Displaying publications 1 - 20 of 25 in total

  1. Ngan KW, Shaari S, Subramaniam T
    Singapore Med J, 2009 Sep;50(9):e329-31.
    PMID: 19787163
    We report a six-year-old Malay girl who presented with a right retroperitoneal tumour that measured 7.5 cm in diameter. A wide excision of the lesion was performed. The tumour was separated from a normal-appearing right kidney by a capsule. Microscopically, this well-encapsulated tumour was composed of classical triphasic components: epithelial, mesenchymal and blastemal areas. The immunohistochemical study showed WT1 expression in the blastemal area. Thus, a diagnosis of Wilms' tumour with favourable histology was made. The patient was well for 12 months. Extrarenal Wilms' tumour is uncommon, with the majority of cases occurring in the retroperitoneal and inguinal areas. Wilms' tumour that is not arising from the intrarenal area but shares a common capsule with the ipsilateral kidney, is even rarer. Indeed, our case would be more appropriately classified as juxtarenal/pararenal Wilms' tumour. Despite its rarity, an extrarenal or even juxtarenal/pararenal Wilms' tumour should be included in the differential diagnosis of retroperitoneal tumour.
  2. Subramaniam Y, Loganathan N, Subramaniam T
    J Environ Manage, 2024 Feb;351:119646.
    PMID: 38042078 DOI: 10.1016/j.jenvman.2023.119646
    Governance has become indispensable within the healthcare sector, but previous studies have not explored the potential environmental benefits linked to healthcare governance. Thus, this study focuses on the role of governance in moderating healthcare and environmental emissions in 159 low, lower-middle, upper-middle and high-income countries. To do so, cross-sectional autoregressive distributed lag (CS-ARDL) techniques were applied using panel data from 1999 to 2021, followed by the computation of threshold and marginal effect of governance on healthcare and environmental emissions nexus. Findings revealed that, with the exception of high-income countries in the short run, governance has an insignificant impact on healthcare and emissions nexus in low-, lower-middle and upper-middle-income countries. Surprisingly, the findings imply that, in the long run, countries with greater levels of governance are likely to have lesser environmental impacts related to healthcare. There was also evidence indicating that low, lower-middle, upper-middle and high-income countries must reach a certain level of governance before realising the benefits of healthcare. Therefore, to achieve lower environmental impacts from healthcare, countries must promote effective governance policies that can incentivise and enforce sustainable practices and technologies in the healthcare sector.
  3. Subramaniam T, Loo RCN, Poovaneswaran S
    Background: At the International Medical University (IMU), a half day cardiac life support teaching session was provided to fourth year medical students which included training on the use of the defibrillator machine, how to handle cardiac or respiratory arrest and drugs used for resuscitation. A new CLS (cardiac life support) training session was introduced and increased to a oneday course where students were given practical training first, which included 5 stations (airway equipment, mega codes, drugs for resuscitation, defibrillator use and cardiac rhythm identification) , MCQ (multiple choice questions) test and a mega code (practical)assessment. Objective: To evaluate the students’ knowledge on cardiac resuscitation after a change in the delivery of the cardiac life support training (CLS).
    Methodology: Group I, consisted of 82 students taught using the traditional teaching and Group II consisted of 77 students taught using hands on simulation. The students in both groups had an online manual to read prior to the session, were given an identical written exam six months after the CLS training. Group II, however, had an online pre-test.
    Results: There was a statistical difference in the final mean marks between the two groups with group II scoring higher (67.3) than group 1 (62.1). No significant marks difference was noted between male and female students for both the cohorts.
    Conclusion: There is a significant difference in medical students’ knowledge when cardiac life support is taught using simulation. IMU has adopted the new teaching method with simulated training for the cardiac life support courses with plans to implement higher fidelity and technology to the existing simulated teaching in other areas of medicine.
  4. Subramaniam T, Loo RCN, Poovaneswaran S
    Background: This cross sectional study was done to identify the areas of lack of knowledge, practice and awareness of students about the effective use of personal protective equipment (PPE).
    Methods: A total of 40 students were selected when they were posted to the accident and emergency unit (A&E) in Seremban Hospital; all of them answered a questionnaire and were observed unaware on the effective use of PPE in the A&E.
