTB (not EPTB) even though disseminated
5. Cured vs Treatment Completed: Cured needs bacteriological confirmation; Treatment Completed is clinical only
6. TST positivity cut-off: Different thresholds for different risk groups (5/10/15 mm)
7. IGRA vs TST: Both detect LTBI; neither distinguishes active from latent
8. BCG and TST: BCG causes false-positive TST (up to 15 mm) but doesn't affect IGRA
9. IP extension in DS-TB: NOT recommended even if smear positive at end of IP (new guideline)
10. Thioacetazone: CONTRAINDICATED in HIV (fatal skin reactions)
11. N95 vs Surgical mask: N95 = protects HCW; Surgical mask = protects others from patient
12. LFU definition: Interrupted treatment ≥2 consecutive months (NOT just missed a few doses)

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📄 ONE-PAGE RAPID REVISION SHEET

NTEP - NATIONAL TB ELIMINATION PROGRAMME
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

CAUSATIVE AGENT: M. tuberculosis (acid-fast, aerobe, slow-growing)
RNTCP → NTEP (2020) | Goal: Eliminate by 2025

GLOBAL (2019): 10 million cases | 1.2M deaths (HIV-neg) | India = 26%
INDIA: 2.64M cases | 4.4 lakh deaths | TB kills more women in repro age than maternal mortality combined

TRANSMISSION: Airborne droplet NUCLEI (1-5 µm) | 10-15 persons infected/year by one infectious case
INCUBATION: 4-12 weeks (to TST positivity)

DIAGNOSIS:
- NAAT (Xpert/TrueNat) = First-line initial test
- ZN stain: Carbol fuchsin → acid-alcohol decolorize → methylene blue counter stain
- Scanty = 1-9 AFB/100 fields; 1+ = 10-99/100 fields; 2+ = 1-10/field; 3+ = >10/field
- TST: Intradermal PPD; read 48-72h; induration (not erythema)
  - ≥5mm = HIV/contacts; ≥10mm = HCW/congregate; ≥15mm = general population
- IGRA: Uses ESAT-6/CFP-10; not affected by BCG; 1 visit

CLASSIFICATION:
- New | Relapse | After failure | After LFU | Transfer in
- MDR = H+R resistant | XDR = MDR + FQ + SLI

TREATMENT OUTCOMES: Cured | Completed | Failed (smear+ at Mo.5+) | Died | LFU (≥2 months) | Not evaluated
Treatment Success = Cured + Completed

DS-TB REGIMEN (2019): 2HRZE + 4HR (DAILY; FDC tablets)
Adult doses: H=5mg/kg; R=10mg/kg; Z=25mg/kg; E=15mg/kg

MDR-TB: Group A (Bdq+Lfx/Mfx+Lzd) + Group B (Cfz+Cs) + Group C as needed
Shorter regimen: 9-12 months | Longer regimen: 18-20 months

NTEP STRUCTURE:
CTD (National) → STC (State) → DTC (District) → TU (2.5L pop) → DMC (1L pop) → ASHA/ANM

KEY INDICATORS: CDR ≥90% | TSR ≥90% | Default <5%

BCG: Attenuated M. bovis | At birth | ID left arm | Prevents miliary TB (80%) + TBM (70-80%)

NSP PILLARS: Find - Treat - Prevent - Build
NIKSHAY: Mandatory notification + ₹500/month (Nikshay Poshan Yojana)
TPT: 6H or 3HP for contacts <5yr + PLHIV

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🏆 TOP 25 MOST IMPORTANT POINTS

1. NTEP = renamed from RNTCP in 2020; goal = TB elimination by 2025
2. TB caused by M. tuberculosis; acid-fast, obligate aerobe
3. 1/3 of world population infected; only 5-10% develop disease
4. India accounts for ~26% of global TB burden (highest globally)
5. HIV = most potent risk factor for progression of LTBI to active TB
6. Transmission: airborne droplet nuclei (1-5 µm)
7. Incubation (to TST positivity) = 4-12 weeks (usually 6-8 wks)
8. NTEP diagnostic algorithm: NAAT first (Xpert MTB/RIF or TrueNat)
9. ZN staining: Carbol fuchsin → acid-alcohol → methylene blue (AFB = red on blue)
10. Sputum slide reporting: Scanty (1-9/100 fields), 1+ (10-99/100), 2+ (1-10/field), 3+ (>10/field)
11. TST thresholds: ≥5mm (HIV/immunocompromised), ≥10mm (HCW/congregate), ≥15mm (general)
12. IGRA uses ESAT-6/CFP-10 - NOT affected by BCG vaccination
13. MDR-TB = resistant to both H and R; XDR-TB = MDR + FQ + SLI
14. Treatment success = Cured + Treatment completed
15. LFU = treatment interrupted for ≥2 consecutive months
16. Treatment failed = smear/culture positive at month 5 or later
17. Current DS-TB regimen: 2HRZE + 4HR (daily dose, FDCs)
18. Ethambutol = optic neuritis; Streptomycin = contraindicated in pregnancy
19. Bedaquiline: inhibits mycobacterial ATP synthase; contraindicated in pregnancy + cardiac arrhythmia
20. IP extension NOT recommended even if smear positive at end of 2 months (do NAAT, continue CP)
21. BCG = attenuated M. bovis; ID at birth; protects against miliary TB (80%) and TBM (70-80%)
22. TU covers 2.5 lakh (rural); DMC covers 1 lakh (rural) / 50,000 (urban)
23. NSP 2017-2025 = FIND, TREAT, PREVENT, BUILD
24. Nikshay Poshan Yojana = ₹500/month DBT to TB patients
25. TPT (6H or 3HP) for contacts <5 yrs and PLHIV

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🔥 TOP 20 MCQ FACTS

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📝 TOP 10 UNIVERSITY SAQ/LAQ QUESTIONS

1. [LAQ] Describe the epidemiology of tuberculosis in India. Discuss the National Tuberculosis Elimination Programme (NTEP) in detail, including its objectives, structure, diagnostic algorithm, and treatment regimens.
2. [LAQ] Write in detail about the diagnosis of tuberculosis including sputum smear microscopy, NAAT, tuberculin test, and IGRA. Add a note on slide reporting.
3. [SAQ] Write short notes on DOTS (Directly Observed Treatment, Short Course) - components and current changes under NTEP.
4. [SAQ] Discuss the classification of tuberculosis cases under the revised 2013 definitions.
5. [SAQ] Write about treatment outcome definitions in tuberculosis.
6. [SAQ] Describe MDR-TB and XDR-TB - definitions, causes, and management.
7. [SAQ] Write a note on Bedaquiline and Delamanid in drug-resistant TB.
8. [SAQ] Describe the tuberculin skin test (Mantoux test) - procedure, interpretation, and significance.
9. [SAQ] What is LTBI? How is TB preventive treatment given under NTEP?
10. [SAQ] Write about BCG vaccination - organism, efficacy, schedule, and limitations.

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🗣️ TOP 10 VIVA QUESTIONS

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❌ COMMON MISTAKES STUDENTS MAKE

1. Confusing DOTS with NTEP - DOTS is a strategy (component); NTEP is the national programme
2. Saying IP should be extended if smear positive at end of 2 months - WRONG under new guidelines; proceed with CP and do NAAT
3. Using the wrong slide reporting scale - students mix up "per 100 fields" vs "per field"
4. Missing the TST cut-off for HIV - it's ≥5 mm, not ≥10 mm
5. Confusing BCG's effect - BCG prevents progression to severe disease, NOT initial infection
6. Wrong RNTCP→NTEP year - it was renamed in 2020, not earlier
7. Missing miliary TB classification - it's PTB, not EPTB
8. Saying IGRA is affected by BCG - it is NOT (uses ESAT-6/CFP-10)
9. Confusing MDR and XDR definitions - XDR needs FQ resistance PLUS SLI resistance
10. Forgetting Streptomycin is contraindicated in pregnancy - a classic MCQ trap

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✅ LAST-MINUTE REVISION CHECKLIST

• NTEP renamed 2020, goal = 2025
• India = 26% global TB burden
• Transmission = droplet NUCLEI (airborne)
• Incubation to TST positivity = 4-12 weeks
• ZN stain steps: carbol fuchsin → acid-alcohol → methylene blue
• Slide reporting: Scanty / 1+ / 2+ / 3+ (with denominators)
• Case definitions: bacteriologically confirmed vs clinically diagnosed
• Classification: New / Relapse / After failure / After LFU / Transfer in
• MDR-TB = H+R resistant; XDR-TB = MDR + FQ + SLI
• Treatment outcomes: Cured / Completed / Failed / Died / LFU / Not evaluated
• LFU = ≥2 consecutive months interruption
• Failed = positive at month 5 or later
• DS-TB regimen = 2HRZE + 4HR (daily, FDC)
• Drug side effects: E=eye, S=ear+pregnancy CI, H=peripheral neuropathy (Vit B6), R=enzyme inducer+orange urine, Z=hyperuricemia
• Bdq: ATP synthase inhibitor; CI in pregnancy + arrhythmia
• BCG: attenuated M. bovis; ID at birth; best against miliary TB + TBM
• TST: 5mm (HIV), 10mm (HCW/congregate), 15mm (general)
• IGRA: not affected by BCG; ESAT-6/CFP-10
• NTEP structure: CTD → STC → DTC → TU → DMC
• TU = 2.5 lakh (rural); DMC = 1 lakh (rural)
• NSP pillars: FTPB (Find-Treat-Prevent-Build)
• Nikshay Poshan Yojana = ₹500/month DBT
• TPT: 6H or 3HP for contacts <5yr + PLHIV
• Thioacetazone = CI in HIV (fatal skin reactions)

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import os
from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import mm, cm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY

# ── Output path ──────────────────────────────────────────────────────────────
OUTPUT = "NTEP_Park_28e_Summary.pdf"

# ── Document ─────────────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=18*mm, leftMargin=18*mm,
    topMargin=20*mm, bottomMargin=20*mm,
    title="NTEP - Park's 28th Edition Summary",
    author="Orris Study Notes",
)

