PSM / Community Medicine - Complete High-Yield Notes

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# ── MCQ data: (question, [options], answer_letter, explanation) ───────────────
MCQ_DATA = [
    # ── SECTION 1: EPIDEMIOLOGY ────────────────────────────────────────────
    ("1. A researcher follows 500 smokers and 500 non-smokers for 10 years to compare lung cancer rates. This is a:",
     ["A) Case-control study","B) Cross-sectional study","C) Cohort study","D) Ecological study"],
     "C","Cohort study: starts with exposure → follows forward → measures incidence/RR."),

    ("2. The measure of association calculated in a case-control study is:",
     ["A) Relative Risk","B) Odds Ratio","C) Attributable Risk","D) Incidence Rate Ratio"],
     "B","OR = (a×d)/(b×c) from a 2×2 table. RR cannot be calculated in case-control studies."),

    ("3. Sensitivity of a test (TP=80, FP=20, FN=40, TN=160) is:",
     ["A) 80%","B) 89%","C) 67%","D) 44%"],
     "C","Sensitivity = TP/(TP+FN) = 80/(80+40) = 80/120 = 66.7% ≈ 67%."),

    ("4. Which study design is BEST for studying rare diseases?",
     ["A) Cohort study","B) Cross-sectional study","C) Case-control study","D) Ecological study"],
     "C","Case-control: starts from disease backward; efficient for rare diseases."),

    ("5. 'SnNout' means:",
     ["A) Specific test, negative = rule out","B) Sensitive test, negative = rule out","C) Sensitive test, positive = rule in","D) Specific test, positive = rule in"],
     "B","Sn=Sensitive; N=Negative; out=rules OUT. High sensitivity → negative result excludes disease."),

    ("6. Prevalence = 200/1000; Incidence = 20/1000/year. Average disease duration is:",
     ["A) 2 years","B) 5 years","C) 10 years","D) 20 years"],
     "C","P = I × D → D = P/I = (200/1000)÷(20/1000) = 10 years."),

    ("7. In a screening programme, the most important property of the test is:",
     ["A) High specificity","B) High PPV","C) High sensitivity","D) High NPV"],
     "C","High sensitivity ensures no true cases are missed (false negatives minimised)."),

    ("8. Disease prevalence 1%, sensitivity 99%, specificity 99%. PPV is approximately:",
     ["A) 99%","B) 50%","C) 25%","D) 75%"],
     "B","With low prevalence, many false positives occur even with 99% specificity → PPV ≈ 50%."),

    ("9. Gold standard study design for establishing causation:",
     ["A) Cohort study","B) Case-control study","C) Randomized Controlled Trial","D) Systematic review"],
     "C","RCT: randomisation eliminates confounding; gold standard for causation."),

    ("10. Analysing patients in the group they were assigned to (regardless of treatment received):",
     ["A) Per protocol analysis","B) Intention to treat analysis","C) On-treatment analysis","D) Modified ITT"],
     "B","ITT preserves randomisation integrity by including all assigned patients."),

    ("11. Phase III clinical trial involves:",
     ["A) First-in-human safety","B) Small efficacy study","C) Large-scale comparison with standard treatment","D) Post-marketing surveillance"],
     "C","Phase III: large RCT vs standard/placebo; basis for regulatory approval."),

    ("12. 'Father of Epidemiology' is:",
     ["A) Louis Pasteur","B) Robert Koch","C) John Snow","D) Edward Jenner"],
     "C","John Snow: Broad Street cholera pump 1854; classic epidemiological investigation."),

    ("13. Attack rate is used in:",
     ["A) Endemic diseases","B) Epidemic/outbreak settings","C) Chronic NCDs","D) Occupational diseases"],
     "B","Attack rate = cases/exposed × 100; used during outbreaks/epidemics."),

    ("14. Recall bias is most common in:",
     ["A) Cohort studies","B) RCTs","C) Case-control studies","D) Ecological studies"],
     "C","Cases recall past exposures differently from controls → recall bias in case-control."),

    ("15. A point-source epidemic curve shows:",
     ["A) Multiple peaks separated by incubation period","B) Rapid rise and fall with a single peak","C) Gradual rise over months","D) Plateau for several weeks"],
     "B","Common-source/point-source: rapid rise → rapid fall; single bell-shaped peak."),

    ("16. Attributable Risk Percent (AR%) measures:",
     ["A) Proportion of disease in exposed attributable to exposure","B) Excess risk in total population","C) Risk in unexposed population","D) Odds ratio minus 1"],
     "A","AR% = (Ie − Iu)/Ie × 100; proportion of disease in exposed due to that specific exposure."),

    ("17. Cross-sectional study measures:",
     ["A) Incidence","B) Relative Risk","C) Prevalence","D) Attributable Risk"],
     "C","Cross-sectional (prevalence survey) measures point or period prevalence."),

    ("18. In a double-blind RCT, who is blinded?",
     ["A) Patient only","B) Investigator only","C) Both patient and investigator","D) Patient, investigator, and statistician"],
     "C","Double-blind: both patient AND investigator are unaware of treatment allocation."),

    ("19. Koch's postulates do NOT include:",
     ["A) Organism found in all cases","B) Organism isolated in pure culture","C) Organism transmitted by a vector","D) Inoculation produces disease in healthy host"],
     "C","Vector transmission is NOT part of Koch's postulates."),

    ("20. Which is a prospective study?",
     ["A) Case-control","B) Cross-sectional","C) Ecological","D) Cohort"],
     "D","Cohort study follows subjects forward in time (prospective direction)."),

    ("21. Doll & Hill's 1950 smoking–lung cancer study was:",
     ["A) Cohort study","B) Case-control study","C) Cross-sectional study","D) RCT"],
     "B","The 1950 Doll & Hill study was a hospital-based case-control study."),

    ("22. Framingham Heart Study is an example of:",
     ["A) Case-control study","B) Ecological study","C) Cohort study","D) Cross-sectional study"],
     "C","Framingham: classic long-term prospective cohort study (started 1948)."),

    ("23. Highest level of evidence in EBM:",
     ["A) RCT","B) Cohort study","C) Systematic review with meta-analysis","D) Expert opinion"],
     "C","Systematic review + meta-analysis of RCTs = apex of evidence pyramid."),

    ("24. Specificity = ?",
     ["A) TP/(TP+FN)","B) TN/(TN+FP)","C) TP/(TP+FP)","D) TN/(TN+FN)"],
     "B","Specificity = TN/(TN+FP); correctly identifies true negatives."),

    ("25. Secondary attack rate measures:",
     ["A) Severity of disease","B) Transmissibility/communicability","C) Case fatality rate","D) Herd immunity"],
     "B","SAR = new cases among susceptible contacts/total susceptible contacts × 100; measures transmissibility."),

    ("26. Natural history of disease is the basis of:",
     ["A) Koch's postulates","B) Levels of prevention","C) Herd immunity","D) Demographic transition"],
     "B","Primordial, primary, secondary, tertiary prevention map onto different phases of natural history."),

    ("27. Primordial prevention targets:",
     ["A) Early disease detection","B) Rehabilitation","C) Prevention of risk factor emergence","D) Specific protection"],
     "C","Primordial = prevent risk factors from ever appearing (e.g., preventing childhood obesity)."),

    ("28. RR = 1 means:",
     ["A) Strong positive association","B) No association","C) Negative association","D) Strong protective effect"],
     "B","RR=1: incidence in exposed = incidence in unexposed; no association exists."),

    ("29. Herd immunity threshold for measles is approximately:",
     ["A) 50%","B) 70%","C) 83–94%","D) 40%"],
     "C","Measles R0=12–18; herd immunity requires 83–94% immune population."),

    ("30. Best measure of central tendency for skewed data:",
     ["A) Mean","B) Mode","C) Median","D) Standard deviation"],
     "C","Median is resistant to outliers; ideal for skewed distributions."),