    Results: We found that 17.5% of students were unaware of the right technique of removing the gloves after a procedure and 25% of students were unaware of safety of hand washing. During invasive procedures, 12.5 % of students did not wash their hands before invasive procedures, 65% did not wear aprons and 57.5% did not wear masks. During non- invasive procedures more than 25% of students did not wash hands before or after the procedures.
    Conclusion: There is still significant lack of knowledge in students about the effective use of PPE that needs to be addressed.
    Keywords: PPE, Personal protective equipment, effective practice of PPE, A&E
  5. Subramaniam T, Valuyeetham PS, Tay JS
    MyJurnal DOI: 10.21315/eimj2018.10.2.2
    Simulation-based medical education enables knowledge, skills and attitudes to be taught in a safe,
    realistic manner. Flipped classroom teaching encourages self-learning. Emergency medicine exposes
    students to diverse group of patients and physicians’ decision making. This study aims to determine
    students’ perception on knowledge, skills and confidence after combined flipped classroom and
    simulated teaching. Two cohorts of Semester 7 students Group 1 (n = 120) and Group 2 (n = 78)
    completed a 5-point Likert scale questionnaire. Group 1 completed the questionnaire after a lapse
    of six months while Group 2 at the end the posting. Responses from both cohorts were compared
    using the Mann-Whitney U test. Of 198 (Groups 1 and 2) students, 91.41% (n = 181) felt the
    simulated sessions helped better understand care of emergency patients. The sessions helped identify
    knowledge gaps (89.90%; n = 178), improve knowledge and understanding of oxygen therapy devices
    (85.35%; n = 169), and airway equipment (90.91%; n = 180). They prepared better for the flipped
    classroom teaching than traditional sessions (80.81%; n = 160). They felt that their communication
    skills (82.32%; n = 163) and confidence (63.64%; n = 126) improved. Significant differences noted
    to questions (p = 0.006, p = 0.005, p = 0.041 respectively) targeting knowledge on oxygen therapy
    devices, confidence, and identification of gaps in knowledge respectively. Combined simulation and
    flipped classroom teaching was well received by students though this requires more preparation.
  6. Subramanian GC, Arip M, Saraswathy Subramaniam TS
    Saf Health Work, 2017 Sep;8(3):246-249.
    PMID: 28951800 DOI: 10.1016/j.shaw.2016.12.007
    Health-care workers are at risk of exposure to occupational infections with subsequent risk of contracting diseases, disability, and even death. A systematic collection of occupational disease data is useful for monitoring current trends in work situations and disease exposures; however, these data are usually limited due to under-reporting. The objective of this study was to review literature related to knowledge, risk perceptions, and practices regarding occupational exposures to infectious diseases in Malaysian health-care settings, in particular regarding blood-borne infections, universal precautions, use of personal protective equipment, and clinical waste management. The data are useful for determining improvements in knowledge and risk perceptions among health-care workers with developments of health policies and essential interventions for prevention and control of occupational diseases.
  7. Subramaniam TS, Valuyeetham PS, Kamaru Ambu V
    Med J Malaysia, 2023 May;78(3):344-349.
    PMID: 37271844
    INTRODUCTION: Empathy is the ability to put oneself in another's emotional space and experience what they feel. Either due to lack of experience or mundaness of practice, a state of empathy can become premised, and individuals become indifferent or detached. We aimed to explore the level of empathy among doctors at different levels of practice, age, gender, academics, non-academics and discipline.

    MATERIALS AND METHODS: This was a cross-sectional, observational study on empathy among doctors practicing in the private, public hospital sector and faculty at a medical university in Negeri Sembilan, Malaysia that utilised convenience sampling for data collection. The Toronto Empathy Questionnaire (TEQ) a validated tool was used to measure empathy.

    RESULTS: The questionnaire was completed by 127 doctors, 52% (n= 66) were males and 48% (n=61) females. There was no significant difference in empathy between male (M=46.44; SD=6.01) and female (M=45.05, SD=5.69) doctors; t (123) = 1.326, p=0.187. Pearson correlation coefficient was computed to assess the linear relationship between age and empathy and revealed no correlation between the two variables: r (125) =0.15, p=0.099. Medical-based doctors (M= 47.47, SD=5.98) demonstrated more empathy than surgicalbased (M=44.32, SD=5.41); t (123) =-3.09, p=0.002. Those already specialised in their fields (M=47.38, SD=4.57) had more empathy than those who had not (M= 44.36, SD=6.52); t (123) =-2.96, p = 0.004. Doctors in the university (M=47.97, SD=4.31) tended to have more empathy than those in the public hospitals (M= 44.63, SD=6.27); t (117) =-2.91, p=0.004. Academicians had more empathy than non-academicians but there was no difference between those who were in clinical practice and not.