W = A4[0] - 36*mm   # usable width

# ── Colour palette ───────────────────────────────────────────────────────────
NAVY   = colors.HexColor("#0D2B6E")
TEAL   = colors.HexColor("#0B7A75")
AMBER  = colors.HexColor("#E8A21A")
RED    = colors.HexColor("#C0392B")
LGREY  = colors.HexColor("#F2F4F8")
MGREY  = colors.HexColor("#D5D8DC")
WHITE  = colors.white
BLACK  = colors.black
GREEN  = colors.HexColor("#1A7A3C")
PURPLE = colors.HexColor("#6C3483")

# ── Styles ───────────────────────────────────────────────────────────────────
base = getSampleStyleSheet()

def S(name, **kw):
    return ParagraphStyle(name, **kw)

sty = {
    "cover_title": S("cover_title",
        fontName="Helvetica-Bold", fontSize=28, textColor=WHITE,
        alignment=TA_CENTER, spaceAfter=6),
    "cover_sub": S("cover_sub",
        fontName="Helvetica", fontSize=13, textColor=WHITE,
        alignment=TA_CENTER, spaceAfter=4),
    "cover_badge": S("cover_badge",
        fontName="Helvetica-Bold", fontSize=11, textColor=AMBER,
        alignment=TA_CENTER, spaceAfter=2),

    "h1": S("h1",
        fontName="Helvetica-Bold", fontSize=16, textColor=WHITE,
        backColor=NAVY, borderPad=6, spaceBefore=14, spaceAfter=4,
        leftIndent=-2, rightIndent=-2, leading=20),
    "h2": S("h2",
        fontName="Helvetica-Bold", fontSize=13, textColor=NAVY,
        spaceBefore=10, spaceAfter=3, borderPad=2,
        borderColor=TEAL, borderWidth=0),
    "h3": S("h3",
        fontName="Helvetica-Bold", fontSize=11, textColor=TEAL,
        spaceBefore=7, spaceAfter=2),
    "h4": S("h4",
        fontName="Helvetica-Bold", fontSize=10, textColor=PURPLE,
        spaceBefore=5, spaceAfter=2),

    "body": S("body",
        fontName="Helvetica", fontSize=9.5, leading=14,
        spaceAfter=3, alignment=TA_JUSTIFY),
    "bullet": S("bullet",
        fontName="Helvetica", fontSize=9.5, leading=13,
        leftIndent=12, bulletIndent=2, spaceAfter=2),
    "bullet2": S("bullet2",
        fontName="Helvetica", fontSize=9, leading=12,
        leftIndent=24, bulletIndent=14, spaceAfter=1),

    "note": S("note",
        fontName="Helvetica-Oblique", fontSize=9, textColor=NAVY,
        backColor=colors.HexColor("#EAF0FB"), borderPad=5,
        leftIndent=8, rightIndent=8, spaceAfter=4, leading=13),
    "warn": S("warn",
        fontName="Helvetica-Bold", fontSize=9, textColor=RED,
        backColor=colors.HexColor("#FDEDEC"), borderPad=5,
        leftIndent=8, rightIndent=8, spaceAfter=4, leading=13),
    "fire": S("fire",
        fontName="Helvetica-Bold", fontSize=9, textColor=GREEN,
        backColor=colors.HexColor("#EAFAF1"), borderPad=5,
        leftIndent=8, rightIndent=8, spaceAfter=4, leading=13),
    "box": S("box",
        fontName="Courier", fontSize=8.5, leading=12,
        backColor=LGREY, borderPad=6, leftIndent=6, rightIndent=6,
        spaceAfter=4),
    "code": S("code",
        fontName="Courier-Bold", fontSize=8, leading=11,
        backColor=colors.HexColor("#EFF0F1"), borderPad=5,
        spaceAfter=4),

    "tbl_hdr": S("tbl_hdr",
        fontName="Helvetica-Bold", fontSize=9, textColor=WHITE,
        alignment=TA_CENTER),
    "tbl_cell": S("tbl_cell",
        fontName="Helvetica", fontSize=8.8, leading=12),
    "tbl_cell_c": S("tbl_cell_c",
        fontName="Helvetica", fontSize=8.8, leading=12,
        alignment=TA_CENTER),
    "mono": S("mono",
        fontName="Courier", fontSize=8.8, leading=12),

    "rapid": S("rapid",
        fontName="Courier", fontSize=8.2, leading=11.5,
        backColor=colors.HexColor("#FDFEFE"), borderPad=6,
        leftIndent=4, spaceAfter=2),

    "footer": S("footer",
        fontName="Helvetica-Oblique", fontSize=7.5,
        textColor=colors.HexColor("#7F8C8D"), alignment=TA_CENTER),
}

# ── Helpers ───────────────────────────────────────────────────────────────────
def h1(text):
    return Paragraph(f"  {text}", sty["h1"])

def h2(text):
    return Paragraph(text, sty["h2"])

def h3(text):
    return Paragraph(text, sty["h3"])

def h4(text):
    return Paragraph(text, sty["h4"])

def p(text, style="body"):
    return Paragraph(text, sty[style])

def bl(text, level=1):
    style = "bullet" if level == 1 else "bullet2"
    return Paragraph(f"• {text}", sty[style])

def sp(h=4):
    return Spacer(1, h*mm)

def hr(color=TEAL, thickness=0.8):
    return HRFlowable(width="100%", thickness=thickness, color=color,
                      spaceAfter=3, spaceBefore=3)

def note(text):
    return Paragraph(f"📘 {text}", sty["note"])

def warn(text):
    return Paragraph(f"⚠ {text}", sty["warn"])

def fire(text):
    return Paragraph(f"🔥 {text}", sty["fire"])

def star(text):
    return Paragraph(f"⭐ {text}", sty["note"])

def code_box(text):
    return Paragraph(text.replace("\n", "<br/>"), sty["box"])

# ── Table builder ─────────────────────────────────────────────────────────────
def make_table(headers, rows, col_widths=None, hdr_color=NAVY):
    if col_widths is None:
        col_widths = [W / len(headers)] * len(headers)
    data = [[Paragraph(h, sty["tbl_hdr"]) for h in headers]]
    for row in rows:
        data.append([Paragraph(str(c), sty["tbl_cell"]) for c in row])
    t = Table(data, colWidths=col_widths, repeatRows=1)
    style = TableStyle([
        ("BACKGROUND",  (0,0), (-1,0), hdr_color),
        ("TEXTCOLOR",   (0,0), (-1,0), WHITE),
        ("ALIGN",       (0,0), (-1,0), "CENTER"),
        ("FONTNAME",    (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",    (0,0), (-1,0), 9),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [WHITE, LGREY]),
        ("GRID",        (0,0), (-1,-1), 0.4, MGREY),
        ("VALIGN",      (0,0), (-1,-1), "TOP"),
        ("TOPPADDING",  (0,0), (-1,-1), 3),
        ("BOTTOMPADDING",(0,0), (-1,-1), 3),
        ("LEFTPADDING", (0,0), (-1,-1), 4),
        ("RIGHTPADDING",(0,0), (-1,-1), 4),
    ])
    t.setStyle(style)
    return t

# ── Cover page ────────────────────────────────────────────────────────────────
def cover_page():
    cover_data = [[
        Paragraph(
            "<br/><br/>🫁  NTEP<br/>National Tuberculosis Elimination Programme",
            sty["cover_title"]),
        Paragraph(
            "Park's Textbook of Preventive &amp; Social Medicine — 28th Edition",
            sty["cover_sub"]),
        Paragraph(
            "Comprehensive High-Yield Chapter Summary",
            sty["cover_sub"]),
        Spacer(1, 10*mm),
        Paragraph("⭐ MBBS University Exams  •  🔥 INICET / NEET PG", sty["cover_badge"]),
        Spacer(1, 8*mm),
        Paragraph("Generated by Orris AI Study Assistant", sty["cover_badge"]),
        Paragraph("July 2026", sty["cover_badge"]),
    ]]
    cover_table = Table(cover_data, colWidths=[W + 4*mm])
    cover_table.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,-1), NAVY),
        ("TOPPADDING",  (0,0), (-1,-1), 20),
        ("BOTTOMPADDING",(0,0), (-1,-1), 20),
        ("LEFTPADDING", (0,0), (-1,-1), 14),
        ("RIGHTPADDING",(0,0), (-1,-1), 14),
        ("ROUNDEDCORNERS", [6]),
    ]))
    return [cover_table, PageBreak()]

# ═══════════════════════════════════════════════════════════════════════════════
# CONTENT BUILDER
# ═══════════════════════════════════════════════════════════════════════════════
def build_content():
    E = []   # elements list

    # ── Cover ──────────────────────────────────────────────────────────────────
    E += cover_page()

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 1: Introduction / Definition
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 1: TUBERCULOSIS — THE DISEASE"), sp(2)]
    E += [
        star("<b>Definition:</b> Tuberculosis is a specific infectious disease caused by "
             "<i>Mycobacterium tuberculosis</i>. Primarily affects the lungs (pulmonary TB). "
             "Also affects intestine, meninges, bones &amp; joints, lymph glands, skin. "
             "<i>M. bovis</i> causes bovine TB (communicable to humans)."),
        sp(2),
    ]

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 2: Problem Statement
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 2: PROBLEM STATEMENT — EPIDEMIOLOGY"), sp(2)]

    E += [h2("2A. Global Statistics (2019)")]
    E += [make_table(
        ["Statistic", "Value"],
        [
            ["Global TB cases", "10 million"],
            ["TB deaths (HIV-negative)", "1.2 million"],
            ["TB deaths (HIV-positive)", "208,000"],
            ["Men ≥15 yrs", "56% of cases"],
            ["Women", "32% of cases"],
            ["Children <15 yrs", "12% of cases"],
            ["People with HIV among TB cases", "8.2%"],
            ["1/3 of world population infected (latent)", "~2.5 billion"],
            ["% who develop clinical disease (lifetime)", "5–10% of infected"],
            ["Annual infection risk (high-burden countries)", "0.5–2%"],
            ["Infectious patient infects others per year", "10–15 persons"],
            ["New cases with MDR/RR-TB", "3.3%"],
            ["Previously treated with MDR/RR-TB", "18%"],
        ],
        col_widths=[W*0.65, W*0.35],
    ), sp(3)]