    ("31. In a positively skewed distribution:",
     ["A) Mean = Median = Mode","B) Mean < Median < Mode","C) Mean > Median > Mode","D) Mode > Mean > Median"],
     "C","Positive skew (right tail): Mean pulled highest → Mean > Median > Mode."),

    ("32. NNT (Number Needed to Treat) = ?",
     ["A) 1/Relative Risk","B) 1/Absolute Risk Reduction","C) RR × incidence","D) AR%/100"],
     "B","NNT = 1/ARR; lower NNT = more effective treatment."),

    ("33. Sampling method used in EPI coverage surveys:",
     ["A) Simple random","B) Systematic","C) Cluster","D) Stratified"],
     "C","EPI 30-cluster sampling: 30 clusters × 7 children = 210 children."),

    ("34. Confounding in observational studies can be controlled by:",
     ["A) Increasing sample size","B) Randomisation and stratification","C) Longer follow-up","D) Larger population"],
     "B","Randomisation (RCT) or stratification/multivariate analysis (observational) controls confounding."),

    ("35. The 'iceberg phenomenon' in epidemiology means:",
     ["A) Most disease is diagnosed","B) Most disease is subclinical/undiagnosed below the surface","C) Incidence decreasing","D) Only severe cases reported"],
     "B","Visible tip = diagnosed cases; submerged mass = subclinical/undetected cases."),

    # ── SECTION 2: BIOSTATISTICS ───────────────────────────────────────────
    ("36. Type I error (alpha) is:",
     ["A) Accepting a false null hypothesis","B) Rejecting a true null hypothesis","C) Accepting a true null hypothesis","D) Rejecting a false null hypothesis"],
     "B","Type I = false positive; incorrectly rejecting H₀ when it is true. α = p-value threshold."),

    ("37. p-value of 0.03 means:",
     ["A) 3% chance alternative hypothesis is true","B) 3% probability of results if H₀ is true","C) 97% power","D) Clinically significant result"],
     "B","p-value = P(data as extreme as observed | H₀ is true); does NOT measure clinical significance."),

    ("38. Power of a study = ?",
     ["A) 1 − alpha","B) 1 − beta","C) Alpha + beta","D) Beta/alpha"],
     "B","Power = 1 − β = probability of correctly detecting a true effect (rejecting false H₀)."),

    ("39. Chi-square test is used for:",
     ["A) Comparing means of two groups","B) Comparing proportions/categorical data","C) Correlation of continuous variables","D) Comparing variances"],
     "B","Chi-square tests association between categorical variables."),

    ("40. Student's t-test compares:",
     ["A) Three or more group means","B) Two group means (normal distribution)","C) Categorical proportions","D) Ranked non-parametric data"],
     "B","t-test: two-group comparison of means; requires normal distribution and continuous data."),

    ("41. ANOVA is used when comparing:",
     ["A) Two proportions","B) Two means","C) Three or more means","D) Ordinal data between two groups"],
     "C","One-way ANOVA compares means across 3+ groups simultaneously."),

    ("42. Normal distribution: Mean ± 2 SD covers:",
     ["A) 68.2%","B) 95.4%","C) 99.7%","D) 50%"],
     "B","±1SD=68.2%, ±2SD=95.4%, ±3SD=99.7% — memorise this triad."),

    ("43. Pearson's correlation coefficient (r) ranges from:",
     ["A) 0 to 1","B) −1 to 0","C) −1 to +1","D) 0 to infinity"],
     "C","r: −1 (perfect negative) to +1 (perfect positive); 0 = no linear correlation."),

    ("44. Non-parametric equivalent of paired t-test:",
     ["A) Mann-Whitney U test","B) Kruskal-Wallis test","C) Wilcoxon signed-rank test","D) Fisher's exact test"],
     "C","Wilcoxon signed-rank = non-parametric paired t-test equivalent."),

    ("45. Histogram is used for:",
     ["A) Categorical data","B) Continuous data frequency distribution","C) Two categorical variables","D) Trends over time"],
     "B","Histogram: continuous variable frequency distribution; bars are contiguous (no gaps)."),

    ("46. Standard Error of Mean (SEM) = ?",
     ["A) SD × √n","B) SD / √n","C) Variance / n","D) SD²"],
     "B","SEM = SD/√n; measures precision of sample mean; smaller SEM = more precise estimate."),

    ("47. Fisher's exact test is used when:",
     ["A) Sample size is large","B) Expected cell frequency <5","C) Continuous normal data","D) Comparing 3+ proportions"],
     "B","Fisher's exact test replaces chi-square when any expected cell frequency is <5."),

    ("48. Middle line in a box plot represents:",
     ["A) Mean","B) Mode","C) Median","D) 75th percentile"],
     "C","Box plot: middle line = median (Q2); box edges = Q1 and Q3; whiskers = range."),

    ("49. Coefficient of Variation (CV) is used to:",
     ["A) Compare variability across different measurement scales","B) Compare variability in same units","C) Measure skewness","D) Measure association"],
     "A","CV = (SD/Mean) × 100; dimensionless; allows comparison across different units/scales."),

    ("50. Graph to study correlation between two continuous variables:",
     ["A) Bar chart","B) Pie chart","C) Scatter diagram","D) Histogram"],
     "C","Scatter diagram (scatter plot) shows relationship between two continuous variables."),

    ("51. Systematic sampling: N=1000, n=100. Sampling interval k = ?",
     ["A) 5","B) 10","C) 100","D) 50"],
     "B","k = N/n = 1000/100 = 10; select every 10th individual after random start."),

    ("52. Lorenz curve measures:",
     ["A) Disease incidence","B) Income/wealth inequality","C) Test sensitivity","D) Normal distribution"],
     "B","Lorenz curve shows cumulative income distribution; Gini coefficient = area between curve and diagonal."),

    ("53. Stratified random sampling ensures:",
     ["A) Every sample has equal chance","B) Proportional representation of all subgroups","C) Consecutive patients selected","D) Whole groups selected as units"],
     "B","Stratified sampling guarantees all subgroups (strata) are proportionally represented."),

    ("54. Non-parametric equivalent of one-way ANOVA:",
     ["A) Mann-Whitney U test","B) Wilcoxon signed-rank test","C) Kruskal-Wallis test","D) Spearman's rho"],
     "C","Kruskal-Wallis = non-parametric ANOVA; compares 3+ independent groups by ranks."),

    ("55. 95% CI for OR that does NOT include 1.0 indicates:",
     ["A) Not statistically significant","B) Statistically significant result","C) Type II error occurred","D) Low study power"],
     "B","OR 95% CI excluding 1.0 (null value) = statistically significant at p<0.05."),

    # ── SECTION 3: IMMUNIZATION ────────────────────────────────────────────
    ("56. BCG vaccine is a:",
     ["A) Killed vaccine","B) Toxoid","C) Live attenuated vaccine","D) Recombinant subunit vaccine"],
     "C","BCG = live attenuated Mycobacterium bovis; protects against severe TB in children."),

    ("57. Which vaccine is CONTRAINDICATED in immunocompromised children?",
     ["A) Hepatitis B","B) IPV","C) MMR","D) PCV"],
     "C","MMR is live attenuated; contraindicated in immunocompromised (risk of vaccine-strain disease)."),

    ("58. Birth dose vaccines in India's UIP:",
     ["A) BCG + OPV-0 + Hepatitis B","B) BCG + DPT + OPV-0","C) BCG + Hep B + IPV","D) OPV-0 + DPT + Hep B"],
     "A","BCG + OPV-0 + Hepatitis B given within 24 hours of birth."),

    ("59. Pentavalent vaccine contains:",
     ["A) DPT + HepB + Hib","B) DPT + IPV + Hib","C) DPT + MMR + Hib","D) DPT + HepB + OPV"],
     "A","Penta = DPT + Hepatitis B + Hib = 5 antigens in one injection."),

    ("60. VVM: when should vaccine be DISCARDED?",
     ["A) Inner square lighter than outer circle","B) Inner square same or darker than outer circle","C) Outer circle turns white","D) Inner square turns blue"],
     "B","Discard when inner square ≥ outer circle darkness; indicates cumulative heat damage."),