    CONCLUSION: Our findings indicate that medical-based doctors demonstrate more empathy than surgical-based doctors, and there appeared to be no correlation between age and empathy. However, clinical experience and growth within the specialty seem to improve empathy. Doctors teaching in the university setting demonstrated more empathy than those practicing in the hospital setting. Inclusion of empathy-related sessions in the undergraduate and post-graduate curriculum could bridge the gap in empathy noted with age, discipline, and experience in practice. Further research on empathy among doctors using a wider population in Malaysia and a TEQ questionnaire validated to the Asian population would provide better insight regarding this area of medical practice. Future research on outcomes of inclusion of programmes targeted at improving empathy to create awareness during practice would support patient satisfaction and safety.

  8. Subramaniam Y, Loganathan N, Subramaniam T, Bulut U
    Environ Sci Pollut Res Int, 2023 Oct;30(50):108802-108824.
    PMID: 37755592 DOI: 10.1007/s11356-023-29965-w
    This study investigates the energy security and income roles in testing environmental Kuznets curve (EKC) for developing countries from 1990 to 2019. The panel quantile regression approaches are employed to examine the relationship between the variables, considering that income and energy security effects on carbon emissions may vary across distributions. Findings revealed that the EKC hypothesis was inconsistent at low and high quantiles when estimating energy availability, affordability, and acceptability. The validity of inverted U-shaped EKC is supported at high quantiles for energy affordability and accessibility in developing countries. However, given the energy accessibility and acceptability, the EKC hypothesis becomes invalid in developing countries. Notably, developing countries have yet to progress toward achieving energy security as a switch component to low carbon emissions. This study contributes to the literature by revealing the effect of availability, accessibility, affordability, and acceptability of energy security on carbon dioxide emissions (CO2). Thus, it suggests implications for improving environmental quality in developing countries by enhancing energy security. Diversifying energy sources with nuclear, renewable, and developing technologies reduces dependence risks on a single source while improving efficiency through technology and demand management lowers carbon emissions and strengthens energy security. Beyond energy security, this study emphasises sustainable urban planning to promote compact development, effective transportation, and green infrastructure to reduce energy use and improve environmental sustainability, ultimately reducing carbon emissions.
  9. Subramaniam TS, Lee HL, Ahmad NW, Murad S
    Biotechnol J, 2012 Nov;7(11):1323-7.
    PMID: 23125042 DOI: 10.1002/biot.201200282
    On December 21, 2010, 6000 genetically modified (GM) mosquitoes were released in an uninhabited forest in Malaysia. The purpose of the deliberate release was a limited “marked release and recapture” (MRR) experiment, a standard ecological method in entomology, to evaluate under field conditions, the flight distance and longevity of the sterile male Aedes aegypti strain OX513A(My1), a GM strain. As with any other GM technologies, the release was received with mixed responses. As the scientific community debate over the public engagement strategies for similar GM releases, dengue incidence continues to rise with a heavy toll on morbidity, mortality and healthcare budgets. Meanwhile the wild female Aedes aegypti continues to breed offspring, surviving and evading conventional interventions for vector control.
  10. Subramaniam T, Fauzi MB, Lokanathan Y, Law JX
    Int J Mol Sci, 2021 Jun 17;22(12).
    PMID: 34204292 DOI: 10.3390/ijms22126486
    Skin injury is quite common, and the wound healing is a complex process involving many types of cells, the extracellular matrix, and soluble mediators. Cell differentiation, migration, and proliferation are essential in restoring the integrity of the injured tissue. Despite the advances in science and technology, we have yet to find the ideal dressing that can support the healing of cutaneous wounds effectively, particularly for difficult-to-heal chronic wounds such as diabetic foot ulcers, bed sores, and venous ulcers. Hence, there is a need to identify and incorporate new ideas and methods to design a more effective dressing that not only can expedite wound healing but also can reduce scarring. Calcium has been identified to influence the wound healing process. This review explores the functions and roles of calcium in skin regeneration and reconstruction during would healing. Furthermore, this review also investigates the possibility of incorporating calcium into scaffolds and examines how it modulates cutaneous wound healing. In summary, the preliminary findings are promising. However, some challenges remain to be addressed before calcium can be used for cutaneous wound healing in clinical settings.