    E += [h2("2B. India Statistics")]
    E += [make_table(
        ["Indicator", "Value"],
        [
            ["India's share of global TB burden", "~26% (HIGHEST globally)"],
            ["TB incidence (India, 2019)", "~2.64 million"],
            ["TB mortality (India)", "~4.4 lakh/year"],
            ["Female infertility due to TB (India)", "~1/3 of all female infertility"],
            ["Children dropping school due to parent's TB", "~3 lakh"],
            ["Recovery time = income loss", "3–4 months"],
            ["Economic burden — primary cause", "Loss of life (>90%), not morbidity"],
            ["Female cases before age 34 yrs", ">50% of female cases"],
        ],
        col_widths=[W*0.62, W*0.38],
    ), sp(2)]

    E += [
        fire("HIV is the <b>MOST POTENT risk factor</b> for progression of TB infection "
             "to active disease. TB = earliest &amp; most common opportunistic infection in HIV."),
        warn("TB kills MORE women in reproductive age than ALL causes of maternal mortality "
             "combined."),
        sp(2),
    ]

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 3: Epidemiological Indices
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 3: EPIDEMIOLOGICAL INDICES"), sp(2)]
    E += [make_table(
        ["Index", "Definition"],
        [
            ["Annual Risk of TB Infection (ARTI)",
             "Probability of a person being infected with TB in a year; "
             "used to estimate TB incidence. ARTI 1% ≈ 50 smear-positive cases/1,00,000 pop."],
            ["Incidence", "New cases per 1,00,000 population per year"],
            ["Prevalence", "Total active cases per 1,00,000 at a point in time"],
            ["Case Detection Rate (CDR)", "% of estimated cases detected and notified"],
            ["Treatment Success Rate (TSR)", "% of Cured + Completed from treatment cohort"],
        ],
        col_widths=[W*0.38, W*0.62],
    ), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 4: Case Definitions
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 4: REVISED TB CASE DEFINITIONS (2013)"), sp(2)]

    E += [h2("4A. By Bacteriological Status")]
    E += [make_table(
        ["Type", "Definition"],
        [
            ["Bacteriologically Confirmed TB",
             "Biological specimen positive by smear microscopy, culture, or WHO-approved "
             "rapid diagnostic (e.g. Xpert MTB/RIF)"],
            ["Clinically Diagnosed TB",
             "Does NOT meet bacteriological criteria; diagnosed by clinician based on "
             "symptoms, signs, X-ray, histology, etc."],
        ],
        col_widths=[W*0.35, W*0.65],
    ), sp(2)]

    E += [h2("4B. By Site of Disease")]
    E += [make_table(
        ["Type", "Definition"],
        [
            ["Pulmonary TB (PTB)",
             "TB of lung parenchyma or tracheobronchial tree (includes smear +ve & -ve). "
             "MILIARY TB = classified as PTB."],
            ["Extrapulmonary TB (EPTB)",
             "TB of organs other than lungs: pleura, lymph nodes, abdomen, GU tract, "
             "skin, joints, bones, meninges. If both PTB + EPTB → classified as PTB."],
        ],
        col_widths=[W*0.28, W*0.72],
    ), sp(2)]

    E += [warn("⚠ Miliary TB = classified as PTB (lungs involved). "
               "Tuberculous pleural effusion alone = EPTB. Both PTB+EPTB present → PTB.")]

    E += [h2("4C. By History of Previous TB Treatment")]
    E += [make_table(
        ["Category", "Definition"],
        [
            ["New", "Never treated for TB OR treated for <1 month"],
            ["Relapse",
             "Previously declared cured/treatment completed; now bacteriologically confirmed again"],
            ["Treatment after failure",
             "Started treatment after failing previous regimen (smear/culture +ve at month 5+)"],
            ["Treatment after LFU",
             "Previously lost to follow-up (interrupted ≥2 months); now returning"],
            ["Previously treated, unknown outcome",
             "Treated ≥1 month but outcome unknown to reporting unit"],
            ["Transfer in", "Transferred from another treatment unit"],
        ],
        col_widths=[W*0.36, W*0.64],
    ), sp(2)]

    E += [h2("4D. By Drug Resistance")]
    E += [make_table(
        ["Type", "Definition"],
        [
            ["Mono-resistant TB", "Resistant to ONE first-line drug"],
            ["Poly-resistant TB", "Resistant to >1 first-line drug, NOT both H+R"],
            ["MDR-TB", "Resistant to BOTH Isoniazid (H) + Rifampicin (R)"],
            ["RR-TB", "Rifampicin-resistant by any method, with/without other resistance"],
            ["XDR-TB",
             "MDR-TB + resistant to any fluoroquinolone + at least one of 3 second-line "
             "injectables (amikacin, kanamycin, capreomycin)"],
            ["TDR-TB", "Resistant to ALL drugs tested (totally drug resistant)"],
        ],
        col_widths=[W*0.28, W*0.72],
    ), sp(2)]

    E += [fire("Mnemonic for increasing resistance: Mono → Poly → MDR → XDR → TDR")]

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 5: Treatment Outcomes
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 5: TREATMENT OUTCOME DEFINITIONS"), sp(2)]

    E += [h2("5A. Drug-Sensitive TB (DS-TB)")]
    E += [make_table(
        ["Outcome", "Definition"],
        [
            ["Cured",
             "Bacteriologically confirmed TB; smear/culture-NEGATIVE in LAST month of treatment "
             "AND on at least ONE previous occasion"],
            ["Treatment Completed",
             "Completed treatment without evidence of failure BUT no smear/culture results "
             "available (tests not done or results unavailable)"],
            ["Treatment Failed",
             "Smear/culture POSITIVE at month 5 or LATER during treatment"],
            ["Died", "Died for ANY reason before starting or during treatment"],
            ["Lost to Follow-up (LFU)",
             "Did not start treatment OR treatment interrupted for ≥2 CONSECUTIVE months"],
            ["Not Evaluated",
             "No outcome assigned — includes 'transferred out' and unknown outcomes"],
            ["Treatment Success", "SUM of CURED + TREATMENT COMPLETED"],
            ["Cohort",
             "Group of patients diagnosed and registered for treatment in a specified period; "
             "forms the DENOMINATOR for treatment outcome calculations"],
        ],
        col_widths=[W*0.28, W*0.72],
    ), sp(2)]

    E += [fire("Treatment Success = Cured + Treatment Completed  |  "
               "LFU = interrupted for ≥2 consecutive months  |  "
               "Failed = smear positive at month 5 or later")]

    E += [h2("5B. RR-TB / MDR-TB / XDR-TB (Second-Line Treatment)")]
    E += [make_table(
        ["Outcome", "Key Difference vs DS-TB"],
        [
            ["Cured",
             "Completed as per national policy + 3 or MORE consecutive cultures taken "
             "≥30 days apart are NEGATIVE after intensive phase"],
            ["Treatment Completed",
             "Completed without failure BUT no 3 consecutive negative cultures documented"],
            ["Treatment Failed",
             "Termination or permanent change of ≥2 drugs due to: lack of conversion by end of IP; "
             "bacteriological reversion in CP; evidence of additional acquired resistance; "
             "or adverse drug reactions"],
        ],
        col_widths=[W*0.25, W*0.75],
    ), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 6: Natural History
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 6: NATURAL HISTORY OF TUBERCULOSIS"), sp(2)]

    E += [h2("6A. Agent Factors")]
    E += [make_table(
        ["Feature", "Details"],
        [
            ["Causative agent", "Mycobacterium tuberculosis (Koch's bacillus)"],
            ["Type", "Obligate aerobe, acid-fast bacillus (AFB)"],
            ["Size", "2–4 µm long"],
            ["Acid-fastness", "Due to mycolic acid in cell wall"],
            ["Doubling time", "~15–20 hours (very slow growth)"],
            ["Survival outside host", "Days to weeks in dark, moist conditions"],
            ["Killed by", "UV light, heat, 70% alcohol"],
            ["Main virulence factor", "Cord factor (trehalose dimycolate)"],
            ["Other species", "M. bovis (bovine TB), M. africanum, M. microti"],
        ],
        col_widths=[W*0.38, W*0.62],
    ), sp(2)]

    E += [h3("4 Populations of TB Bacilli (basis of treatment)")]
    E += [make_table(
        ["Population", "Location", "Best Killed By"],
        [
            ["Large, actively dividing", "Extracellular (cavity walls)", "Isoniazid (INH)"],
            ["Slow-growing / intermittently active", "Closed lesions", "Rifampicin"],
            ["Intracellular bacilli", "Inside macrophages (acidic pH)", "Pyrazinamide"],
            ["Dormant / persisters", "Semi-dormant lesions", "Rifampicin + INH (long course)"],
        ],
        col_widths=[W*0.32, W*0.38, W*0.30],
    ), sp(2)]

    E += [h2("6B. Host Factors")]
    E += [make_table(
        ["Risk Factor", "Notes"],
        [
            ["Age", "Young adults + infants (highest risk); elderly also vulnerable"],
            ["Sex", "Males > Females (2:1); females disproportionately affected <34 yrs"],
            ["Nutritional status", "Malnutrition = major independent risk factor"],
            ["HIV", "MOST POTENT risk factor for LTBI → active TB"],
            ["Diabetes mellitus", "3× increased risk"],
            ["Silicosis", "High risk — synergistic with TB"],
            ["Steroids / immunosuppressants", "TNF-α inhibitors especially high risk"],
            ["Pregnancy", "Increases risk of developing active TB"],
            ["BCG vaccination", "Protects against severe forms; less effective for PTB"],
        ],
        col_widths=[W*0.38, W*0.62],
    ), sp(2)]

