(a) The ‘End TB Strategy’ is an evolution over the previous strategies to win over tuberculosis. (i) What are the key principles…

(a)(i) Key principles

Adopted by the World Health Assembly in 2014 for 2016-2035, with the vision of a world free of TB. Its four principles:

1. Government stewardship and accountability, with monitoring and evaluation.
2. A strong coalition with civil society organisations and communities.
3. Protection and promotion of human rights, ethics and equity.
4. Adaptation of the strategy and targets at country level, with global collaboration.

Targets against 2015: 90% fall in incidence and 95% fall in deaths by 2035, and no TB-affected family facing catastrophic costs.

(a)(ii) Pillars and components

Pillar 1, integrated patient-centred care and prevention:

• Early diagnosis including universal drug-susceptibility testing, systematic screening of contacts and high-risk groups.
• Treatment of all people with TB, including drug-resistant TB, with patient support.
• Collaborative TB/HIV activities and management of comorbidities (diabetes, undernutrition).
• Preventive treatment of high-risk persons and vaccination against TB.

Pillar 2, bold policies and supportive systems:

• Political commitment with adequate resources for care and prevention.
• Engagement of communities, civil society and public and private providers.
• Universal health coverage, regulation for case notification, vital registration, quality and rational use of medicines, infection control.
• Social protection, poverty alleviation and action on other determinants.

Pillar 3, intensified research and innovation:

• Discovery, development and rapid uptake of new tools (diagnostics, drugs, vaccines).
• Operational research to optimise implementation.

India’s National Strategic Plan (Detect, Treat, Prevent, Build) translates these through NAAT-based diagnosis, Ni-kshay notification, private sector engagement, TB preventive therapy, Ni-kshay Poshan Yojana (₹1000 a month) and Ni-kshay Mitra community support.

(a)(iii) Barriers

1. Missing cases: under-diagnosis and under-notification, especially in the private sector.
2. Drug resistance: MDR and pre-XDR TB, with gaps in drug-susceptibility testing.
3. Undernutrition, poverty, overcrowding, smoking, alcohol, diabetes and HIV.
4. Stigma and delayed care-seeking, high out-of-pocket and catastrophic costs.
5. Weak primary care, staff shortages, drug stock-outs, loss to follow-up.
6. Slow uptake of new tools and no effective adult vaccine, disruption by COVID-19.
7. Funding gaps. WHO’s Global TB Report 2025 shows a 21% fall in India’s incidence from 2015 to 2024, well short of End TB milestones, with India still carrying about a quarter of global cases.

(b)(i) Impact of HPV vaccination in India

• Burden: India has about 1.27 lakh new cervical cancer cases and about 80,000 deaths a year, around one-fifth of the global burden.
• Early programmes: Punjab (2016, Bathinda and Mansa), Delhi (2016) and Sikkim (2018, school-based, over 95% coverage) showed that school-based delivery is feasible and acceptable.
• Evidence: the IARC multicentre trial in India showed one dose gave protection against persistent HPV 16/18 infection similar to two or three doses, which informed WHO’s 2022 single-dose recommendation.
• Indigenous quadrivalent vaccine Cervavac (Serum Institute, 2022) lowered cost.
• National campaign: launched on 28 February 2026, offering a single free dose of Gardasil-4 to about 1.15 crore girls aged 14.
• Impact on cancer incidence will appear only after decades, but countries with high coverage show steep falls in HPV infection, precancer and cervical cancer. Combined with screening, this supports the WHO 90-70-90 elimination targets.

(b)(ii) Vaccines and schedules

1. Bivalent (Cervarix): HPV 16 and 18. Two doses at 0 and 6 months for 9-14 years, three doses (0, 1, 6 months) from 15 years.
2. Quadrivalent (Gardasil-4, and Cervavac): HPV 6, 11, 16, 18, also preventing genital warts. Two doses (0, 6-12 months) for 9-14 years, three doses (0, 2, 6 months) from 15 years.
3. Nonavalent (Gardasil-9): adds 31, 33, 45, 52, 58. Two doses for 9-14 years, three doses (0, 2, 6 months) for older ages.

• WHO (2022): one or two doses for girls 9-14 (primary target), one or two doses for 15-20 years, two doses for those over 21, three doses for immunocompromised (including HIV).
• Given intramuscularly, ideally before sexual debut. No boosters needed.

(c)(i) Findings if malignant

1. Lump: hard, irregular, ill-defined, non-tender, possibly fixed to skin, pectoralis major (fixed on contraction) or chest wall.
2. Skin: dimpling, puckering, peau d’orange, ulceration, satellite nodules.
3. Nipple: recent retraction, deviation, eczematous change (Paget disease), blood-stained discharge from a single duct.
4. Nodes: hard, matted or fixed axillary nodes, supraclavicular nodes.
5. Distant spread: hepatomegaly, bone tenderness, pleural effusion.

(c)(ii) Investigations

• Triple assessment: clinical examination, imaging (bilateral mammography and ultrasound of breast and axilla), and image-guided core needle biopsy for histology with ER, PR, HER2 and Ki-67. FNAC of palpable nodes.
• Nipple discharge cytology, ductography or MRI if needed.
• Staging (a 6 cm tumour is T3, locally advanced): chest X-ray, ultrasound abdomen or CECT chest-abdomen, bone scan or PET-CT.
• Baseline: CBC, LFT, RFT, blood sugar, ECG, echocardiography before anthracyclines or trastuzumab. Genetic testing (BRCA) if indicated.

(c)(iii) Structures preserved in MRM

1. Pectoralis major with its medial and lateral pectoral nerves.
2. Long thoracic nerve (to serratus anterior, to prevent a winged scapula).
3. Thoracodorsal nerve and vessels (to latissimus dorsi, for later flap reconstruction).
4. Axillary vein, and the intercostobrachial nerve and cephalic vein where possible. Pectoralis minor is preserved (Auchincloss), divided (Scanlon) or removed (Patey).