  11. Saraswathy Subramaniam TS, Apandi MA, Jahis R, Samsudin MS, Saat Z
    J Trop Med, 2014;2014:814908.
    PMID: 24772175 DOI: 10.1155/2014/814908
    Since 1992, surveillance for acute flaccid paralysis (AFP) cases was introduced in Malaysia along with the establishment of the National Poliovirus Laboratory at the Institute for Medical Research. In 2008, the Ministry of Health, Malaysia, approved a vaccine policy change from oral polio vaccine to inactivated polio vaccine (IPV). Eight states started using IPV in the Expanded Immunization Programme, followed by the remaining states in January 2010. The objective of this study was to determine the viral aetiology of AFP cases below 15 years of age, before and after vaccine policy change from oral polio vaccine to inactivated polio vaccine. One hundred and seventy-nine enteroviruses were isolated from the 3394 stool specimens investigated between 1992 and December 2012. Fifty-six out of 107 virus isolates were polioviruses and the remaining were non-polio enteroviruses. Since 2009 after the sequential introduction of IPV in the childhood immunization programme, no Sabin polioviruses were isolated from AFP cases. In 2012, the laboratory AFP surveillance was supplemented with environmental surveillance with sewage sampling. Thirteen Sabin polioviruses were also isolated from sewage in the same year, but no vaccine-derived poliovirus was detected during this period.
  12. Palanisamy UD, Sivanathan M, Radhakrishnan AK, Haleagrahara N, Subramaniam T, Chiew GS
    Molecules, 2011 Jul 05;16(7):5709-19.
    PMID: 21730920 DOI: 10.3390/molecules16075709
    Ostrich oil has been used extensively in the cosmetic and pharmaceutical industries. However, rancidity causes undesirable chemical changes in flavour, colour, odour and nutritional value. Bleaching is an important process in refining ostrich oil. Bleaching refers to the removal of certain minor constituents (colour pigments, free fatty acid, peroxides, odour and non-fatty materials) from crude fats and oils to yield purified glycerides. There is a need to optimize the bleaching process of crude ostrich oil prior to its use for therapeutic purposes. The objective of our study was to establish an effective method to bleach ostrich oil using peroxide value as an indicator of refinement. In our study, we showed that natural earth clay was better than bentonite and acid-activated clay to bleach ostrich oil. It was also found that 1 hour incubation at a 150 °C was suitable to lower peroxide value by 90%. In addition, the nitrogen trap technique in the bleaching process was as effective as the continuous nitrogen flow technique and as such would be the recommended technique due to its cost effectiveness.
  13. Palanisamy UD, Ling LT, Manaharan T, Sivapalan V, Subramaniam T, Helme MH, et al.
    Int J Cosmet Sci, 2011 Jun;33(3):269-75.
    PMID: 21284663 DOI: 10.1111/j.1468-2494.2010.00637.x
    Syzygium aqueum, a species in the Myrtaceae family, commonly called the water jambu is native to Malaysia and Indonesia. It is well documented as a medicinal plant, and various parts of the tree have been used in traditional medicine, for instance as an antibiotic. In this study, we show S. aqueum leaf extracts to have a significant composition of phenolic compounds, protective activity against free radicals as well as low pro-oxidant capability. Its ethanolic extract, in particular, is characterized by its excellent radical scavenging activity of EC(50) of 133 μg mL(-1) 1,1-diphenyl-2-picryl-hydrazyl (DPPH), 65 μg mL(-1) 2,2'-azino-bis(3-ethylbenzthiazoline-6-sulphonic acid) (ABTS) and 71 μg mL(-1) (Galvinoxyl), low pro-oxidant capabilities and a phenolic content of 585-670 mg GAE g(-1) extract. The extract also displayed other activities, deeming it an ideal cosmetic ingredient. A substantial tyrosinase inhibition activity with an IC(50) of about 60 μg mL(-1) was observed. In addition, the extract was also found to have anti-cellulite activity tested for its ability to cause 98% activation of lipolysis of adipocytes (fat cells) at a concentration of 25 μg mL(-1). In addition, the extract was not cytotoxic to Vero cell lines up to a concentration of 600 μg mL(-1). Although various parts of this plant have been used in traditional medicine, this is the first time it has been shown to have cosmeceutical properties. Therefore, the use of this extract, alone or in combination with other active principles, is of interest to the cosmetic industry.