    E += [h2("6C. Mode of Transmission")]
    E += [
        star("PRIMARY route: Airborne — <b>droplet nuclei</b> (Wells droplets, 1–5 µm)"),
        bl("Produced by coughing, sneezing, speaking, singing"),
        bl("Float in air for hours; reach alveoli of susceptible host"),
        bl("One infectious patient can infect <b>10–15 persons/year</b>"),
        bl("Other routes (rare): Ingestion (M. bovis from unpasteurized milk), "
           "Skin inoculation, Transplacental (congenital TB)"),
        sp(2),
    ]

    E += [h2("6D. Incubation Period")]
    E += [make_table(
        ["Interval", "Duration"],
        [
            ["Infection → TST positivity", "4–12 weeks (usually 6–8 weeks)"],
            ["Infection → Active disease", "Months to years (lifetime risk of reactivation)"],
        ],
        col_widths=[W*0.5, W*0.5],
    ), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 7: Control / Case Finding
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 7: CONTROL OF TUBERCULOSIS — CASE FINDING"), sp(2)]

    E += [make_table(
        ["Approach", "Description"],
        [
            ["Passive Case Finding",
             "Patient presents with symptoms → health facility investigates. "
             "MOST COMMON method under NTEP."],
            ["Active Case Finding (ACF)",
             "Health system proactively screens community — house-to-house, camps."],
            ["Intensified Case Finding (ICF)",
             "Active screening in special settings: prisons, mines, slums, TB contacts, "
             "HIV clinics, DM clinics."],
        ],
        col_widths=[W*0.32, W*0.68],
    ), sp(2)]

    E += [h3("High-Risk / Vulnerable Groups for Screening")]
    groups = [
        "Household contacts of bacteriologically-confirmed TB patients",
        "HIV-positive individuals (PLHIV)",
        "Prisoners / inmates of correctional facilities",
        "Healthcare workers (regular screening)",
        "Malnourished patients",
        "Diabetics",
        "Silica-exposed workers",
        "Children <5 yrs in TB-affected households",
        "Residents of tribal/backward areas and slums",
        "Migrant labourers",
    ]
    for g in groups:
        E.append(bl(g))
    E.append(sp(2))

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 8: Diagnosis
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 8: CASE-FINDING TOOLS — DIAGNOSIS"), sp(2)]

    E += [h2("8A. Sputum Collection")]
    E += [make_table(
        ["Day", "Sample", "Instructions"],
        [
            ["Day 1", "Sample 1 (Spot)",
             "On-the-spot sample under supervision at the health facility"],
            ["Day 2", "Sample 2 (Early morning)",
             "Patient brings early morning sample (most bacteria-rich)"],
            ["Long-distance patient", "2 Spot samples",
             "Both collected at the facility with a 1-hour gap between them"],
        ],
        col_widths=[W*0.18, W*0.22, W*0.60],
    ), sp(2)]

    E += [h2("8B. Ziehl-Neelsen (ZN) Staining — AFB")]
    E += [make_table(
        ["Step", "Procedure"],
        [
            ["1. Fix smear", "Pass slide 3× through flame (smear side up)"],
            ["2. Primary stain", "Carbol fuchsin — steam GENTLY for 5 min over flame "
             "(or 20 min over water bath). Do NOT boil/dry."],
            ["3. Wash", "Deionized water"],
            ["4. Decolorize", "3% acid-alcohol (95% ethanol + 3% HCl) until faint pink"],
            ["5. Wash", "Water"],
            ["6. Counter stain", "Loeffler's methylene blue — 1 minute"],
            ["7. Dry & Examine", "At 1000× (oil immersion)"],
        ],
        col_widths=[W*0.28, W*0.72],
    ), sp(1)]
    E += [fire("AFB appear RED/PINK on BLUE background under ZN stain"), sp(2)]

    E += [h2("8C. Slide Reporting at 1000× Magnification")]
    E += [make_table(
        ["AFB Count", "Per", "Result Reported"],
        [
            ["None", "per 100 oil immersion fields", "0 (Negative)"],
            ["1–9", "per 100 oil immersion fields", "Scanty (report actual number)"],
            ["10–99", "per 100 oil immersion fields", "1+ (one plus)"],
            ["1–10", "per single oil immersion field", "2+ (two plus)"],
            [">10", "per single oil immersion field", "3+ (three plus)"],
        ],
        col_widths=[W*0.18, W*0.52, W*0.30],
    ), sp(1)]
    E += [warn("NOTE the denominator switch: Scanty and 1+ use 'per 100 fields'; "
               "2+ and 3+ use 'per single field'. Common exam trap!"), sp(2)]

    E += [h2("8D. Rapid Diagnostic Tools — NTEP Endorsed")]
    E += [make_table(
        ["Tool", "Details"],
        [
            ["Xpert MTB/RIF (CBNAAT)",
             "Cartridge-Based NAAT; detects MTB AND Rifampicin resistance in ~2 hours; "
             "WHO FIRST-LINE recommended initial diagnostic test under NTEP"],
            ["Xpert MTB/RIF Ultra",
             "More sensitive than original Xpert; especially useful in paucibacillary "
             "disease and HIV-positive patients"],
            ["TrueNat",
             "Indian point-of-care NAAT; detects MTB; add-on chip for RIF resistance; "
             "usable at peripheral level (district/sub-district)"],
            ["FL-LPA (First-Line LPA)",
             "Line Probe Assay; detects resistance to H + R; GenoType MTBDRplus"],
            ["SL-LPA (Second-Line LPA)",
             "Detects resistance to fluoroquinolones (FQ) + second-line injectables (SLI)"],
        ],
        col_widths=[W*0.27, W*0.73],
    ), sp(2)]

    E += [h3("NTEP Diagnostic Algorithm (Order of Tests)")]
    E += [make_table(
        ["Step", "Test"],
        [
            ["Step 1 (Initial)", "NAAT — Xpert MTB/RIF or TrueNat"],
            ["Step 2 (If NAAT +ve)", "FL-LPA (First-Line LPA) for H+R resistance"],
            ["Step 3 (If MDR/RR-TB confirmed)", "SL-LPA for FQ + SLI resistance"],
            ["Step 4 (Confirmation/Extended DST)", "Liquid Culture + DST"],
        ],
        col_widths=[W*0.35, W*0.65],
    ), sp(2)]

    E += [h2("8E. Tuberculin Skin Test (Mantoux / TST)")]
    E += [make_table(
        ["Parameter", "Detail"],
        [
            ["Antigen used",
             "PPD (Purified Protein Derivative) — 5 TU (international standard); "
             "2 TU RT23 (used in India NTEP)"],
            ["Route", "Intradermal (inner forearm)"],
            ["Reading time", "48–72 hours after injection"],
            ["Measure", "INDURATION (not erythema) — in millimetres"],
        ],
        col_widths=[W*0.30, W*0.70],
    ), sp(2)]

    E += [h3("TST Positivity Cut-offs")]
    E += [make_table(
        ["Induration", "Positive In"],
        [
            ["≥5 mm",
             "HIV-positive; recent close TB contact; fibrotic changes on CXR; "
             "immunosuppressed (organ transplant, TNF-α inhibitors); children at high risk"],
            ["≥10 mm",
             "Recent immigrants from high-burden countries; IV drug users; "
             "congregate settings; healthcare workers; children <5 yrs; "
             "DM, renal failure, malnutrition"],
            ["≥15 mm", "Low-risk individuals in general population"],
        ],
        col_widths=[W*0.18, W*0.82],
    ), sp(2)]

    E += [h3("Causes of False Negative TST")]
    fn_tst = ["HIV / Immunosuppression (most important)", "Overwhelming TB (miliary, meningitis)",
              "Malnutrition", "Viral infections (measles, influenza)", "Recent infection (<8–10 weeks — window period)",
              "Steroids / immunosuppressants", "Improper technique or storage of PPD"]
    for f in fn_tst:
        E.append(bl(f))
    E += [sp(1), note("BCG vaccination causes FALSE POSITIVE TST (up to 15 mm) "
                      "but does NOT affect IGRA"), sp(2)]

    E += [h2("8F. Two-Step TST Testing")]
    E += [p("Used for baseline TST in healthcare workers. If 1st TST negative → repeat in 1–3 weeks. "
            "A positive 2nd test = boosted reaction (not new infection). Done to avoid falsely "
            "attributing a 'boosted' reaction to new occupational exposure."), sp(2)]

    E += [h2("8G. IGRA (Interferon Gamma Release Assay)")]
    E += [make_table(
        ["Feature", "IGRA", "TST"],
        [
            ["Antigens used", "ESAT-6, CFP-10 (absent in BCG strain)", "PPD (shared with BCG)"],
            ["Affected by BCG vaccination", "NO", "YES (false positive)"],
            ["Visits needed", "1 (blood draw)", "2 (injection + reading)"],
            ["Tests available", "QuantiFERON-TB Gold; T-SPOT.TB", "Mantoux"],
            ["Specificity", "Higher (BCG does NOT cross-react)", "Lower"],
            ["Distinguishes active vs latent TB", "NO", "NO"],
            ["Cost", "Higher", "Lower"],
            ["Use in India (NTEP)", "Not routine; mainly research", "Programme standard"],
        ],
        col_widths=[W*0.38, W*0.32, W*0.30],
    ), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 9: Anti-TB Drugs
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 9: ANTI-TUBERCULOSIS DRUGS"), sp(2)]

    E += [note("Mnemonic for 1st-line drugs: RIPES — Rifampicin, INH, Pyrazinamide, "
               "Ethambutol, Streptomycin")]