    ("61. Freeze-sensitive vaccine among the following:",
     ["A) OPV","B) BCG","C) Measles","D) DPT"],
     "D","DPT, TT, Hep B, Hib, IPV, PCV are freeze-sensitive; freezing destroys them."),

    ("62. Recommended storage temperature for OPV:",
     ["A) +2°C to +8°C","B) −15°C to −25°C","C) Room temperature","D) +4°C to +8°C"],
     "B","OPV stored at −15°C to −25°C in deep freezer at district level."),

    ("63. Mission Indradhanush was launched in:",
     ["A) 2012","B) 2014","C) 2016","D) 2018"],
     "B","Mission Indradhanush launched December 2014; target >90% immunization coverage."),

    ("64. Open vial policy does NOT apply to:",
     ["A) DPT","B) Hepatitis B","C) BCG","D) OPV"],
     "C","BCG must be used within 4 hours of reconstitution; OVP does not apply."),

    ("65. HPV strains responsible for genital warts:",
     ["A) 16 and 18","B) 6 and 11","C) 31 and 33","D) 16 and 31"],
     "B","HPV 6 & 11 → genital warts (condylomata acuminata) and recurrent respiratory papillomatosis."),

    ("66. HPV strains responsible for 70% of cervical cancers:",
     ["A) 6 and 11","B) 31 and 33","C) 16 and 18","D) 45 and 52"],
     "C","HPV 16 & 18 account for approximately 70% of all cervical cancers."),

    ("67. PEP for rabies Category III wound includes:",
     ["A) Wound wash only","B) Wound wash + vaccine","C) Wound wash + vaccine + RIG","D) RIG only"],
     "C","Cat. III (deep bite/mucosal exposure): wound wash + vaccine course + Rabies Immunoglobulin."),

    ("68. Essen regimen for rabies PEP:",
     ["A) Days 0, 7, 28 (3 doses)","B) Days 0, 0, 7, 21 (4 doses)","C) Days 0, 3, 7, 14, 28 (5 doses)","D) Days 0 and 28 (2 doses)"],
     "C","Essen: 5 IM doses on days 0, 3, 7, 14, 28."),

    ("69. Ice Lined Refrigerator (ILR) stores vaccines at:",
     ["A) −15°C to −25°C","B) +2°C to +8°C","C) 0°C to +4°C","D) +8°C to +15°C"],
     "B","ILR: +2°C to +8°C; designed to maintain temperature even during power cuts."),

    ("70. Conjugate vaccines are effective in infants <2 years because they:",
     ["A) Cannot be used in children under 5","B) Elicit T-cell dependent response","C) Require only one dose","D) Have no booster effect"],
     "B","Conjugate vaccines (Hib, PCV) generate T-cell memory → effective in infants; plain polysaccharide vaccines are T-independent and fail in <2 years."),

    ("71. Vaccine carrier maintains cold chain for approximately:",
     ["A) 24–48 hours","B) 4–6 hours","C) 12–24 hours","D) 72 hours"],
     "B","Vaccine carrier with 4 ice packs: 4–6 hours; used for outreach sessions."),

    ("72. Zagreb regimen for rabies PEP:",
     ["A) 5 doses over 28 days","B) 2 doses day 0 (bilateral), then day 7 and day 21","C) 3 doses on days 0, 7, 21","D) 6 doses over 30 days"],
     "B","Zagreb (2-1-1): Day 0 → 2 doses (one each deltoid), Day 7 → 1 dose, Day 21 → 1 dose = 4 total."),

    ("73. Example of a toxoid vaccine:",
     ["A) BCG","B) OPV","C) Tetanus","D) Hepatitis B"],
     "C","Tetanus toxoid = formaldehyde-inactivated tetanus toxin; produces antitoxin immunity."),

    ("74. MR (Measles-Rubella) vaccine is given at:",
     ["A) Birth","B) 6 weeks","C) 9–12 months and 16–24 months","D) 5 years"],
     "C","UIP: MR-1 at 9–12 months; MR-2 at 16–24 months."),

    ("75. Cold box maintains vaccines at temperature for:",
     ["A) 4–6 hours","B) 12 hours","C) 24–72 hours","D) 1 week"],
     "C","Cold box: 24–72 hours; used for transport and district-level storage."),

    ("76. Not included in India's Universal Immunization Programme:",
     ["A) BCG","B) Rotavirus vaccine","C) Typhoid conjugate vaccine","D) PCV"],
     "C","Typhoid conjugate vaccine is not yet universally part of UIP. BCG, Rotavirus, and PCV are."),

    ("77. JE vaccine in UIP is given in:",
     ["A) All districts","B) Only endemic districts","C) Only Northeast India","D) Only urban areas"],
     "B","JE vaccine administered only in Japanese Encephalitis endemic districts."),

    ("78. Vaccine safe in HIV-positive children:",
     ["A) OPV","B) IPV","C) Yellow fever","D) Varicella"],
     "B","IPV (inactivated) is safe in HIV+ children. Live vaccines (OPV, Yellow fever, Varicella) avoided in severe immunocompromise."),

    ("79. One Anganwadi centre per how much population?",
     ["A) 200–400","B) 400–800","C) 1000–1500","D) 2000–3000"],
     "B","One AWC per 400–800 population (urban: 1 per 400; rural/tribal: 1 per 300–800)."),

    ("80. Pre-exposure rabies prophylaxis schedule:",
     ["A) Days 0, 3, 7","B) Days 0, 7, 28","C) Days 0, 14, 28","D) Days 0, 7, 14, 28"],
     "B","PrEP: 3 doses on Days 0, 7, 28 (IM or ID route)."),

    ("81. Dose of Human Rabies Immunoglobulin (HRIG):",
     ["A) 10 IU/kg","B) 20 IU/kg","C) 40 IU/kg","D) 80 IU/kg"],
     "B","HRIG = 20 IU/kg; ERIG (equine) = 40 IU/kg. Infiltrate wound first, rest given IM."),

    ("82. India's indigenous HPV vaccine:",
     ["A) Gardasil","B) Cervarix","C) Cervavac","D) Gardasil 9"],
     "C","Cervavac: quadrivalent (types 6, 11, 16, 18) developed by Serum Institute of India."),

    ("83. Intensive Mission Indradhanush (IMI) 3.0 was launched in:",
     ["A) 2017","B) 2019","C) 2021","D) 2023"],
     "C","IMI 3.0 (2021): focused on COVID pandemic-related immunization catch-up."),

    ("84. Quadrivalent HPV vaccine covers strains:",
     ["A) 16, 18","B) 6, 11, 16, 18","C) 6, 11, 16, 18, 31, 33, 45, 52, 58","D) 16, 18, 31, 33"],
     "B","Quadrivalent (Gardasil/Cervavac): HPV 6, 11, 16, 18."),

    ("85. Vaccine that requires reconstitution before use:",
     ["A) OPV","B) Hepatitis B","C) BCG","D) DPT"],
     "C","BCG requires reconstitution with provided diluent; must be used within 4 hours."),

    # ── SECTION 4: MCH ─────────────────────────────────────────────────────
    ("86. Infant Mortality Rate (IMR) is defined as:",
     ["A) Deaths <5 years per 1000 live births","B) Deaths <1 year per 1000 live births","C) Deaths <1 year per 1000 total births","D) Neonatal deaths per 1000 live births"],
     "B","IMR = deaths in first year of life per 1000 live births; best MCH indicator."),

    ("87. Maternal Mortality Ratio (MMR) is expressed per:",
     ["A) 1000 live births","B) 10,000 live births","C) 100,000 live births","D) 1000 total births"],
     "C","MMR = maternal deaths per 100,000 live births. India MMR ≈ 97 (SRS 2018–20)."),

    ("88. Best indicator of MCH services:",
     ["A) MMR","B) IMR","C) U5MR","D) NRR"],
     "B","IMR is the single best indicator of MCH services and overall socioeconomic development."),

