Prevention of Neonatal Tetanus

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

OUTPUT = "/tmp/workspace/neonatal-tetanus/Prevention_of_Neonatal_Tetanus.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=2.2*cm, rightMargin=2.2*cm,
    topMargin=2.2*cm, bottomMargin=2.2*cm,
    title="Prevention of Neonatal Tetanus",
    author="Orris Medical Reference",
    subject="Preventive Medicine – Neonatal Tetanus"
)

W = A4[0] - 4.4*cm  # usable width

# ── Colour palette ──────────────────────────────────────────────────────────
DARK_BLUE   = colors.HexColor("#1a3a5c")
MID_BLUE    = colors.HexColor("#2e6da4")
LIGHT_BLUE  = colors.HexColor("#dbe9f8")
TEAL        = colors.HexColor("#0e7c7b")
LIGHT_TEAL  = colors.HexColor("#d4f0ef")
ORANGE      = colors.HexColor("#d9600a")
LIGHT_GREY  = colors.HexColor("#f4f6f8")
MID_GREY    = colors.HexColor("#c8cdd3")
WHITE       = colors.white
BLACK       = colors.HexColor("#1a1a1a")

# ── Styles ──────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

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

title_style = S("DocTitle",
    fontSize=22, leading=28, textColor=WHITE,
    fontName="Helvetica-Bold", alignment=TA_CENTER)

subtitle_style = S("DocSub",
    fontSize=11, leading=14, textColor=colors.HexColor("#cce0f5"),
    fontName="Helvetica", alignment=TA_CENTER)

h1 = S("H1",
    fontSize=13, leading=17, textColor=WHITE,
    fontName="Helvetica-Bold", spaceAfter=0, spaceBefore=0,
    leftIndent=0)

h2 = S("H2",
    fontSize=11, leading=14, textColor=DARK_BLUE,
    fontName="Helvetica-Bold", spaceBefore=14, spaceAfter=4)

body = S("Body",
    fontSize=9.5, leading=14, textColor=BLACK,
    fontName="Helvetica", alignment=TA_JUSTIFY,
    spaceBefore=4, spaceAfter=4)

bullet = S("Bullet",
    fontSize=9.5, leading=14, textColor=BLACK,
    fontName="Helvetica", leftIndent=16, firstLineIndent=-10,
    spaceBefore=2, spaceAfter=2)

bold_body = S("BoldBody",
    fontSize=9.5, leading=14, textColor=BLACK,
    fontName="Helvetica-Bold")

note_style = S("Note",
    fontSize=8.5, leading=12, textColor=colors.HexColor("#555555"),
    fontName="Helvetica-Oblique", alignment=TA_LEFT)

golden_style = S("Golden",
    fontSize=9.5, leading=14, textColor=ORANGE,
    fontName="Helvetica-Bold", alignment=TA_JUSTIFY)

# ── Helper: section header bar ───────────────────────────────────────────────
def section_header(text, color=DARK_BLUE):
    tbl = Table([[Paragraph(text, h1)]], colWidths=[W])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), color),
        ("TOPPADDING",    (0,0), (-1,-1), 6),
        ("BOTTOMPADDING", (0,0), (-1,-1), 6),
        ("LEFTPADDING",   (0,0), (-1,-1), 10),
        ("RIGHTPADDING",  (0,0), (-1,-1), 10),
        ("ROUNDEDCORNERS", [4]),
    ]))
    return tbl

def bullet_item(text):
    return Paragraph(f"<bullet>&bull;</bullet> {text}", bullet)

def sp(h=6):
    return Spacer(1, h)

# ── Build story ──────────────────────────────────────────────────────────────
story = []

# ── Title block ──────────────────────────────────────────────────────────────
title_tbl = Table(
    [[Paragraph("Prevention of Neonatal Tetanus", title_style)],
     [Paragraph("A Comprehensive Preventive Medicine Reference", subtitle_style)]],
    colWidths=[W]
)
title_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), DARK_BLUE),
    ("TOPPADDING",    (0,0), (-1,-1), 18),
    ("BOTTOMPADDING", (0,0), (-1,-1), 18),
    ("LEFTPADDING",   (0,0), (-1,-1), 14),
    ("RIGHTPADDING",  (0,0), (-1,-1), 14),
    ("ROUNDEDCORNERS", [6]),
]))
story.append(title_tbl)
story.append(sp(12))