    E += [h2("9A. First-Line Drugs")]
    E += [make_table(
        ["Drug", "Mechanism", "Type", "Key Side Effects"],
        [
            ["Isoniazid (H/INH)",
             "Inhibits mycolic acid synthesis (InhA enzyme)",
             "Bactericidal",
             "Peripheral neuropathy (prevent with pyridoxine/Vit B6), hepatotoxicity, lupus-like syndrome"],
            ["Rifampicin (R/RMP)",
             "Inhibits RNA polymerase (β subunit)",
             "Bactericidal",
             "Hepatotoxicity, orange discoloration of urine/secretions, enzyme INDUCER (↓OCP efficacy), flu-like syndrome"],
            ["Pyrazinamide (Z/PZA)",
             "Converted to pyrazinoic acid; disrupts membrane transport",
             "Bactericidal (acidic pH, intracellular)",
             "Hepatotoxicity, hyperuricemia/gout, arthralgia"],
            ["Ethambutol (E/EMB)",
             "Inhibits arabinosyl transferase (cell wall)",
             "BACTERIOSTATIC",
             "Optic neuritis (retrobulbar); dose-related, reversible; red-green colour vision loss"],
            ["Streptomycin (S/SM)",
             "Inhibits protein synthesis (30S ribosome)",
             "Bactericidal",
             "Ototoxicity (vestibular > auditory), nephrotoxicity; CONTRAINDICATED in pregnancy"],
        ],
        col_widths=[W*0.18, W*0.26, W*0.16, W*0.40],
    ), sp(2)]

    E += [warn("Hepatotoxic 1st-line drugs: H + R + Z (NOT E or S primarily). "
               "If hepatotoxicity — STOP all three. Can use S+E temporarily.")]
    E += [warn("STREPTOMYCIN is CONTRAINDICATED in PREGNANCY (ototoxicity to fetus)")]
    E += [warn("ETHAMBUTOL = Eyes (optic neuritis). Check visual acuity before and during Rx."),
          sp(2)]

    E += [h2("9B. Key Second-Line Drugs")]
    E += [make_table(
        ["Group / Drug", "Key Features"],
        [
            ["Fluoroquinolones (Levofloxacin/Moxifloxacin)",
             "Bactericidal. PREFERRED FQ for MDR-TB. DO NOT use Ciprofloxacin (suboptimal for TB)."],
            ["Injectable agents (Amikacin, Kanamycin, Capreomycin)",
             "Nephrotoxic + ototoxic. Being phased out in favour of all-oral regimens (WHO 2019)."],
            ["Bedaquiline (Bdq)",
             "Diarylquinoline; inhibits mycobacterial ATP synthase; bactericidal. "
             "CI: pregnancy, cardiac arrhythmia. Half-life up to 5.5 months post-stopping."],
            ["Delamanid (Dlm)",
             "Nitroimidazole; inhibits methoxymycolic + ketomycolic acid synthesis (cell wall). "
             "Duration: 24 weeks. CI: pregnancy, severe hepatic impairment."],
            ["Linezolid (Lzd)",
             "Oxazolidinone; protein synthesis inhibitor. Important in XDR-TB. "
             "Side effect: myelosuppression, peripheral neuropathy."],
            ["Clofazimine (Cfz)",
             "Riminophenazine; multiple mechanisms. Used in MDR/XDR regimens."],
            ["Cycloserine (Cs)",
             "Mainly bacteriostatic; inhibits cell wall synthesis. "
             "Side effects: CNS/psychiatric effects."],
            ["Thioacetazone",
             "Bacteriostatic. NEVER use in HIV patients — can cause SEVERE and FATAL skin reactions."],
        ],
        col_widths=[W*0.35, W*0.65],
    ), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 10: Treatment Regimens
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 10: TREATMENT REGIMENS — NTEP 2019 GUIDELINES"), sp(2)]

    E += [h2("10A. DOTS — Five Elements")]
    dots_elements = [
        "Political commitment with increased and sustained financing",
        "Case detection by quality sputum smear microscopy (now NAAT)",
        "Standardized short-course chemotherapy under direct observation",
        "Regular uninterrupted supply of quality anti-TB drugs",
        "Standardized recording and reporting system (Nikshay)",
    ]
    for i, d in enumerate(dots_elements, 1):
        E.append(bl(f"<b>{i}.</b> {d}"))
    E += [fire("NTEP 2019 change: Switched from THRICE-WEEKLY (3x/week) DOTS to DAILY DOSE regimen"), sp(2)]

    E += [h2("10B. Two-Phase Chemotherapy")]
    E += [make_table(
        ["Phase", "Duration", "Purpose", "Drugs (DS-TB)"],
        [
            ["Intensive Phase (IP)",
             "2 months",
             "Kill actively dividing bacilli; achieve rapid sputum conversion",
             "H + R + Z + E (daily)"],
            ["Continuation Phase (CP)",
             "4 months",
             "Eliminate remaining/dormant bacilli; prevent relapse",
             "H + R (daily)"],
        ],
        col_widths=[W*0.24, W*0.14, W*0.34, W*0.28],
    ), sp(2)]

    E += [h2("10C. Standard DS-TB Regimen: 2HRZE + 4HR (Daily)")]
    E += [make_table(
        ["Phase", "Duration", "Drugs", "Follow-up"],
        [
            ["Intensive Phase", "2 months", "H + R + Z + E daily (FDC)",
             "Sputum smear at END of IP"],
            ["Continuation Phase", "4 months", "H + R daily (FDC)",
             "Sputum smear at END of treatment"],
        ],
        col_widths=[W*0.22, W*0.17, W*0.30, W*0.31],
    ), sp(1)]
    E += [fire("If smear POSITIVE at end of IP: Do NOT extend IP. Perform NAAT/Xpert. "
               "Proceed with CP and investigate for DR-TB."), sp(2)]

    E += [h2("10D. Adult Daily Dose (Weight-Based)")]
    E += [make_table(
        ["Drug", "Daily Dose (mg/kg)", "Range", "Maximum"],
        [
            ["Isoniazid (H)", "5 mg/kg/day", "4–6 mg/kg", "300 mg/day"],
            ["Rifampicin (R)", "10 mg/kg/day", "8–12 mg/kg", "600 mg/day"],
            ["Pyrazinamide (Z)", "25 mg/kg/day", "20–30 mg/kg", "—"],
            ["Ethambutol (E)", "15 mg/kg/day", "15–20 mg/kg", "—"],
            ["Streptomycin (S)", "15 mg/kg/day", "12–18 mg/kg", "1 g/day (IM)"],
        ],
        col_widths=[W*0.25, W*0.25, W*0.25, W*0.25],
    ), sp(2)]

    E += [h2("10E. Adult FDC Compositions")]
    E += [make_table(
        ["Phase", "FDC Composition", "Tablet Content"],
        [
            ["Intensive Phase", "HRZE",
             "H 75 mg + R 150 mg + Z 400 mg + E 275 mg"],
            ["Continuation Phase", "HR",
             "H 75 mg + R 150 mg"],
            ["Alternative CP", "HRE",
             "H 75 mg + R 150 mg + E 275 mg"],
        ],
        col_widths=[W*0.27, W*0.20, W*0.53],
    ), sp(2)]

    E += [h2("10F. Paediatric TB Treatment")]
    E += [
        bl("Regimen: <b>2HRZE + 4HR</b> (same structure as adults)"),
        bl("Dispersible FDC tablets used for children"),
        bl("Weight bands: 4–7 kg, 8–11 kg, 12–15 kg, 16–24 kg, 25–29 kg, 30–39 kg"),
        bl("Pyridoxine: <b>10 mg/day</b> for ALL children on INH-containing therapy"),
        bl("Nikshay entry mandatory: treatment card opened + all events recorded digitally"),
        sp(2),
    ]

    E += [h2("10G. Follow-up of Treatment")]
    E += [make_table(
        ["Component", "Schedule"],
        [
            ["Clinical follow-up", "Monthly"],
            ["Sputum smear microscopy", "End of Intensive Phase + End of Treatment"],
            ["Weight monitoring", "Monthly"],
            ["Adverse drug reaction monitoring", "Every visit"],
        ],
        col_widths=[W*0.45, W*0.55],
    ), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 11: DR-TB Management
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 11: MANAGEMENT OF DRUG-RESISTANT TB (DR-TB)"), sp(2)]

    E += [h2("11A. Drug Groups for MDR-TB (WHO Revised)")]
    E += [make_table(
        ["Group", "Drugs", "Priority"],
        [
            ["Group A (Core — include all 3 if possible)",
             "Levofloxacin OR Moxifloxacin, Bedaquiline (Bdq), Linezolid (Lzd)",
             "HIGHEST"],
            ["Group B (Add to strengthen regimen)",
             "Clofazimine (Cfz), Cycloserine (Cs) / Terizidone",
             "HIGH"],
            ["Group C (Add when Groups A+B insufficient)",
             "Ethambutol (E), Delamanid (Dlm), Pyrazinamide (Z), "
             "Imipenem-cilastatin, Amikacin (Am), Ethionamide/Prothionamide, PAS",
             "SUPPLEMENTAL"],
        ],
        col_widths=[W*0.32, W*0.45, W*0.23],
    ), sp(2)]

    E += [fire("Injectable agents (Kanamycin, Amikacin) largely PHASED OUT from MDR-TB regimens. "
               "All-oral regimens now preferred (WHO 2019 update).")]