    ("89. Low Birth Weight (LBW) is defined as:",
     ["A) <3000 g","B) <2500 g","C) <2000 g","D) <1500 g"],
     "B","LBW = birth weight <2500 g regardless of gestational age."),

    ("90. Exclusive breastfeeding is recommended for:",
     ["A) 3 months","B) 4 months","C) 6 months","D) 12 months"],
     "C","WHO recommends exclusive breastfeeding for the first 6 months; complementary feeding from 6 months."),

    ("91. MUAC for SAM in children 6–59 months:",
     ["A) <12.5 cm","B) <11.5 cm","C) <13.5 cm","D) <10.0 cm"],
     "B","SAM (Red): MUAC <11.5 cm; MAM (Yellow): 11.5–12.4 cm; Normal (Green): ≥12.5 cm."),

    ("92. ICDS was launched on:",
     ["A) August 15, 1975","B) October 2, 1975","C) January 26, 1976","D) November 14, 1975"],
     "B","ICDS launched October 2, 1975 (Gandhi Jayanti / International Day of Non-Violence)."),

    ("93. Service NOT provided under ICDS:",
     ["A) Supplementary nutrition","B) Pre-school education","C) Curative medical care","D) Immunization"],
     "C","ICDS does NOT provide curative care; it provides 6 services: nutrition, immunization, health check-up, referral, pre-school education, NCHE."),

    ("94. Anemia Mukt Bharat was launched under:",
     ["A) NHM","B) POSHAN Abhiyan","C) ICDS","D) JSY"],
     "B","Anemia Mukt Bharat (2018) is a flagship programme under POSHAN Abhiyan (National Nutrition Mission)."),

    ("95. Colostrum is rich in all EXCEPT:",
     ["A) IgA","B) Vitamin A","C) Lactose (relatively less)","D) Leukocytes"],
     "C","Colostrum is rich in IgA, Vit A, protein, and leukocytes. It has LESS fat and lactose than mature milk."),

    ("96. ASHA newborn home visit days:",
     ["A) Days 1, 3, 7","B) Days 1, 3, 7, 14, 28, 42","C) Days 1, 7, 14, 28","D) Days 3, 7, 21, 42"],
     "B","HBNC protocol: ASHA visits on Days 1, 3, 7, 14, 28, 42 — 6 home visits per newborn."),

    ("97. WHO-recommended minimum ANC visits:",
     ["A) 4 visits","B) 6 visits","C) 8 visits","D) 3 visits"],
     "C","WHO 2016 ANC guidelines: minimum 8 contacts (updated from older 4-visit model)."),

    ("98. Mid-Day Meal programme renamed PM POSHAN in:",
     ["A) 2018","B) 2019","C) 2021","D) 2023"],
     "C","PM POSHAN Shakti Nirman launched September 2021, renaming the National MDM scheme."),

    ("99. Neonatal Mortality Rate (NNMR) includes deaths in:",
     ["A) First 7 days","B) First 28 days","C) First 6 weeks","D) First year"],
     "B","NNMR = deaths 0–28 days per 1000 live births. Early neonatal = 0–7 days; late = 8–28 days."),

    ("100. Best indicator of overall child development and social progress:",
     ["A) MMR","B) IMR","C) U5MR","D) NNMR"],
     "C","UNICEF considers U5MR the single most important indicator of child well-being."),

    ("101. Population norm for Sub-Centre in plain areas:",
     ["A) 3000","B) 5000","C) 10,000","D) 30,000"],
     "B","Sub-Centre: 5000 population (plains); 3000 (hilly/tribal)."),

    ("102. Calories provided to a normal child under ICDS (6 months–6 years):",
     ["A) 300 kcal","B) 400 kcal","C) 500 kcal","D) 700 kcal"],
     "C","ICDS: 500 kcal + 12–15 g protein for normal children; 600 kcal for severely malnourished."),

    ("103. Perinatal Mortality Rate includes:",
     ["A) Deaths in first 28 days only","B) Stillbirths (≥28 wks) + deaths in first 7 days","C) Deaths from 7–28 days","D) All deaths under 1 year"],
     "B","Perinatal MR = (stillbirths ≥28 weeks + early neonatal deaths <7 days) / 1000 total births."),

    ("104. JSY incentive is given for:",
     ["A) Home delivery with skilled attendant","B) Institutional delivery","C) Breastfeeding initiation","D) Full immunization completion"],
     "B","JSY: cash incentive for institutional delivery; higher amounts in Low-Performing States."),

    ("105. Early initiation of breastfeeding should occur within:",
     ["A) 1 hour of birth","B) 4 hours","C) 24 hours","D) Any time in first week"],
     "A","WHO: initiate breastfeeding within 1 hour of birth to provide colostrum ('first vaccine')."),

    # ── SECTION 5: FAMILY PLANNING & DEMOGRAPHY ───────────────────────────
    ("106. Pearl Index is expressed as:",
     ["A) Pregnancies per 100 woman-years of exposure","B) Pregnancies per 1000 woman-months","C) Failures per 1000 cycles","D) % women pregnant annually"],
     "A","Pearl Index = (accidental pregnancies × 1200) / total months exposure = pregnancies per 100 woman-years."),

    ("107. Most effective reversible contraceptive (lowest Pearl Index):",
     ["A) Male condom","B) Copper IUCD","C) Combined OCP","D) Depo-Provera"],
     "B","Cu-T 380A PI ~0.6–0.8; among reversible methods, IUCD (and LNG-IUS) are most effective."),

    ("108. Depo-Provera (DMPA) injection frequency:",
     ["A) Monthly","B) 3-monthly","C) Weekly SC","D) Bi-annual"],
     "B","Depo-Provera 150 mg DMPA given IM every 3 months (every 13 weeks)."),

    ("109. No-scalpel vasectomy introduced in India in:",
     ["A) 1985","B) 1988","C) 1992","D) 1995"],
     "C","NSV introduced in India in 1992; technique uses special forceps — no scalpel incision."),

    ("110. TFR represents:",
     ["A) Total births per year","B) Average children born per woman over reproductive lifespan","C) Birth rate per 1000","D) Female births per woman"],
     "B","TFR = average number of children per woman if she lives through age 15–49."),

    ("111. NRR = 1 indicates:",
     ["A) Population declining","B) Rapid growth","C) Replacement level fertility","D) High infant mortality"],
     "C","NRR=1: each woman is replaced by exactly one daughter surviving to reproductive age; population eventually stabilises."),

    ("112. India's TFR as per NFHS-5 (2019–21):",
     ["A) 3.4","B) 2.7","C) 2.0","D) 1.6"],
     "C","NFHS-5: India TFR = 2.0 (declined from 2.2 in NFHS-4)."),

    ("113. Stage II of Demographic Transition:",
     ["A) High BR, high DR","B) High BR, falling DR (rapid growth)","C) Falling BR, low DR","D) Low BR, low DR"],
     "B","Stage II: death rate falls (improved sanitation/medicine) while birth rate stays high → rapid population explosion."),

    ("114. Copper IUD primary mechanism:",
     ["A) Prevents ovulation","B) Thickens cervical mucus","C) Copper ions spermicidal + prevents implantation","D) Thins endometrium"],
     "C","Copper ions are toxic to sperm and prevent fertilisation; also creates hostile uterine environment."),

    ("115. Emergency contraception (levonorgestrel) must be taken within:",
     ["A) 24 hours","B) 48 hours","C) 72 hours","D) 120 hours"],
     "C","Levonorgestrel EC (1.5 mg): within 72 hours; most effective within first 24 hours."),

    ("116. Expansive population pyramid (broad base, narrow apex) indicates:",
     ["A) Aging population, low BR","B) High BR, high DR, young population","C) Stable population","D) Declining population"],
     "B","Broad base: high birth rate; rapid tapering: high childhood mortality; developing-country pattern."),