  14. Ling LT, Radhakrishnan AK, Subramaniam T, Cheng HM, Palanisamy UD
    Molecules, 2010 Apr;15(4):2139-51.
    PMID: 20428033 DOI: 10.3390/molecules15042139
    Thirteen Malaysian plants; Artocarpus champeden, Azadirachta indica, Fragaria x ananassa, Garcinia mangostana, Lawsonia inermis, Mangifera indica, Nephelium lappaceum, Nephelium mutobile, Peltophorum pterocarpum, Psidium guajava and Syzygium aqueum, selected for their use in traditional medicine, were subjected to a variety of assays. Antioxidant capability, total phenolic content, elemental composition, as well as it cytotoxity to several cell lines of the aqueous and ethanolic extracts from different parts of these selected Malaysian plants were determined. In general, the ethanolic extracts were better free radical scavengers than the aqueous extracts and some of the tested extracts were even more potent than a commercial grape seed preparation. Similar results were seen in the lipid peroxidation inhibition studies. Our findings also showed a strong correlation of antioxidant activity with the total phenolic content. These extracts when tested for its heavy metals content, were found to be below permissible value for nutraceutical application. In addition, most of the extracts were found not cytotoxic to 3T3 and 4T1 cells at concentrations as high as 100 microg/mL. We conclude that although traditionally these plants are used in the aqueous form, its commercial preparation could be achieved using ethanol since a high total phenolic content and antioxidant activity is associated with this method of preparation.
  15. Palanisamy U, Cheng HM, Masilamani T, Subramaniam T, Ling LT, Radhakrishnan AK
    Food Chem, 2008 Jul 1;109(1):54-63.
    PMID: 26054264 DOI: 10.1016/j.foodchem.2007.12.018
    The rind of rambutan, which is normally discarded was found to contain extremely high antioxidant activity when assessed using several methods. Although having a yield of only 18%, the ethanolic rambutan rind extract had a total phenolic content of 762±10mg GAE/g extract, which is comparable to that of a commercial preparation of grape seed extract. Comparing the extract's pro-oxidant capabilities with vitamin C, α-tocopherol, grape seed and green tea, the rind had the lowest pro-oxidant capacity. In addition, the extract at 100μg/ml was seen to limit oxidant-induced cell death (DPPH at 50μM) by apoptosis to an extent similar to that of grape seed. The extracts were not cytotoxic to normal mouse fibroblast cells or splenocytes while the powderised rind was seen to have heavy metals contents far below the permissible levels for nutraceuticals. Our study for the first time reveals the high phenolic content, low pro-oxidant capacity and strong antioxidant activity of the extract from rind of Nephelium lappaceum. This extract, either alone or in combination with other active principles, can be used in cosmetic, nutraceutical and pharmaceutical applications.
  16. Liau LL, Looi QH, Chia WC, Subramaniam T, Ng MH, Law JX
    Cell Biosci, 2020;10:112.
    PMID: 32983406 DOI: 10.1186/s13578-020-00475-3
    Background: Spinal cord injury (SCI) is the damage to the spinal cord that can lead to temporary or permanent loss of function due to injury to the nerve. The SCI patients are often associated with poor quality of life.

    Results: This review discusses the current status of mesenchymal stem cell (MSC) therapy for SCI, criteria to considering for the application of MSC therapy and novel biological therapies that can be applied together with MSCs to enhance its efficacy. Bone marrow-derived MSCs (BMSCs), umbilical cord-derived MSCs (UC-MSCs) and adipose tissue-derived MSCs (ADSCs) have been trialed for the treatment of SCI. Application of MSCs may minimize secondary injury to the spinal cord and protect the neural elements that survived the initial mechanical insult by suppressing the inflammation. Additionally, MSCs have been shown to differentiate into neuron-like cells and stimulate neural stem cell proliferation to rebuild the damaged nerve tissue.

    Conclusion: These characteristics are crucial for the restoration of spinal cord function upon SCI as damaged cord has limited regenerative capacity and it is also something that cannot be achieved by pharmacological and physiotherapy interventions. New biological therapies including stem cell secretome therapy, immunotherapy and scaffolds can be combined with MSC therapy to enhance its therapeutic effects.