    E += [h2("11B. MDR-TB Regimens")]
    E += [make_table(
        ["Regimen", "Duration", "Notes"],
        [
            ["Shorter MDR-TB regimen",
             "9–12 months",
             "IP (4–6 mo): Bdq+Mfx/Lfx+Cfz+Z+E+H+Eto → CP (5 mo): Mfx/Lfx+Cfz+Z+E"],
            ["All-oral longer MDR-TB regimen",
             "18–20 months",
             "IP (6–8 mo): Bdq+Lfx/Mfx+Lzd+Cfz (+/-Cs) → CP (10 mo): Lfx/Mfx+Cfz+Lzd/Cs"],
            ["All-oral H mono-poly DR-TB regimen",
             "6 months",
             "Lfx + R + Z + E daily"],
        ],
        col_widths=[W*0.30, W*0.17, W*0.53],
    ), sp(2)]

    E += [h2("11C. Bedaquiline (Bdq) — Inclusion & Exclusion")]
    E += [make_table(
        ["Criteria", "Details"],
        [
            ["Inclusion (eligible patients)",
             "MDR/RR-TB with resistance to any FQ or SLI; XDR-TB; "
             "Mixed pattern resistant TB; Treatment failure of MDR-TB+FQ/SLI resistance"],
            ["Age", "≥18 years required"],
            ["Contraindications (Exclusion)",
             "Pregnancy; Cardiac arrhythmia / prolonged QTc; Age <18 years; "
             "Severe hepatic impairment; Hormonal contraception not reliable (non-hormonal required)"],
        ],
        col_widths=[W*0.30, W*0.70],
    ), sp(2)]

    E += [h2("11D. Pretreatment Evaluation for DR-TB")]
    pre_tx = ["NAAT + FL-LPA + SL-LPA + Liquid Culture + DST",
              "ECG (baseline QTc — mandatory for Bdq/Dlm use)",
              "Audiometry (for second-line injectable use)",
              "Renal function tests (creatinine, eGFR)",
              "Liver function tests",
              "Visual acuity and colour vision (for Ethambutol/Linezolid)",
              "HIV testing + CD4 count",
              "Pregnancy test in women of reproductive age",
              "Baseline weight and nutritional status"]
    for item in pre_tx:
        E.append(bl(item))
    E.append(sp(2))

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 12: NTEP Programme Structure
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 12: NTEP — PROGRAMME STRUCTURE & KEY FEATURES"), sp(2)]

    E += [h2("12A. NTEP Key Features")]
    E += [make_table(
        ["Feature", "Details"],
        [
            ["Old name", "RNTCP (Revised National TB Control Programme)"],
            ["New name", "NTEP (National Tuberculosis Elimination Programme)"],
            ["Renamed in", "2020"],
            ["Goal", "Eliminate TB from India by 2025 (SDG global target = 2030)"],
            ["Vision", "TB-Free India"],
            ["Strategy", "National Strategic Plan (NSP) 2017–2025"],
            ["NSP pillars", "FIND – TREAT – PREVENT – BUILD"],
        ],
        col_widths=[W*0.30, W*0.70],
    ), sp(2)]

    E += [h2("12B. NSP 2017–2025 Pillars — FTPB")]
    E += [make_table(
        ["Pillar", "Focus"],
        [
            ["FIND", "Universal access to early, accurate diagnosis of ALL TB cases"],
            ["TREAT", "Effective treatment with patient support; prevent LFU; DR-TB management"],
            ["PREVENT",
             "TB preventive therapy (TPT) for contacts/PLHIV; infection control; BCG; "
             "address social determinants"],
            ["BUILD",
             "Health system strengthening; research & innovation; accountability; "
             "engagement of private sector"],
        ],
        col_widths=[W*0.15, W*0.85],
    ), sp(2)]

    E += [h2("12C. NTEP Organogram")]
    E += [make_table(
        ["Level", "Unit / Body", "Head / Key Staff", "Population Coverage"],
        [
            ["National", "Central TB Division (CTD), MoHFW, New Delhi", "Deputy Director General (TB)", "Entire India"],
            ["State", "State TB Cell (STC)", "State TB Officer (STO)", "Entire state"],
            ["District", "District TB Centre (DTC)", "District TB Officer (DTO)", "Entire district"],
            ["Sub-district/Block", "Tuberculosis Unit (TU)", "Senior Treatment Supervisor (STS) + Senior TB Lab Supervisor (STLS)",
             "2.5 lakh (rural) / 4 lakh (urban)"],
            ["Peripheral", "Designated Microscopy Centre (DMC)", "Lab Technician", "1 lakh (rural) / 50,000 (urban)"],
            ["Community/Village", "ASHA, ANM, MPHW, Treatment Supporter", "—", "Village level"],
        ],
        col_widths=[W*0.18, W*0.27, W*0.27, W*0.28],
    ), sp(2)]

    E += [h2("12D. Key Programme Indicators")]
    E += [make_table(
        ["Indicator", "Target"],
        [
            ["Case Detection Rate (CDR)", "≥90%"],
            ["Treatment Success Rate (TSR)", "≥90%"],
            ["ARTI target by 2025", "<1%"],
            ["Treatment default rate", "<5%"],
            ["Mandatory notification", "ALL TB cases (public + private) since 2012"],
        ],
        col_widths=[W*0.55, W*0.45],
    ), sp(2)]

    E += [h2("12E. NIKSHAY — National TB Information System")]
    E += [
        bl("<b>Nikshay</b> = web-based national IT platform for TB patient management"),
        bl("Mandatory registration of ALL TB patients (public AND private sector)"),
        bl("Real-time tracking: notification → diagnosis → treatment start → follow-up → outcome"),
        bl("Enables <b>Nikshay Poshan Yojana</b>: Direct Benefit Transfer of "
           "<b>₹500/month</b> to patient's bank account for nutritional support"),
        bl("All treatment events recorded digitally — replaces paper registers"),
        sp(2),
    ]

    E += [h2("12F. TB Preventive Treatment (TPT)")]
    E += [make_table(
        ["Regimen", "Details"],
        [
            ["6H", "Isoniazid 5 mg/kg/day × 6 months"],
            ["9H", "Isoniazid × 9 months"],
            ["3HP", "Weekly INH + Rifapentine × 3 months"],
            ["1HP", "Daily INH + Rifapentine × 1 month (newer shorter regimen)"],
        ],
        col_widths=[W*0.18, W*0.82],
    ), sp(1)]
    E += [note("Who receives TPT under NTEP: (1) Household contacts <5 yrs of bacteriologically-confirmed "
               "PTB — regardless of TST result; (2) PLHIV (all HIV+ve patients); "
               "(3) TST/IGRA positive individuals in high-risk groups"), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 13: BCG Vaccination
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 13: BCG VACCINATION"), sp(2)]

    E += [make_table(
        ["Feature", "Details"],
        [
            ["Full form", "Bacille Calmette-Guérin"],
            ["Organism", "Attenuated Mycobacterium bovis"],
            ["Developed by", "Calmette and Guérin (France, 1921)"],
            ["Route", "Intradermal (ID) — left upper arm"],
            ["Age (UIP)", "At birth"],
            ["Dose", "0.1 mL (infants >1 month); 0.05 mL (neonates ≤1 month)"],
            ["Efficacy — Miliary TB", "~80% protective"],
            ["Efficacy — TB Meningitis", "~70–80% protective"],
            ["Efficacy — Pulmonary TB", "Variable (0–80%); less reliable"],
            ["Duration of protection", "~10–15 years"],
            ["Side effects",
             "Local ulceration (expected/normal); BCGitis; Disseminated BCG (in immunocompromised)"],
            ["Contraindications",
             "Symptomatic HIV; immunocompromised state; immunosuppressive therapy; "
             "widespread skin disease"],
        ],
        col_widths=[W*0.35, W*0.65],
    ), sp(2)]

    E += [warn("BCG does NOT prevent TB infection — it prevents progression to SEVERE/DISSEMINATED "
               "disease. TB persists even in BCG-vaccinated populations.")]
    E += [note("BCG scar appears 2–4 weeks after injection. BCG vaccination causes FALSE POSITIVE "
               "TST but does NOT affect IGRA results."), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 14: Prevention Levels
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 14: LEVELS OF PREVENTION IN TB"), sp(2)]

    E += [make_table(
        ["Level", "Measures"],
        [
            ["Primordial Prevention",
             "Poverty reduction; improved living standards; nutrition; reduce overcrowding"],
            ["Primary Prevention",
             "BCG vaccination; health education; infection control; "
             "TB preventive therapy (TPT) for contacts and PLHIV"],
            ["Secondary Prevention",
             "Early case detection (DOTS/NAAT); prompt effective treatment; "
             "contact tracing and screening"],
            ["Tertiary Prevention",
             "Rehabilitation; management of complications; "
             "prevent disability from sequelae"],
        ],
        col_widths=[W*0.28, W*0.72],
    ), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION 15: Infection Control
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("SECTION 15: INFECTION CONTROL IN TB"), sp(2)]

    E += [make_table(
        ["Hierarchy", "Controls", "Examples"],
        [
            ["1st (Most Important)", "Administrative Controls",
             "Fast-track TB suspects; separate infectious patients; "
             "cough etiquette; respiratory hygiene; screen HCW for TB"],
            ["2nd", "Environmental Controls",
             "Natural ventilation (open windows); mechanical ventilation (exhaust fans); "
             "UV germicidal irradiation (UVGI); negative pressure rooms"],
            ["3rd", "Personal Protective Equipment (PPE)",
             "N95 respirators for HCW in high-risk areas; "
             "surgical masks for TB patients"],
        ],
        col_widths=[W*0.22, W*0.25, W*0.53],
    ), sp(1)]
    E += [fire("N95 respirator = protects the WEARER (HCW). "
               "Surgical mask = protects OTHERS from patient's secretions."), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # MNEMONICS
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("MNEMONICS & MEMORY AIDS"), sp(2)]