    ("117. General Fertility Rate (GFR) is calculated per:",
     ["A) 1000 total population","B) 1000 women aged 15–44/49","C) 1000 married women","D) 1000 live births"],
     "B","GFR = live births / mid-year women aged 15–44 (or 49) × 1000."),

    ("118. GRR differs from NRR in that GRR:",
     ["A) Includes male births","B) Does not account for female mortality in reproductive age","C) Uses total births","D) Is always less than NRR"],
     "B","GRR ignores mortality; NRR adjusts for probability that daughters survive to reproductive age."),

    ("119. Couple Protection Rate (CPR) target for India:",
     ["A) 50%","B) 65%","C) 75%","D) 80%"],
     "B","CPR target: ≥65% of eligible couples (wife 15–44 years) using contraception."),

    ("120. Primary mechanism of combined OCP:",
     ["A) Thickening cervical mucus","B) Preventing implantation","C) Inhibiting ovulation","D) Killing sperm"],
     "C","Combined OCP: primarily inhibits LH surge → prevents ovulation."),

    ("121. Cu-T 380A duration of effectiveness:",
     ["A) 3 years","B) 5 years","C) 7 years","D) 10 years"],
     "D","Cu-T 380A: 10 years; Cu-T 200B: 3 years; Multiload 375: 5 years."),

    ("122. PPIUCD = insertion within:",
     ["A) 24 hours before delivery","B) 12 minutes of placental expulsion","C) 6 weeks postpartum","D) 3 months postpartum"],
     "B","PPIUCD: inserted within 10–12 minutes of placental delivery (interval IUCD = 6 weeks postpartum)."),

    ("123. Demographic transition theory was described by:",
     ["A) Warren Thompson","B) Thomas Malthus","C) John Snow","D) Frank Notestein"],
     "A","Warren Thompson described the stages in 1929; Frank Notestein coined 'demographic transition' in 1945."),

    ("124. Method with HIGHEST Pearl Index (least effective):",
     ["A) Tubectomy","B) Vasectomy","C) Male condom","D) Cu-T 380A"],
     "C","Male condom PI 2–15 (typical use); tubectomy ~0.5; vasectomy ~0.1; Cu-T 380A ~0.6."),

    ("125. Replacement level TFR:",
     ["A) 1.8","B) 2.0","C) 2.1","D) 2.5"],
     "C","Replacement TFR ≈ 2.1 globally (slightly higher ~2.3 in high-mortality settings)."),

    # ── SECTION 6: ENVIRONMENT & VECTORS ──────────────────────────────────
    ("126. Anopheles mosquito identification:",
     ["A) Parallel resting + raft eggs","B) 45° resting + single eggs with floats","C) Parallel resting + single eggs","D) 45° resting + raft eggs"],
     "B","Anopheles: 45° resting angle; single eggs with lateral floats; breeds in clean water."),

    ("127. Main vector of Kala-azar in India:",
     ["A) Anopheles mosquito","B) Culex mosquito","C) Phlebotomus argentipes (sandfly)","D) Xenopsylla cheopis"],
     "C","Phlebotomus argentipes transmits Leishmania donovani; endemic in Bihar, Jharkhand, UP, West Bengal."),

    ("128. JE vector in rural India:",
     ["A) Aedes aegypti","B) Culex tritaeniorhynchus","C) Anopheles culicifacies","D) Phlebotomus papatasi"],
     "B","Culex tritaeniorhynchus: main rural JE vector; amplification in pigs + wading birds; breeds in paddy fields."),

    ("129. Dengue fever is transmitted by:",
     ["A) Anopheles stephensi","B) Culex quinquefasciatus","C) Aedes aegypti","D) Phlebotomus argentipes"],
     "C","Aedes aegypti: primary dengue vector; day-biting; breeds in domestic clean water collections."),

    ("130. Plague is transmitted by:",
     ["A) Anopheles mosquito","B) Xenopsylla cheopis","C) Ixodes tick","D) Pediculus louse"],
     "B","Xenopsylla cheopis (Oriental rat flea) transmits Yersinia pestis from dead rats to humans."),

    ("131. Kyasanur Forest Disease (KFD) is transmitted by:",
     ["A) Sandfly","B) Rat flea","C) Haemaphysalis spinigera tick","D) Culex mosquito"],
     "C","KFD: tick-borne viral haemorrhagic fever; vector = Haemaphysalis spinigera; Karnataka forests."),

    ("132. Scrub typhus is transmitted by:",
     ["A) Louse","B) Tick","C) Chigger mite (Leptotrombidium)","D) Rat flea"],
     "C","Scrub typhus (Orientia tsutsugamushi): transmitted by larval Leptotrombidium mites (chiggers)."),

    ("133. Yellow biomedical waste bag treatment:",
     ["A) Autoclave then recycle","B) Incineration or deep burial","C) Authorised recycler","D) Shred and landfill"],
     "B","Yellow: anatomical waste (body parts), soiled items → incineration (or deep burial in remote areas)."),

    ("134. Sharps waste should be in:",
     ["A) Yellow bag","B) Red bag","C) White puncture-proof container","D) Blue cardboard box"],
     "C","White (translucent) puncture-proof container for sharps; autoclaved + shredded/encapsulated."),

    ("135. Residual chlorine at consumer end:",
     ["A) 0.1 mg/L","B) 0.5 mg/L","C) 1.0 mg/L","D) 2.0 mg/L"],
     "B","Free residual chlorine at point of use: 0.5 mg/L (minimum 0.2 mg/L in distribution system)."),

    ("136. 'Schmutzdecke' is associated with:",
     ["A) Rapid sand filtration","B) Slow sand filtration","C) Reverse osmosis","D) Chlorination"],
     "B","Schmutzdecke = biological film on slow sand filter; responsible for superior pathogen removal."),

    ("137. Aedes mosquito breeds in:",
     ["A) Polluted stagnant water","B) Paddy fields and ponds","C) Clean collected water (tyres, pots, coolers)","D) Slow streams"],
     "C","Aedes: peridomestic breeder in small clean-water containers; domestic source reduction is key control."),

    ("138. AQI 'Severe' category in India (NAQI) = ?",
     ["A) 201–300","B) 301–400","C) 401–500","D) >500"],
     "C","India NAQI: Good (0–50), Satisfactory (51–100), Moderate (101–200), Poor (201–300), Very Poor (301–400), Severe (401–500)."),

    ("139. Byssinosis is caused by:",
     ["A) Silica","B) Asbestos","C) Cotton dust","D) Coal dust"],
     "C","Byssinosis: cotton/flax/hemp dust; 'Monday fever'; bronchoconstriction worst after weekend break."),

    ("140. Filariasis vector in India:",
     ["A) Anopheles gambiae","B) Culex quinquefasciatus","C) Aedes albopictus","D) Mansonia mosquito"],
     "B","Culex quinquefasciatus: main vector of Wuchereria bancrofti (lymphatic filariasis) in India."),

    ("141. Horrock's apparatus is used for:",
     ["A) Field blood pressure measurement","B) Determining chlorine demand of water","C) Measuring water turbidity","D) Testing water hardness"],
     "B","Horrock's apparatus: field test for chlorine demand; guides correct chlorine dosing."),

    ("142. Minamata disease is caused by:",
     ["A) Lead","B) Arsenic","C) Methyl mercury","D) Cadmium"],
     "C","Minamata (Japan, 1950s): methyl mercury industrial poisoning → neurological damage."),

    ("143. Itai-itai disease is associated with:",
     ["A) Lead","B) Mercury","C) Cadmium","D) Fluoride"],
     "C","Itai-itai ('ouch-ouch'): cadmium poisoning → osteomalacia, renal tubular dysfunction, fractures."),

    ("144. Most carcinogenic air pollutant component:",
     ["A) SO₂","B) NO₂","C) PM2.5","D) Benzo[a]pyrene (in PM)"],
     "D","Benzo[a]pyrene (PAH adsorbed on PM): potent chemical carcinogen; causes lung cancer."),