# Source note
story.append(Paragraph(
    "<i>Source: Park's Textbook of Preventive and Social Medicine | "
    "Creasy &amp; Resnik's Maternal-Fetal Medicine | Rosen's Emergency Medicine | WHO MNTE Programme</i>",
    note_style))
story.append(sp(10))
story.append(HRFlowable(width=W, thickness=1.5, color=MID_BLUE))
story.append(sp(10))

# ── 1. Overview ──────────────────────────────────────────────────────────────
story.append(section_header("1.  Overview"))
story.append(sp(8))
story.append(Paragraph(
    "Neonatal tetanus (NT) – also called <i>tetanus neonatorum</i> – is caused by <i>Clostridium tetani</i> "
    "spores introduced through the umbilical cord during unclean delivery. It is the second leading cause "
    "of death among EPI target diseases (after measles) in developing countries, with a case-fatality rate "
    "of 80-100% without high-quality treatment. It is <b>nearly 100% preventable</b> through two "
    "complementary pillars: maternal immunization and clean delivery practices.", body))
story.append(sp(4))

# Key facts box
facts = [
    ["Key Epidemiological Facts"],
    ["Global NT deaths: ~787,000 (1988)  →  ~34,000 (2015)  =  96% reduction (WHO)"],
    ["Elimination target: < 1 case per 1,000 live births per district"],
    ["Occurs almost exclusively where maternal immunization is inadequate & cord care is unclean"],
    ["C. tetani spores are environmentally persistent — eradication is NOT possible; only elimination"],
]
facts_tbl = Table(facts, colWidths=[W])
facts_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (0,0), TEAL),
    ("TEXTCOLOR",     (0,0), (0,0), WHITE),
    ("FONTNAME",      (0,0), (0,0), "Helvetica-Bold"),
    ("FONTSIZE",      (0,0), (0,0), 10),
    ("BACKGROUND",    (0,1), (-1,-1), LIGHT_TEAL),
    ("FONTNAME",      (0,1), (-1,-1), "Helvetica"),
    ("FONTSIZE",      (0,1), (-1,-1), 9),
    ("LEADING",       (0,1), (-1,-1), 13),
    ("TOPPADDING",    (0,0), (-1,-1), 6),
    ("BOTTOMPADDING", (0,0), (-1,-1), 6),
    ("LEFTPADDING",   (0,0), (-1,-1), 10),
    ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#9ececa")),
]))
story.append(facts_tbl)
story.append(sp(12))

# ── 2. Maternal Immunization ─────────────────────────────────────────────────
story.append(section_header("2.  Maternal Immunization with Tetanus Toxoid-Containing Vaccines (TTCV)"))
story.append(sp(8))
story.append(Paragraph(
    "Tetanus toxoid (TT) protects both the mother and her newborn through "
    "transplacental transfer of maternal IgG antibodies. It is the cornerstone of NT prevention.", body))
story.append(sp(6))

story.append(Paragraph("A.  Unimmunized Pregnant Women — Two-Dose Primary Course", h2))
tt_data = [
    ["Dose", "Timing", "Protection Conferred"],
    ["TT1", "As early as possible in pregnancy", "Minimal individual protection"],
    ["TT2", "≥ 1 month after TT1; ≥ 3 weeks before delivery\n(India: 16–36 weeks; 1–2 month interval)", "~80% for ≈ 3 years"],
]
tt_tbl = Table(tt_data, colWidths=[W*0.10, W*0.52, W*0.38])
tt_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), MID_BLUE),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",      (0,0), (-1,-1), 9),
    ("LEADING",       (0,0), (-1,-1), 13),
    ("BACKGROUND",    (0,1), (-1,1), LIGHT_BLUE),
    ("BACKGROUND",    (0,2), (-1,2), WHITE),
    ("GRID",          (0,0), (-1,-1), 0.5, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING",   (0,0), (-1,-1), 7),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))
story.append(tt_tbl)
story.append(sp(6))