    E += [make_table(
        ["Topic", "Mnemonic / Memory Aid"],
        [
            ["1st-line TB drugs",
             "RIPES — Rifampicin, INH, Pyrazinamide, Ethambutol, Streptomycin"],
            ["DOTS 5 elements",
             "PCS-DS — Political commitment, Case detection (NAAT), Short-course DOT, "
             "Drug supply, Standardized recording"],
            ["NSP pillars", "FTPB — Find, Treat, Prevent, Build"],
            ["MDR-TB Group A drugs", "BLL — Bedaquiline, Levofloxacin/Moxifloxacin, Linezolid"],
            ["Drug side effects",
             "E = Eyes (optic neuritis)  |  S = Stops in pregnancy (CI)  |  "
             "H = Helps with B6 (peripheral neuropathy needs pyridoxine)  |  "
             "R = Red urine + enzyme inducer  |  Z = uriZa (hyperuricemia)"],
            ["DR-TB progression",
             "Mono → Poly → MDR → XDR → TDR (increasing resistance)"],
            ["TST false negatives",
             "NIMM — No immunity (HIV), Immature system (newborn), Miliary/meningeal TB, Medications (steroids)"],
            ["Rifampicin side effects",
             "RHOS — Red/orange urine/secretions, Hepatotoxicity, OCP failure (enzyme inducer), Stevens-Johnson/flu-like"],
        ],
        col_widths=[W*0.30, W*0.70],
    ), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # COMMONLY CONFUSED CONCEPTS
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("⚠ FREQUENTLY CONFUSED CONCEPTS"), sp(2)]

    confused = [
        ("DOTS vs NTEP", "DOTS is the treatment strategy; NTEP is the national programme framework"),
        ("RNTCP vs NTEP", "Same programme — RNTCP was renamed NTEP in 2020"),
        ("Smear-negative PTB vs EPTB", "Both can be clinically diagnosed — they are NOT the same"),
        ("Miliary TB classification", "Miliary TB = PTB (lungs involved), NOT EPTB, even though disseminated"),
        ("Cured vs Treatment Completed",
         "Cured = bacteriological confirmation (negative smear/culture); "
         "Treatment Completed = clinical completion without bacteriological proof"),
        ("TST positivity cut-off",
         "Different thresholds: ≥5 mm (HIV), ≥10 mm (HCW/congregate), ≥15 mm (general). "
         "NOT a single universal cut-off"),
        ("IGRA vs TST for active vs latent",
         "NEITHER IGRA nor TST can distinguish ACTIVE TB from LTBI"),
        ("BCG and TST",
         "BCG causes false-positive TST (up to 15 mm) but does NOT affect IGRA"),
        ("IP extension in DS-TB",
         "IP extension NOT recommended even if smear positive at end of 2 months (new guideline)"),
        ("Thioacetazone in HIV",
         "Thioacetazone is CONTRAINDICATED in HIV — causes severe and FATAL skin reactions"),
        ("N95 vs Surgical mask",
         "N95 = protects the HCW (wearer); Surgical mask = protects others from the patient"),
        ("LFU definition",
         "LFU = interrupted ≥2 CONSECUTIVE months — not just missing a few doses"),
    ]
    E += [make_table(
        ["Confused Pair / Concept", "Correct Distinction"],
        confused,
        col_widths=[W*0.32, W*0.68],
    ), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # RAPID REVISION SHEET (one page)
    # ══════════════════════════════════════════════════════════════════════════
    E += [PageBreak()]
    E += [h1("📄 ONE-PAGE RAPID REVISION SHEET"), sp(2)]

    rapid_lines = [
        "NTEP = National TB Elimination Programme | Renamed from RNTCP in 2020 | Goal: Eliminate TB by 2025",
        "Causative agent: M. tuberculosis (acid-fast, obligate aerobe, slow-growing — doubling time 15-20 hrs)",
        "India = ~26% of global TB burden (HIGHEST) | 2.64M cases/yr | 4.4 lakh deaths/yr",
        "GLOBAL (2019): 10 million cases | 1.2M deaths (HIV-neg) | 208,000 deaths (HIV+)",
        "1/3 world infected asymptomatically | 5-10% develop active disease lifetime",
        "Transmission: Airborne DROPLET NUCLEI (1-5 µm) | One patient infects 10-15/year",
        "Incubation to TST positivity: 4-12 weeks (usually 6-8 weeks)",
        "─────────────────────────────────────────────────────────────────────────────",
        "DIAGNOSIS: NAAT (Xpert/TrueNat) = First-line initial test under NTEP",
        "ZN stain: Carbol fuchsin (primary) → 3% acid-alcohol (decolorize) → Methylene blue (counter)",
        "SLIDE REPORTING: Scanty=1-9/100 fields | 1+=10-99/100 fields | 2+=1-10/field | 3+=>10/field",
        "TST: Intradermal PPD | Read 48-72 hrs | Measure INDURATION (not redness)",
        "TST +ve: ≥5mm (HIV) | ≥10mm (HCW/congregate) | ≥15mm (general population)",
        "IGRA: Uses ESAT-6/CFP-10 | NOT affected by BCG | 1 visit needed",
        "─────────────────────────────────────────────────────────────────────────────",
        "CASE DEFINITIONS: New | Relapse | After Failure | After LFU | Transfer In",
        "MDR-TB = Resistant to H + R | XDR-TB = MDR + FQ + SLI",
        "─────────────────────────────────────────────────────────────────────────────",
        "TREATMENT OUTCOMES: Cured | Completed | Failed (smear+ at Mo 5+) | Died | LFU (≥2 months) | Not evaluated",
        "TREATMENT SUCCESS = Cured + Treatment Completed",
        "─────────────────────────────────────────────────────────────────────────────",
        "DS-TB REGIMEN (2019): 2HRZE + 4HR (DAILY; FDC tablets)",
        "Adult doses: H=5mg/kg | R=10mg/kg | Z=25mg/kg | E=15mg/kg | max: H=300mg, R=600mg",
        "MDR-TB Group A: Bdq + Lfx/Mfx + Lzd | Group B: Cfz + Cs | Group C as needed",
        "Shorter MDR regimen: 9-12 months | Longer all-oral regimen: 18-20 months",
        "─────────────────────────────────────────────────────────────────────────────",
        "DRUG SIDE EFFECTS: E=Optic neuritis | S=Ototoxic/Nephrotoxic/CI in pregnancy",
        "H=Peripheral neuropathy (give Vit B6) | R=Orange urine+enzyme inducer | Z=Hyperuricemia",
        "Bdq=inhibits ATP synthase | CI: pregnancy+arrhythmia | Thioacetazone=CI in HIV",
        "─────────────────────────────────────────────────────────────────────────────",
        "BCG: Attenuated M. bovis | ID at birth (left arm) | Protects: Miliary TB (80%), TBM (70-80%)",
        "BCG does NOT prevent infection — prevents severe/disseminated disease",
        "─────────────────────────────────────────────────────────────────────────────",
        "NTEP STRUCTURE: CTD (National) → STC (State) → DTC (District) → TU → DMC",
        "TU = 2.5 lakh population (rural) | DMC = 1 lakh (rural) / 50,000 (urban)",
        "NSP PILLARS: Find - Treat - Prevent - Build",
        "Nikshay = mandatory notification + ₹500/month (Nikshay Poshan Yojana) DBT",
        "TPT: 6H or 3HP for contacts <5 yrs + ALL PLHIV",
        "KEY INDICATORS: CDR ≥90% | TSR ≥90% | Default <5%",
    ]
    for line in rapid_lines:
        E.append(Paragraph(line, sty["rapid"]))
    E.append(sp(2))

    # ══════════════════════════════════════════════════════════════════════════
    # TOP 25 POINTS
    # ══════════════════════════════════════════════════════════════════════════
    E += [PageBreak()]
    E += [h1("🏆 TOP 25 MOST IMPORTANT POINTS"), sp(2)]

    top25 = [
        "NTEP = renamed from RNTCP in 2020; goal = TB elimination by 2025",
        "TB caused by M. tuberculosis — acid-fast, obligate aerobe, doubling time 15-20 hrs",
        "1/3 of world population infected (latent); only 5-10% develop active disease lifetime",
        "India accounts for ~26% of global TB burden — HIGHEST globally",
        "HIV = most potent risk factor for progression of LTBI to active TB",
        "Transmission: Airborne droplet NUCLEI (1-5 µm), not large droplets",
        "Incubation (infection → TST positivity) = 4-12 weeks (usually 6-8 weeks)",
        "NTEP diagnostic algorithm: NAAT first (Xpert MTB/RIF or TrueNat)",
        "ZN staining: Carbol fuchsin → acid-alcohol decolorize → methylene blue (AFB = red on blue)",
        "Slide reporting: Scanty (1-9/100 fields) | 1+ (10-99/100) | 2+ (1-10/field) | 3+ (>10/field)",
        "TST thresholds: ≥5 mm (HIV), ≥10 mm (HCW/congregate), ≥15 mm (general)",
        "IGRA uses ESAT-6/CFP-10 — NOT affected by BCG vaccination",
        "MDR-TB = resistant to BOTH H and R; XDR-TB = MDR + FQ + SLI",
        "Treatment Success = Cured + Treatment Completed",
        "LFU = treatment interrupted for ≥2 consecutive months",
        "Treatment Failed = smear/culture positive at month 5 or LATER",
        "Current DS-TB regimen: 2HRZE + 4HR (daily dose, FDCs) — not thrice-weekly",
        "Ethambutol = optic neuritis (check vision); Streptomycin = contraindicated in pregnancy",
        "Bedaquiline: inhibits mycobacterial ATP synthase; CI = pregnancy + cardiac arrhythmia",
        "IP extension NOT recommended even if smear positive at end of 2 months",
        "BCG = attenuated M. bovis; ID at birth; best protects against miliary TB (80%) + TBM (70-80%)",
        "TU covers 2.5 lakh (rural); DMC covers 1 lakh (rural) / 50,000 (urban)",
        "NSP 2017-2025 = FIND, TREAT, PREVENT, BUILD",
        "Nikshay Poshan Yojana = ₹500/month DBT to TB patients for nutritional support",
        "TPT (6H or 3HP) for contacts <5 yrs AND ALL PLHIV (regardless of TST result)",
    ]
    for i, pt in enumerate(top25, 1):
        E.append(bl(f"<b>{i}.</b> {pt}"))
    E.append(sp(2))