  17. Thanapal MR, Tata MD, Tan AJ, Subramaniam T, Tong JM, Palayan K, et al.
    ANZ J Surg, 2014 Jan-Feb;84(1-2):47-51.
    PMID: 23057502 DOI: 10.1111/j.1445-2197.2012.06210.x
    Although laparoscopic surgeries are associated with reduced surgical stress response and shortened post-operative recovery, intense pain and high analgesia requirements in the immediate post-operative period are often the chief complaints.
  18. Oh AL, Tan AG, Phan HS, Lee BC, Jumaat N, Chew SP, et al.
    Pharm Pract (Granada), 2015 Apr-Jun;13(3):633.
    PMID: 26445624 DOI: 10.18549/PharmPract.2015.03.633
    Proton-pump inhibitors (PPI) and histamine-2 receptor antagonists (H2RA) are common acid suppressants used in gastrointestinal disorders. The trend of usage in Malaysia has changed from predominantly H2RA to PPI from 2007 to 2008, 3.46 versus 2.87 and 2.99 versus 3.24 DDD (Defined Daily Dose)/1000 population/day respectively. This raises concerns as PPI overutilization amounts to higher cost expenditure and are associated with various untoward consequences such as Clostridium difficile-associated diarrhea, pneumonia, and osteoporosis.
  19. Subramaniam T, Shaiful Hadi N, Sulaiman S, Fauzi MB, Hj Idrus RB, Chowdhury SR, et al.
    Burns, 2021 Aug 20.
    PMID: 34893370 DOI: 10.1016/j.burns.2021.08.012
    Skin substitutes are designed dressings intended to promote wound closure. In previous in vitro and in vivo studies on small animal, an acellular skin patch made of collagen hydrogel with dermal fibroblast conditioned medium (Col-DFCM), a collagen sponge scaffold with freshly harvested skin cells (OTC), and a platelet-rich-plasma gel with freshly harvested skin cells (PRP) have been developed and tested for immediate treatment of full-thickness wound. However, to determine the safety and efficacy of these skin patches for clinical applications, further study in a large animal model is needed. The aim of this study is to evaluate the potential of Col-DFCM, OTC and PRP in treating full-thickness wound in an ovine model via histological analysis and immunohistochemistry staining were performed, with the untreated (NT) group serving as the control. Gross examination was conducted on day 7, 14 and 21 to determine the wound closure rate. The findings of percentage of wound size reduction showed that the wound healed fastest in the presence of Col-DFCM (91.34 ± 23.35%) followed by OTC (84.49 ± 23.13%), PRP (77.73 ± 20.9%) and NT group (73.94 ± 23.71%). Histological evaluation with Hematoxylin & Eosin (H & E) and Masson's trichrome staining was used to study the structure of the wound area. The results showed that OTC treated wound was more mature as indicated by the presence of a thinner epidermis followed by the Col-DFCM, PRP and NT group. Immunohistochemistry analysis also confirmed the integrity and maturity of the regenerated skin, with positive expression of cytokeratin 10 (CK10) and involucrin in the epidermal layer. In conclusion, Col-DFCM, OTC and PRP treatments promote healing of full-thickness wound and have the potential to be used clinically for rapid treatment of full-thickness wound.
  20. Saraswathy Subramaniam TS, Thayan R, Yusof MA, Suppiah J, Tg Abd Rashid TR, Zawawi ZM, et al.
    Asian Pac J Trop Med, 2016 Feb;9(2):201-3.
    PMID: 26919957 DOI: 10.1016/j.apjtm.2016.01.016
    An efficient public health preparedness and response plan for infectious disease management is important in recent times when emerging and exotic diseases that hitherto were not common have surfaced in countries with potential to spread outside borders. Stewardship from a reference laboratory is important to take the lead for the laboratory network, to proactively set up disease surveillance, provide referral diagnostic services, on-going training and mentorship and to ensure coordination of an effective laboratory response. In Malaysia, the Institute for Medical Research has provided the stewardship for the Ministry of Health's laboratory network that comprises of hospital pathology, public health and university laboratories. In this paper we share our experiences in recent infectious disease outbreak investigations as a reference laboratory within the Ministry of Health infectious disease surveillance network.
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