# Golden rule
golden_box = Table([[Paragraph(
    "Golden Rule: No pregnant woman should be denied even ONE dose of TT if she presents late "
    "in pregnancy. There is no evidence that tetanus toxoid is harmful to the fetus.", golden_style)]],
    colWidths=[W])
golden_box.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), colors.HexColor("#fff3e0")),
    ("LEFTPADDING",   (0,0), (-1,-1), 12),
    ("RIGHTPADDING",  (0,0), (-1,-1), 12),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("BOX",           (0,0), (-1,-1), 1.5, ORANGE),
]))
story.append(golden_box)
story.append(sp(8))

story.append(Paragraph("B.  Previously Immunized Pregnant Women", h2))
story.append(bullet_item("A single <b>booster dose</b> is sufficient."))
story.append(bullet_item("Booster is <b>not</b> needed at every consecutive pregnancy — risk of hyper-immunization and side effects."))
story.append(sp(8))

story.append(Paragraph("C.  WHO Recommended Lifetime 6-Dose Schedule", h2))
who_data = [
    ["Dose", "When Given", "Duration of Protection"],
    ["TT1", "First contact / ANC", "None"],
    ["TT2", "4 weeks after TT1", "1–3 years"],
    ["TT3", "6 months after TT2", "5 years"],
    ["TT4", "1 year after TT3", "10 years"],
    ["TT5", "1 year after TT4", "Life-long (> 20 years)"],
]
who_tbl = Table(who_data, colWidths=[W*0.10, W*0.45, W*0.45])
who_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), DARK_BLUE),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",      (0,0), (-1,-1), 9),
    ("LEADING",       (0,0), (-1,-1), 13),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_BLUE, WHITE]),
    ("GRID",          (0,0), (-1,-1), 0.5, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING",   (0,0), (-1,-1), 7),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))
story.append(who_tbl)
story.append(sp(6))
story.append(Paragraph(
    "Women who received 6 TTCV doses during childhood, or 5 doses with the last within 10 years, "
    "do <b>not</b> need additional doses during pregnancy.", body))
story.append(sp(8))

story.append(Paragraph("D.  High-Risk Area Strategy", h2))
story.append(Paragraph(
    "In areas where NT incidence is high and ANC coverage is low, the primary 2-dose course "
    "should be extended to <b>all women of childbearing age (15–49 years)</b>, not just pregnant women. "
    "Women of reproductive age in high-risk districts (HRDs) are targeted with <b>3 properly spaced "
    "TTCV doses</b> through specially organized supplementary immunization activities.", body))
story.append(sp(12))

# ── 3. Five Cleans ───────────────────────────────────────────────────────────
story.append(section_header("3.  Clean Delivery Practices — The \"Five Cleans\"", color=TEAL))
story.append(sp(8))
story.append(Paragraph(
    "Training traditional birth attendants (TBAs) in clean delivery practices alone can reduce "
    "NT deaths by <b>up to 90%</b>. The core principle is the <b>Five Cleans</b> (<i>Panch Safai</i>):", body))
story.append(sp(6))

cleans = [
    ["#", "Clean Element", "Details"],
    ["1", "Clean Hands", "Birth attendant washes hands thoroughly with soap and water before delivery"],
    ["2", "Clean Delivery Surface", "A clean mat or cloth placed under the mother"],
    ["3", "Clean Blade", "A new or sterilized blade used to cut the umbilical cord"],
    ["4", "Clean Cord Tie", "Sterile or clean ligature for tying the cord stump"],
    ["5", "Clean Cord Care", "Nothing applied to the cord stump — no dung, soil, ash, ghee, or any traditional application"],
]
cleans_tbl = Table(cleans, colWidths=[W*0.06, W*0.22, W*0.72])
cleans_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), TEAL),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",      (0,0), (-1,-1), 9),
    ("LEADING",       (0,0), (-1,-1), 13),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_TEAL, WHITE]),
    ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#9ececa")),
    ("TOPPADDING",    (0,0), (-1,-1), 6),
    ("BOTTOMPADDING", (0,0), (-1,-1), 6),
    ("LEFTPADDING",   (0,0), (-1,-1), 7),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("FONTNAME",      (0,1), (1,-1), "Helvetica-Bold"),
    ("TEXTCOLOR",     (0,1), (0,-1), TEAL),
]))
story.append(cleans_tbl)
story.append(sp(6))
story.append(Paragraph(
    "Provision of <b>home delivery kits</b> (containing a clean blade, clean cord tie, and instructions) "
    "supports these practices in resource-limited settings where institutional delivery is not feasible.", body))
story.append(sp(12))