    # ══════════════════════════════════════════════════════════════════════════
    # TOP 20 MCQ FACTS
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("🔥 TOP 20 MCQ FACTS"), sp(2)]
    E += [make_table(
        ["#", "Question Stem", "Answer"],
        [
            ["1", "India's TB elimination goal year", "2025 (SDG = 2030)"],
            ["2", "India's share of global TB burden", "~26%"],
            ["3", "Most potent risk factor for LTBI → active TB", "HIV"],
            ["4", "Most important social determinant of TB", "Overcrowding"],
            ["5", "One infectious patient infects per year", "10–15 persons"],
            ["6", "ZN stain — primary stain", "Carbol fuchsin"],
            ["7", "ZN stain — counter stain", "Loeffler's methylene blue"],
            ["8", "1+ smear microscopy result", "10–99 AFB per 100 oil immersion fields"],
            ["9", "Current first-line TB diagnostic test in NTEP", "NAAT (Xpert MTB/RIF or TrueNat)"],
            ["10", "MDR-TB definition", "Resistant to both Isoniazid (H) AND Rifampicin (R)"],
            ["11", "Treatment failure definition", "Smear/culture positive at month 5 or later"],
            ["12", "Lost to follow-up definition", "Treatment interrupted ≥2 consecutive months"],
            ["13", "Current DS-TB regimen (NTEP 2019)", "2HRZE + 4HR (daily dose)"],
            ["14", "Drug causing optic neuritis", "Ethambutol"],
            ["15", "Drug contraindicated in pregnancy", "Streptomycin"],
            ["16", "Bedaquiline mechanism of action", "Inhibits mycobacterial ATP synthase"],
            ["17", "Drug contraindicated in HIV patients (TB treatment)", "Thioacetazone"],
            ["18", "BCG protects best against", "Miliary TB and TB Meningitis"],
            ["19", "TST positive in HIV patients", "≥5 mm induration"],
            ["20", "Nikshay Poshan Yojana amount", "₹500 per month (DBT)"],
        ],
        col_widths=[W*0.06, W*0.50, W*0.44],
    ), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # TOP 10 SAQ/LAQ
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("📝 TOP 10 UNIVERSITY SAQ/LAQ QUESTIONS"), sp(2)]

    saqs = [
        ("[LAQ] Describe the epidemiology of TB in India. Discuss NTEP in detail including "
         "objectives, structure, diagnostic algorithm, and treatment regimens."),
        ("[LAQ] Write in detail about the diagnosis of tuberculosis including sputum smear "
         "microscopy, NAAT, tuberculin test, and IGRA. Add a note on slide reporting."),
        ("[SAQ] Write short notes on DOTS — components and current changes under NTEP."),
        ("[SAQ] Discuss the classification of tuberculosis cases under the revised 2013 definitions."),
        ("[SAQ] Write about treatment outcome definitions in tuberculosis."),
        ("[SAQ] Describe MDR-TB and XDR-TB — definitions, causes, and management."),
        ("[SAQ] Write a note on Bedaquiline and Delamanid in drug-resistant TB."),
        ("[SAQ] Describe the tuberculin skin test (Mantoux test) — procedure, interpretation, "
         "and significance."),
        ("[SAQ] What is LTBI? How is TB preventive treatment given under NTEP?"),
        ("[SAQ] Write about BCG vaccination — organism, efficacy, schedule, and limitations."),
    ]
    for i, q in enumerate(saqs, 1):
        E.append(bl(f"<b>Q{i}.</b> {q}"))
    E.append(sp(2))

    # ══════════════════════════════════════════════════════════════════════════
    # TOP 10 VIVA QUESTIONS
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("🗣️ TOP 10 VIVA QUESTIONS"), sp(2)]
    E += [make_table(
        ["#", "Question", "Key Answer"],
        [
            ["1", "What is NTEP and when was it renamed?",
             "National TB Elimination Programme; renamed from RNTCP in 2020"],
            ["2", "What is the goal of NTEP?",
             "Eliminate TB by 2025 (SDG target = 2030)"],
            ["3", "What is MDR-TB?",
             "Resistant to both Isoniazid (H) AND Rifampicin (R)"],
            ["4", "What is XDR-TB?",
             "MDR-TB + resistant to any fluoroquinolone + any second-line injectable"],
            ["5", "How do you define treatment failure in DS-TB?",
             "Sputum smear/culture positive at month 5 or later during treatment"],
            ["6", "How does Bedaquiline work?",
             "Inhibits mycobacterial ATP synthase — the energy-generating enzyme"],
            ["7", "Which TB drug is contraindicated in HIV patients?",
             "Thioacetazone (causes severe, potentially fatal skin reactions)"],
            ["8", "What is the current first-line test for TB under NTEP?",
             "NAAT — Xpert MTB/RIF or TrueNat (not sputum smear microscopy)"],
            ["9", "What are the 5 elements of DOTS?",
             "Political commitment; Sputum/NAAT diagnostics; Short-course DOT; Drug supply; Standardized recording"],
            ["10", "What is Nikshay Poshan Yojana?",
             "₹500/month Direct Benefit Transfer (DBT) to TB patients for nutritional support"],
        ],
        col_widths=[W*0.06, W*0.44, W*0.50],
    ), sp(2)]

    # ══════════════════════════════════════════════════════════════════════════
    # COMMON MISTAKES
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("❌ COMMON MISTAKES STUDENTS MAKE"), sp(2)]

    mistakes = [
        "Confusing DOTS with NTEP — DOTS is a treatment strategy; NTEP is the national programme",
        "Saying IP should be extended if smear positive at end of 2 months — WRONG under new guidelines; proceed with CP and do NAAT",
        "Wrong slide reporting denominator — confusing 'per 100 fields' (Scanty/1+) with 'per single field' (2+/3+)",
        "Missing TST cut-off for HIV — it is ≥5 mm, NOT ≥10 mm",
        "Saying BCG prevents infection — BCG prevents progression to severe disease, NOT the initial infection itself",
        "Wrong RNTCP→NTEP year — it was renamed in 2020, not earlier",
        "Classifying Miliary TB as EPTB — Miliary TB = PTB (lungs are primarily involved)",
        "Saying IGRA is affected by BCG — IGRA is NOT affected by BCG (uses ESAT-6/CFP-10 not present in BCG)",
        "Confusing MDR and XDR definitions — XDR requires FQ resistance PLUS SLI resistance IN ADDITION to MDR",
        "Forgetting Streptomycin is contraindicated in pregnancy — classic MCQ and viva trap",
    ]
    for i, m in enumerate(mistakes, 1):
        E.append(bl(f"<b>{i}.</b> {m}"))
    E.append(sp(2))

    # ══════════════════════════════════════════════════════════════════════════
    # LAST-MINUTE CHECKLIST
    # ══════════════════════════════════════════════════════════════════════════
    E += [h1("✅ LAST-MINUTE REVISION CHECKLIST"), sp(2)]

    checklist = [
        "NTEP renamed 2020, goal = 2025",
        "India = 26% global TB burden",
        "Transmission = droplet NUCLEI (airborne)",
        "Incubation to TST positivity = 4–12 weeks",
        "ZN stain steps: carbol fuchsin → acid-alcohol → methylene blue",
        "Slide reporting: Scanty / 1+ / 2+ / 3+ (with correct denominators)",
        "Case definitions: bacteriologically confirmed vs clinically diagnosed",
        "Classification: New / Relapse / After failure / After LFU / Transfer in",
        "MDR-TB = H+R resistant | XDR-TB = MDR + FQ + SLI resistant",
        "Treatment outcomes: Cured / Completed / Failed / Died / LFU / Not evaluated",
        "LFU = ≥2 consecutive months interruption",
        "Failed = positive at month 5 or later",
        "DS-TB regimen = 2HRZE + 4HR (daily, FDC)",
        "Drug side effects: E=Eye, S=Ear+Preg CI, H=Neuropathy (Vit B6), R=Enzyme inducer+Orange, Z=Uricemia",
        "Bdq: ATP synthase inhibitor | CI: pregnancy + arrhythmia",
        "BCG: attenuated M. bovis | ID at birth | Miliary TB (80%) + TBM (70-80%)",
        "TST: 5 mm (HIV) | 10 mm (HCW) | 15 mm (general)",
        "IGRA: NOT affected by BCG | ESAT-6/CFP-10",
        "NTEP structure: CTD → STC → DTC → TU → DMC",
        "TU = 2.5 lakh (rural) | DMC = 1 lakh (rural)",
        "NSP pillars: FTPB (Find-Treat-Prevent-Build)",
        "Nikshay Poshan Yojana = ₹500/month DBT",
        "TPT: 6H or 3HP for contacts <5 yrs + ALL PLHIV",
        "Thioacetazone = CI in HIV (fatal skin reactions)",
        "NAAT (Xpert/TrueNat) = first-line diagnostic test under NTEP (not smear microscopy)",
    ]
    for i, item in enumerate(checklist, 1):
        E.append(bl(f"{'☐'} <b>{i}.</b> {item}"))
    E.append(sp(4))

    # Footer note
    E += [
        hr(color=NAVY),
        p("<i>Source: Park's Textbook of Preventive and Social Medicine, 28th Edition — "
          "TUBERCULOSIS / NTEP Chapter. Summary generated by Orris AI Study Assistant, July 2026.</i>",
          "footer"),
    ]

    return E

# ── Page numbering ────────────────────────────────────────────────────────────
def add_page_number(canvas, doc):
    canvas.saveState()
    canvas.setFont("Helvetica", 8)
    canvas.setFillColor(colors.HexColor("#7F8C8D"))
    page_num = canvas.getPageNumber()
    canvas.drawString(18*mm, 10*mm, "NTEP — Park's 28th Edition | High-Yield Summary")
    canvas.drawRightString(A4[0] - 18*mm, 10*mm, f"Page {page_num}")
    canvas.restoreState()

# ── Build ─────────────────────────────────────────────────────────────────────
print("Building NTEP PDF...")
elements = build_content()
doc.build(elements, onFirstPage=add_page_number, onLaterPages=add_page_number)
print(f"Done! Saved to: {OUTPUT}")

1. Save the script above as generate_ntep_pdf.py
2. Install the dependency (if not already installed):

   pip install reportlab
   

3. Run it:

   python generate_ntep_pdf.py
   

4. The file NTEP_Park_28e_Summary.pdf will appear in the same folder.

• Colour-coded section headers (navy/teal)
• All 15 content sections with formatted tables
• Highlighted notes, warnings, and high-yield callouts
• Mnemonics, rapid revision sheet, top 25 points, top 20 MCQs, SAQ/LAQ questions, viva Q&A, common mistakes, and last-minute checklist
• Page numbers and footer on every page