    ("145. Epidemic typhus vector:",
     ["A) Rat flea","B) Tick","C) Body louse (Pediculus humanus corporis)","D) Mite"],
     "C","Epidemic typhus (Rickettsia prowazekii): body louse vector; associated with overcrowding and poor hygiene."),

    # ── SECTION 7: NATIONAL PROGRAMMES ────────────────────────────────────
    ("146. NTEP stands for:",
     ["A) National Tuberculosis Eradication Programme","B) National TB Elimination Programme","C) National Treatment and Elimination Programme","D) National TB Epidemiology Programme"],
     "B","NTEP = National TB Elimination Programme; renamed from RNTCP in 2020; target: elimination by 2025."),

    ("147. DOTS stands for:",
     ["A) Direct Observation Treatment Short-course","B) Directly Observed Treatment Short-course","C) Disease Oriented Treatment Strategy","D) Daily Oral Treatment Schedule"],
     "B","DOTS = Directly Observed Treatment Short-course; ensures adherence by watching each dose."),

    ("148. TB treatment for new DS-TB (NTEP):",
     ["A) 2HRZ/4HR","B) 2HRZE/4HR","C) 6HRE","D) 2HRZES/1HRZE/5HRE"],
     "B","2-month intensive (HRZE) + 4-month continuation (HR) = 6 months total for new drug-sensitive TB."),

    ("149. Nikshay Poshan Yojana provides:",
     ["A) Rs. 500/month to TB patient during treatment","B) Rs. 1000/month","C) Free medicines only","D) Rs. 2000 one-time"],
     "A","Rs. 500/month DBT to TB patient for nutritional support throughout treatment."),

    ("150. NACP V 95-95-95 targets mean:",
     ["A) 95% diagnosed, 95% on ART, 95% virally suppressed","B) 95% treated, 95% cured, 95% followed up","C) 95% tested, 95% vaccinated, 95% counselled","D) 95% diagnosed, 95% linked, 95% retained"],
     "A","95-95-95: 95% of PLHIV know status; 95% of those on ART; 95% of those virally suppressed."),

    ("151. NVBDCP does NOT cover:",
     ["A) Malaria","B) Dengue","C) Tuberculosis","D) Kala-azar"],
     "C","NVBDCP = National Vector Borne Disease Control Programme; TB is under NTEP separately."),

    ("152. Leprosy eliminated from India in:",
     ["A) 2000","B) 2005","C) 2010","D) 2015"],
     "B","Leprosy elimination (<1/10,000 prevalence) declared in December 2005."),

    ("153. MDT duration for Multibacillary leprosy:",
     ["A) 6 months","B) 9 months","C) 12 months","D) 18 months"],
     "C","MB leprosy: 12 months MDT (Dapsone + Clofazimine daily + Rifampicin + Clofazimine monthly)."),

    ("154. PMJAY (Ayushman Bharat) annual health cover:",
     ["A) Rs. 1 lakh","B) Rs. 2 lakh","C) Rs. 5 lakh","D) Rs. 10 lakh"],
     "C","PM Jan Arogya Yojana: Rs. 5 lakh/year per family for secondary and tertiary care; ~50 crore beneficiaries."),

    ("155. IDSP surveillance forms are:",
     ["A) A, B, C","B) S (Syndromic), P (Presumptive), L (Laboratory)","C) Level 1, 2, 3","D) Primary, secondary, tertiary"],
     "B","IDSP S-P-L reporting: S by community/health worker, P by clinician, L by laboratory."),

    ("156. MDT for Paucibacillary leprosy:",
     ["A) Rifampicin + Dapsone + Clofazimine 12 months","B) Rifampicin monthly + Dapsone daily for 6 months","C) Dapsone alone 6 months","D) Rifampicin + Clofazimine 12 months"],
     "B","PB leprosy: Rifampicin 600 mg/month (supervised) + Dapsone 100 mg/day × 6 months."),

    ("157. NHM was formed by merging:",
     ["A) NRHM + NUHM","B) RNTCP + NACP","C) NVBDCP + NLEP","D) NHM + NPCB"],
     "A","NHM (2013) = NRHM (2005, rural) + NUHM (2013, urban)."),

    ("158. JSSK provides:",
     ["A) Cash incentives for delivery","B) Free drugs, diagnostics, diet, transport for pregnant women and sick newborns","C) Insurance only","D) Free medicines only"],
     "B","JSSK: cashless delivery at public facilities; covers drugs, diagnostics, blood, diet, transport, referral."),

    ("159. Mantoux test is read at:",
     ["A) 24 hours","B) 48–72 hours","C) 72–96 hours","D) 1 week"],
     "B","Mantoux (5 TU PPD intradermal): read at 48–72 hours; ≥10 mm induration = positive."),

    ("160. GeneXpert/CBNAAT provides results in:",
     ["A) 24 hours","B) 12 hours","C) 2 hours","D) 4 hours"],
     "C","GeneXpert MTB/RIF: detects TB + rifampicin resistance in approximately 2 hours."),

    ("161. ASHA is deployed at 1 per:",
     ["A) 500 population","B) 1000 population","C) 3000 population","D) 5000 population"],
     "B","1 ASHA per 1000 population in most areas (500 per habitation in difficult terrains)."),

    ("162. DOT in DOTS means:",
     ["A) Family member watching only","B) Trained health worker or community volunteer watching patient swallow each dose","C) Pharmacist-supervised only","D) Doctor-supervised only"],
     "B","Any trained DOT provider (government/private worker, community volunteer, or trained family member)."),

    ("163. HMIS stands for:",
     ["A) Health Management Information System","B) Hospital Monitoring and Inspection System","C) Health Ministry Integration System","D) Health Manpower Information Survey"],
     "A","HMIS: web-based MoHFW data reporting system for tracking NHM indicators."),

    ("164. National programme that introduced community health workers in India:",
     ["A) ICDS","B) RNTCP","C) Srivastava Committee recommendations","D) NHM"],
     "C","Srivastava Committee (1975) recommended CHW scheme → conceptual basis for ASHA under NHM."),

    ("165. Bedaquiline is used in:",
     ["A) Drug-sensitive TB","B) MDR-TB / XDR-TB","C) Leprosy","D) NTM infections"],
     "B","Bedaquiline (diarylquinoline): inhibits mycobacterial ATP synthase; used in MDR/XDR-TB regimens."),

    # ── SECTION 8: HEALTH SYSTEM & COMMITTEES ─────────────────────────────
    ("166. Bhore Committee (1946) recommended:",
     ["A) Multipurpose health workers","B) Community health workers","C) 3-tier health system and PHC concept","D) District mental health programme"],
     "C","Bhore Committee: 'Health Survey & Development Committee'; PHC concept; social physician; 3-tier system."),

    ("167. Kartar Singh Committee (1974) recommended:",
     ["A) Community health workers","B) Multipurpose health workers (MPW) scheme","C) District hospitals as referral centres","D) Integration of ICDS"],
     "B","Kartar Singh: merged male/female health workers into MPW scheme; basis of sub-centre structure."),

    ("168. CHC serves a population of:",
     ["A) 30,000","B) 80,000","C) 1,20,000","D) 3,00,000"],
     "C","CHC: 1,20,000 (plains); 80,000 (hilly/tribal); 30 beds; 4 specialists."),

    ("169. Number of PHCs served by one CHC:",
     ["A) 2","B) 4","C) 6","D) 8"],
     "B","1 CHC covers 4 PHCs (4 × 30,000 = 1,20,000 = CHC population norm)."),

    ("170. Mudaliar Committee (1962) focused on:",
     ["A) Introduction of PHC system","B) Health survey and development","C) Strengthening/upgrading existing PHCs","D) Community health workers"],
     "C","Mudaliar: 'Health Survey & Planning Committee'; recommended quality improvement of existing PHCs."),

    ("171. IPHS stands for:",
     ["A) Indian Primary Health System","B) Indian Public Health Standards","C) Integrated Public Health Services","D) Indian Preventive Health Scheme"],
     "B","IPHS: sets minimum norms for infrastructure, staffing, equipment at each health care level."),