# ── 4. Passive Protection ────────────────────────────────────────────────────
story.append(section_header("4.  Passive Protection of the Newborn"))
story.append(sp(8))
story.append(Paragraph(
    "If a newborn is delivered to an unimmunized mother (who did not receive 2 doses of TT during "
    "pregnancy), passive protection can be provided as a <b>fallback measure</b>:", body))
story.append(sp(4))

passive_data = [
    ["Agent", "Dose", "Timing", "Note"],
    ["Tetanus Antitoxin\n(heterologous serum)", "750 IU", "Within 6 hours of birth",
     "Not a substitute for maternal immunization; emergency fallback only"],
]
passive_tbl = Table(passive_data, colWidths=[W*0.25, W*0.12, W*0.27, W*0.36])
passive_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), MID_BLUE),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",      (0,0), (-1,-1), 9),
    ("LEADING",       (0,0), (-1,-1), 13),
    ("BACKGROUND",    (0,1), (-1,1), LIGHT_BLUE),
    ("GRID",          (0,0), (-1,-1), 0.5, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 6),
    ("BOTTOMPADDING", (0,0), (-1,-1), 6),
    ("LEFTPADDING",   (0,0), (-1,-1), 7),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))
story.append(passive_tbl)
story.append(sp(12))

# ── 5. WHO MNTE ──────────────────────────────────────────────────────────────
story.append(section_header("5.  WHO Maternal and Neonatal Tetanus Elimination (MNTE) Programme", color=colors.HexColor("#4a235a")))
story.append(sp(8))
story.append(Paragraph(
    "The MNTE programme was established in <b>1999</b>. Elimination is defined as "
    "<b>&lt; 1 case per 1,000 live births per district</b>. It employs a <b>four-pronged strategy</b>:", body))
story.append(sp(6))

mnte_data = [
    ["Strategy", "Description"],
    ["1. Clean Delivery & Cord Care",
     "Prevent infection during and after the delivery process through hygienic obstetric practices"],
    ["2. Routine TTCV Vaccination",
     "Systematic vaccination of pregnant women attending ANC with TT-containing vaccines"],
    ["3. Supplemental Immunization Campaigns",
     "Targeting all women of reproductive age in high-risk districts with 3 properly spaced TTCV doses"],
    ["4. Strengthened Surveillance",
     "Identify women at risk, reasons for risk, and potential geographic clustering of cases"],
]
mnte_tbl = Table(mnte_data, colWidths=[W*0.35, W*0.65])
mnte_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), colors.HexColor("#4a235a")),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",      (0,0), (-1,-1), 9),
    ("LEADING",       (0,0), (-1,-1), 13),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [colors.HexColor("#f3eaf7"), WHITE]),
    ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#c9a8d4")),
    ("TOPPADDING",    (0,0), (-1,-1), 6),
    ("BOTTOMPADDING", (0,0), (-1,-1), 6),
    ("LEFTPADDING",   (0,0), (-1,-1), 8),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("FONTNAME",      (0,1), (0,-1), "Helvetica-Bold"),
]))
story.append(mnte_tbl)
story.append(sp(12))

# ── 6. India MNTE ────────────────────────────────────────────────────────────
story.append(section_header("6.  India's MNT Elimination Strategy", color=colors.HexColor("#8b1a1a")))
story.append(sp(8))
story.append(Paragraph(
    "India achieved official MNT elimination certification in <b>May 2015</b>. "
    "Key strategies employed:", body))
story.append(sp(4))

india_items = [
    "Acceleration of TT immunization through the WHO-recommended <b>high-risk district approach</b>",
    "Systematic TT vaccination of all pregnant women at ANC visits",
    "<b>Janani Suraksha Yojana (JSY)</b> — conditional cash transfer scheme to incentivize institutional delivery",
    "Intensive 3-week refresher training for all skilled birth attendants (ANMs, midwives, TBAs)",
    "Distribution of <b>disposable delivery kits</b> to skilled birth attendants for each pregnancy",
    "Engagement of <b>&gt;896,000 ASHA workers</b> to generate community demand for health services",
    "Operationalization of sub-centres and CHCs for <b>24/7 obstetric and neonatal care</b>",
    "Setting up Newborn Care Corners, Special Neonatal Care Units, and Newborn Stabilization Units",
    "Village Health and Nutrition Days integrating vaccination of children, adolescents, and pregnant women",
    "<b>Janani Shishu Suraksha Karyakram (2011)</b> — free delivery and neonatal care entitlements",
]
for item in india_items:
    story.append(bullet_item(item))
story.append(sp(6))

result_tbl = Table([[Paragraph(
    "Result: Safe deliveries rose from 52% (2007) to 76% (2009). "
    "By December 2014, 30 of 36 states/UTs were validated for MNT elimination.", 
    S("Res", fontSize=9.5, leading=14, textColor=colors.HexColor("#8b1a1a"),
      fontName="Helvetica-Bold"))]],
    colWidths=[W])
result_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), colors.HexColor("#fdf0f0")),
    ("LEFTPADDING",   (0,0), (-1,-1), 12),
    ("RIGHTPADDING",  (0,0), (-1,-1), 12),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("BOX",           (0,0), (-1,-1), 1.5, colors.HexColor("#8b1a1a")),
]))
story.append(result_tbl)
story.append(sp(12))

# ── 7. Summary Table ─────────────────────────────────────────────────────────
story.append(section_header("7.  Summary of All Prevention Strategies"))
story.append(sp(8))

summary_data = [
    ["Strategy", "Target Population", "Mechanism"],
    ["TT immunization (2 doses)", "Pregnant women", "Passive IgG transfer across placenta to fetus"],
    ["TT for all women of reproductive age", "Women 15–49 yrs in HRDs", "Sustained herd immunity; prevents future pregnancies being unprotected"],
    ["Five Cleans / clean delivery", "Birth attendant + mother", "Prevents cord contamination with C. tetani spores"],
    ["Home delivery kits", "TBAs / home deliveries", "Provides clean instruments where facility delivery unavailable"],
    ["Institutional delivery promotion", "Communities / rural women", "Sterile environment + skilled staff"],
    ["Tetanus antitoxin at birth", "Neonates of unimmunized mothers", "Passive prophylaxis within 6 hours — emergency fallback"],
    ["Supplemental immunization campaigns", "HRDs with low ANC coverage", "Rapidly boost population immunity"],
    ["Surveillance & monitoring", "Health system", "Identify gaps, high-risk districts, clustering"],
]
sum_tbl = Table(summary_data, colWidths=[W*0.30, W*0.30, W*0.40])
sum_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), DARK_BLUE),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",      (0,0), (-1,-1), 8.5),
    ("LEADING",       (0,0), (-1,-1), 12),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_BLUE, WHITE]),
    ("GRID",          (0,0), (-1,-1), 0.5, MID_GREY),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING",   (0,0), (-1,-1), 6),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))
story.append(sum_tbl)
story.append(sp(12))

# ── 8. References ─────────────────────────────────────────────────────────────
story.append(HRFlowable(width=W, thickness=1, color=MID_GREY))
story.append(sp(6))
story.append(Paragraph("<b>References</b>", h2))
refs = [
    "Park K. Park's Textbook of Preventive and Social Medicine, 25th ed. Banarsidas Bhanot; 2019.",
    "Creasy RK, Resnik R et al. Maternal-Fetal Medicine: Principles and Practice, 8th ed. Elsevier; 2019.",
    "Marx JA et al. Rosen's Emergency Medicine: Concepts and Clinical Practice, 9th ed. Elsevier; 2020.",
    "WHO. Maternal and Neonatal Tetanus Elimination (MNTE) Programme. who.int, 2023.",
    "Yusuf N et al. Progress and barriers towards maternal and neonatal tetanus elimination in the remaining 12 countries. Lancet Glob Health. 2021;9(11):e1500–e1509. PMID 34678200.",
    "WHO. Tetanus vaccines: WHO position paper, February 2017. Wkly Epidemiol Rec. 2017;92(6):53–76.",
]
for i, r in enumerate(refs, 1):
    story.append(Paragraph(f"{i}.  {r}", note_style))
    story.append(sp(2))

# ── Build ─────────────────────────────────────────────────────────────────────
doc.build(story)
print(f"PDF created: {OUTPUT}")