    ("172. World Health Day is on:",
     ["A) April 7","B) March 24","C) December 1","D) October 10"],
     "A","April 7 = World Health Day (WHO founded 1948). March 24 = World TB Day; Dec 1 = World AIDS Day."),

    ("173. Population norm for PHC in plain areas:",
     ["A) 5,000","B) 10,000","C) 20,000","D) 30,000"],
     "D","PHC: 30,000 (plains); 20,000 (hilly/tribal); 6 beds; 1 Medical Officer."),

    ("174. 'Social Physician' concept was introduced by:",
     ["A) Mudaliar Committee","B) Bhore Committee","C) Kartar Singh Committee","D) Srivastava Committee"],
     "B","Bhore Committee (1946) coined the 'social physician' — a doctor who addresses social determinants."),

    ("175. Srivastava Committee (1975) was set up for:",
     ["A) Health finance reform","B) Medical education and support manpower","C) Hospital development","D) Tribal health"],
     "B","Srivastava = 'Group on Medical Education & Support Manpower'; introduced CHW concept."),

    # ── SECTION 9: COMMUNICABLE DISEASES ──────────────────────────────────
    ("176. Incubation period of cholera:",
     ["A) 1–7 days","B) 6 hours – 5 days","C) 2–14 days","D) 7–21 days"],
     "B","Cholera: 6 hours – 5 days (usually 2–3 days); caused by Vibrio cholerae O1/O139."),

    ("177. Reduced-osmolarity ORS (WHO 2002) has osmolarity of:",
     ["A) 311 mOsm/L","B) 245 mOsm/L","C) 200 mOsm/L","D) 290 mOsm/L"],
     "B","Reduced-ORS: 245 mOsm/L; NaCl 2.6 g, KCl 1.5 g, Sodium citrate 2.9 g, Glucose 13.5 g per litre."),

    ("178. Hepatitis E is most dangerous in:",
     ["A) Children <5 years","B) Elderly males","C) Pregnant women","D) Immunocompromised"],
     "C","HEV in pregnancy: mortality up to 25% (3rd trimester); fulminant hepatic failure."),

    ("179. Longest incubation period among:",
     ["A) Cholera","B) Measles","C) Leprosy","D) Typhoid"],
     "C","Leprosy: 2–5 years (range 6 months – 20 years); longest among common infectious diseases."),

    ("180. Weil-Felix reaction diagnoses:",
     ["A) Malaria","B) Typhoid","C) Rickettsial diseases","D) Brucellosis"],
     "C","Weil-Felix: Proteus antigens cross-react with Rickettsia antibodies; used for typhus diagnosis."),

    ("181. Main malaria vector in urban India:",
     ["A) Anopheles culicifacies","B) Anopheles stephensi","C) Anopheles fluviatilis","D) Anopheles minimus"],
     "B","Anopheles stephensi: urban/periurban malaria vector; breeds in water tanks and cisterns."),

    ("182. CBNAAT detects TB and:",
     ["A) Isoniazid resistance","B) Rifampicin resistance","C) Pyrazinamide resistance","D) Ethambutol resistance"],
     "B","GeneXpert MTB/RIF: simultaneously detects Mycobacterium tuberculosis AND rifampicin resistance."),

    ("183. Reduced-ORS sodium content:",
     ["A) 90 mEq/L","B) 75 mEq/L","C) 60 mEq/L","D) 50 mEq/L"],
     "B","Reduced-ORS: Na 75 mEq/L (down from 90), K 20 mEq/L, Cl 65, Citrate 10, Glucose 75 mmol/L."),

    ("184. Paucibacillary leprosy has:",
     ["A) >5 skin lesions","B) 1–5 skin lesions","C) >50 lesions","D) Only nerve involvement"],
     "B","PB: 1–5 skin lesions, smear negative; MB: >5 lesions, smear positive."),

    ("185. Main malaria vector in rural India:",
     ["A) Anopheles stephensi","B) Anopheles culicifacies","C) Anopheles fluviatilis","D) Anopheles dirus"],
     "B","Anopheles culicifacies: responsible for ~60–65% of malaria cases in rural India."),

    ("186. Secondary attack rate of chickenpox in household contacts:",
     ["A) 10–20%","B) 30–40%","C) 70–90%","D) 50–60%"],
     "C","Varicella very highly contagious; household SAR ~70–90% in susceptible individuals."),

    ("187. Lepromin test (Mitsuda reaction) is read at:",
     ["A) 48–72 hours","B) 7 days","C) 28 days","D) 14 days"],
     "C","Mitsuda reaction read at 28 days; indicates cell-mediated immunity — NOT diagnostic of leprosy."),

    ("188. Hepatitis viruses transmitted by feco-oral route:",
     ["A) B and C","B) A and E","C) D only","D) B and D"],
     "B","HAV and HEV: enteric (feco-oral) transmission. HBV, HCV, HDV: parenteral/blood-borne."),

    ("189. Category A bioterrorism agent — which is NOT included?",
     ["A) Anthrax","B) Smallpox","C) Brucellosis","D) Plague"],
     "C","Brucellosis = Category B. Category A: Anthrax, Smallpox, Plague, Tularemia, Botulism, VHFs."),

    ("190. DOT provider in NTEP can be:",
     ["A) Government health worker only","B) Trained health worker, community volunteer, or trained family member","C) Pharmacist only","D) Doctor only"],
     "B","Any trained DOT provider; government/private health worker, community volunteer, or trained family member."),

    # ── SECTION 10: MIXED HIGH-YIELD ──────────────────────────────────────
    ("191. SDG Goal directly related to health:",
     ["A) SDG 1","B) SDG 2","C) SDG 3","D) SDG 5"],
     "C","SDG 3 = 'Good Health and Well-being'; includes MMR, U5MR, HIV, TB, NCD, UHC targets."),

    ("192. START triage 'Red tag' means:",
     ["A) Deceased","B) Minor injuries","C) Life-threatening but survivable with immediate intervention","D) Delayed treatment acceptable"],
     "C","Red = Immediate; life-threatening injuries that are survivable with prompt intervention."),

    ("193. Occupational disease caused by vinyl chloride:",
     ["A) Mesothelioma","B) Angiosarcoma of liver","C) Aplastic anaemia","D) Byssinosis"],
     "B","Vinyl chloride monomer (PVC manufacturing) → angiosarcoma of the liver."),

    ("194. Noise-Induced Hearing Loss (NIHL) threshold:",
     ["A) >65 dB for 8 hours/day","B) >85 dB for 8 hours/day","C) >75 dB for 8 hours/day","D) >100 dB for any duration"],
     "B","Permissible occupational noise: 85 dB(A) for 8 hours; NIHL occurs above this with sustained exposure."),

    ("195. Durkheim's suicide classification does NOT include:",
     ["A) Egoistic","B) Altruistic","C) Anomic","D) Reactive"],
     "D","Durkheim: Egoistic, Altruistic, Anomic, Fatalistic. 'Reactive' is not in his classification."),

    ("196. WHO was founded on:",
     ["A) January 1, 1945","B) April 7, 1948","C) October 24, 1945","D) March 22, 1946"],
     "B","WHO Constitution came into force April 7, 1948 → celebrated as World Health Day annually."),

    ("197. POSHAN Abhiyan (National Nutrition Mission) launched in:",
     ["A) 2016","B) 2017","C) 2018","D) 2019"],
     "C","POSHAN Abhiyan launched March 8, 2018; target: reduce stunting, undernutrition, anaemia, LBW."),

    ("198. '6×6×6 strategy' belongs to:",
     ["A) Mission Indradhanush","B) Anemia Mukt Bharat","C) ICDS","D) NTEP"],
     "B","Anemia Mukt Bharat 6×6×6: 6 beneficiary groups × 6 interventions × 6 institutional mechanisms."),

    ("199. Most common method of suicide in India (NCRB):",
     ["A) Poisoning (pesticides)","B) Hanging","C) Drowning","D) Self-immolation"],
     "B","Hanging is the most common suicide method in India (~34%); followed by self-poisoning."),

    ("200. SDG target year:",
     ["A) 2025","B) 2030","C) 2035","D) 2020"],
     "B","17 SDGs adopted September 2015; target year 2030 (replaced MDGs which ended 2015)."),
]

# section headings: (question_number_start, title, colour)
SECTIONS = [
    (1,   "SECTION 1: EPIDEMIOLOGY",             C_DARK),
    (36,  "SECTION 2: BIOSTATISTICS",             HexColor("#1e3a5f")),
    (56,  "SECTION 3: IMMUNIZATION & VACCINES",   HexColor("#14532d")),
    (86,  "SECTION 4: MATERNAL & CHILD HEALTH",   HexColor("#7c2d12")),
    (106, "SECTION 5: FAMILY PLANNING & DEMOGRAPHY", HexColor("#312e81")),
    (126, "SECTION 6: ENVIRONMENT & VECTORS",     HexColor("#064e3b")),
    (146, "SECTION 7: NATIONAL PROGRAMMES",        HexColor("#1c1917")),
    (166, "SECTION 8: HEALTH SYSTEM & COMMITTEES", HexColor("#3b0764")),
    (176, "SECTION 9: COMMUNICABLE DISEASES",      HexColor("#450a0a")),
    (191, "SECTION 10: MIXED HIGH-YIELD",           HexColor("#0f172a")),
]
section_map = {q: (title, col) for (q, title, col) in SECTIONS}

def section_banner(title, colour):
    data = [[Paragraph(title, sSection)]]
    t = Table(data, colWidths=[PAGE_W - 2*MARGIN])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), colour),
        ('TOPPADDING', (0,0), (-1,-1), 8),
        ('BOTTOMPADDING', (0,0), (-1,-1), 8),
        ('LEFTPADDING', (0,0), (-1,-1), 10),
        ('RIGHTPADDING', (0,0), (-1,-1), 10),
        ('ROUNDEDCORNERS', [5]),
    ]))
    return t

def header_footer(canvas, doc):
    canvas.saveState()
    # header line
    canvas.setStrokeColor(C_MID)
    canvas.setLineWidth(1.5)
    canvas.line(MARGIN, PAGE_H - 1.4*cm, PAGE_W - MARGIN, PAGE_H - 1.4*cm)
    canvas.setFont('Helvetica-Bold', 9)
    canvas.setFillColor(C_MID)
    canvas.drawString(MARGIN, PAGE_H - 1.2*cm, "PSM / Community Medicine — 200 FMGE-Style MCQs")
    canvas.setFont('Helvetica', 8)
    canvas.setFillColor(HexColor("#64748b"))
    canvas.drawRightString(PAGE_W - MARGIN, PAGE_H - 1.2*cm, "Based on Park's Textbook of PSM")
    # footer
    canvas.setFont('Helvetica', 8)
    canvas.setFillColor(HexColor("#64748b"))
    canvas.drawCentredString(PAGE_W/2, 1.2*cm, f"Page {doc.page}")
    canvas.setStrokeColor(C_BORDER)
    canvas.setLineWidth(0.5)
    canvas.line(MARGIN, 1.5*cm, PAGE_W - MARGIN, 1.5*cm)
    canvas.restoreState()

# ── build story ───────────────────────────────────────────────────────────────
story = []

# ── cover page ────────────────────────────────────────────────────────────────
cover_data = [[Paragraph("PSM / Community Medicine", sTitle)],
              [Paragraph("200 FMGE-Style MCQs", sSub)],
              [Paragraph("with Answers &amp; Explanations", sSub)],
              [Spacer(1, 0.3*cm)],
              [Paragraph("All 10 Topics  •  Based on Park's PSM", make_style('cInfo', fontSize=10,
                          textColor=C_LIGHT, alignment=TA_CENTER, fontName='Helvetica'))]]
cover_tbl = Table([[Paragraph(r[0].text if hasattr(r[0],'text') else '', sTitle)
                    if hasattr(r[0],'text') else r[0]] for r in cover_data],
                  colWidths=[PAGE_W - 2*MARGIN])

# simpler approach: single table cell for the whole cover block
cover_inner = [
    Paragraph("PSM / Community Medicine", sTitle),
    Spacer(1, 0.2*cm),
    Paragraph("200 FMGE-Style MCQs", sSub),
    Paragraph("with Answers &amp; Explanations", sSub),
    Spacer(1, 0.4*cm),
    Paragraph("Epidemiology  •  Biostatistics  •  Immunization  •  MCH  •  Family Planning", sSub),
    Paragraph("Environment &amp; Vectors  •  National Programmes  •  Health System  •  Communicable Diseases", sSub),
    Spacer(1, 0.3*cm),
    Paragraph("Based on Park's Textbook of Preventive and Social Medicine", sSub),
]

cover_block = [[item] for item in cover_inner]
ct = Table([[item] for item in cover_inner], colWidths=[PAGE_W - 2*MARGIN])
ct.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,-1), C_DARK),
    ('TOPPADDING', (0,0), (-1,-1), 12),
    ('BOTTOMPADDING', (0,0), (-1,-1), 8),
    ('LEFTPADDING', (0,0), (-1,-1), 20),
    ('RIGHTPADDING', (0,0), (-1,-1), 20),
]))
story.append(Spacer(1, 4*cm))
story.append(ct)
story.append(Spacer(1, 2*cm))

# stats box
stats = [
    ["Total Questions", "200"],
    ["Sections", "10"],
    ["Style", "FMGE (Single Best Answer)"],
    ["Reference", "Park's PSM (23rd Ed.)"],
]
st = Table(stats, colWidths=[6*cm, PAGE_W - 2*MARGIN - 6*cm])
st.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,-1), C_LIGHT),
    ('BACKGROUND', (0,0), (0,-1), C_MID),
    ('TEXTCOLOR', (0,0), (0,-1), white),
    ('TEXTCOLOR', (1,0), (1,-1), C_DARK),
    ('FONTNAME', (0,0), (-1,-1), 'Helvetica-Bold'),
    ('FONTSIZE', (0,0), (-1,-1), 10),
    ('TOPPADDING', (0,0), (-1,-1), 8),
    ('BOTTOMPADDING', (0,0), (-1,-1), 8),
    ('LEFTPADDING', (0,0), (-1,-1), 12),
    ('GRID', (0,0), (-1,-1), 0.5, C_BORDER),
]))
story.append(st)
story.append(PageBreak())

# ── MCQ pages ─────────────────────────────────────────────────────────────────
current_sec = None
for i, (q_text, options, answer, explanation) in enumerate(MCQ_DATA):
    q_num = i + 1

    # check section
    if q_num in section_map:
        if q_num > 1:
            story.append(Spacer(1, 0.3*cm))
        title, col = section_map[q_num]
        story.append(section_banner(title, col))
        story.append(Spacer(1, 0.2*cm))

    # MCQ block
    bg = C_GRAY if q_num % 2 == 0 else white
    block = []
    block.append(Paragraph(q_text, sQ))
    for opt in options:
        # highlight the correct option
        letter = opt[0]
        if letter == answer:
            opt_style = make_style(f'sOptC{q_num}', parent='Normal',
                                    fontSize=9.5, textColor=C_GREEN,
                                    spaceBefore=1, spaceAfter=1,
                                    fontName='Helvetica-Bold', leading=13, leftIndent=12)
        else:
            opt_style = sOpt
        block.append(Paragraph(opt, opt_style))

    block.append(Paragraph(f"✓ Answer: {answer}", sAns))
    block.append(Paragraph(explanation, sExp))
    block.append(HRFlowable(width="100%", thickness=0.3, color=C_BORDER,
                             spaceAfter=3, spaceBefore=2))

    story.append(KeepTogether(block))

# ── build ─────────────────────────────────────────────────────────────────────
doc.build(story, onFirstPage=header_footer, onLaterPages=header_footer)
print("PDF generated successfully!")