Pediatric Malignant Tumors in Malawi: A Diagnostic Report From the Kamuzu Central Hospital Pathology Laboratory 2011–2020
Yolanda Gondwe
University of North Carolina Project-Malawi, Lilongwe, Malawi
Search for more papers by this authorApril Evans
University of North Carolina Project-Malawi, Lilongwe, Malawi
Department of Pediatric Hematology Oncology, University of North Carolina, Chapel Hill, North Carolina, USA
Stanford Health Roger Maris Cancer Center, Fargo, North Dakota, USA
Search for more papers by this authorApatsa Matatiyo
University of North Carolina Project-Malawi, Lilongwe, Malawi
Search for more papers by this authorGugulethu N. Mapurisa
University of North Carolina Project-Malawi, Lilongwe, Malawi
Search for more papers by this authorCoxcilly Kampani
University of North Carolina Project-Malawi, Lilongwe, Malawi
Search for more papers by this authorFred Chimzimu
University of North Carolina Project-Malawi, Lilongwe, Malawi
Search for more papers by this authorRob Krysiak
University of North Carolina Project-Malawi, Lilongwe, Malawi
Search for more papers by this authorNader Kim El-Mallawany
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorJulie M. Gastier-Foster
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
Department of Pathology and Immunology, Texas Childrens Hospital and Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorJohn Hicks
Department of Pathology and Immunology, Texas Childrens Hospital and Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorDavid Berger
Department of Pathology and Immunology, Texas Childrens Hospital and Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorNmazuo W. Ozuah
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorCasey L. McAtee
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorRizine Mzikamanda
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Search for more papers by this authorMinke W. H. Huibers
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Prinses Maxima Centrum voor Kinderoncologie, Utrecht, Netherlands
Search for more papers by this authorAtupele Mpasa
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Search for more papers by this authorStella Wachepa
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Search for more papers by this authorSteve Martin
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Search for more papers by this authorPeter Wasswa
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorMaurice Mulenga
University of North Carolina Project-Malawi, Lilongwe, Malawi
Department of Pathology, Kamuzu Central Hospital, Malawi Ministry of Health, Lilongwe, Malawi
Search for more papers by this authorShiraz Khan
University of North Carolina Project-Malawi, Lilongwe, Malawi
Department of Pathology, Kamuzu Central Hospital, Malawi Ministry of Health, Lilongwe, Malawi
Search for more papers by this authorSatish Gopal
National Cancer Institute Center for Global Health, Bethesda, Maryland, USA
Search for more papers by this authorTamiwe Tomoka
University of North Carolina Project-Malawi, Lilongwe, Malawi
Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
Department of Pathology, Kamuzu University of Health Sciences, Blantyre, Malawi
Search for more papers by this authorYuri Fedoriw
University of North Carolina Project-Malawi, Lilongwe, Malawi
Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
Search for more papers by this authorCorresponding Author
Katherine D. Westmoreland
University of North Carolina Project-Malawi, Lilongwe, Malawi
Department of Pediatric Hematology Oncology, University of North Carolina, Chapel Hill, North Carolina, USA
Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
Search for more papers by this authorYolanda Gondwe
University of North Carolina Project-Malawi, Lilongwe, Malawi
Search for more papers by this authorApril Evans
University of North Carolina Project-Malawi, Lilongwe, Malawi
Department of Pediatric Hematology Oncology, University of North Carolina, Chapel Hill, North Carolina, USA
Stanford Health Roger Maris Cancer Center, Fargo, North Dakota, USA
Search for more papers by this authorApatsa Matatiyo
University of North Carolina Project-Malawi, Lilongwe, Malawi
Search for more papers by this authorGugulethu N. Mapurisa
University of North Carolina Project-Malawi, Lilongwe, Malawi
Search for more papers by this authorCoxcilly Kampani
University of North Carolina Project-Malawi, Lilongwe, Malawi
Search for more papers by this authorFred Chimzimu
University of North Carolina Project-Malawi, Lilongwe, Malawi
Search for more papers by this authorRob Krysiak
University of North Carolina Project-Malawi, Lilongwe, Malawi
Search for more papers by this authorNader Kim El-Mallawany
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorJulie M. Gastier-Foster
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
Department of Pathology and Immunology, Texas Childrens Hospital and Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorJohn Hicks
Department of Pathology and Immunology, Texas Childrens Hospital and Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorDavid Berger
Department of Pathology and Immunology, Texas Childrens Hospital and Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorNmazuo W. Ozuah
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorCasey L. McAtee
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorRizine Mzikamanda
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Search for more papers by this authorMinke W. H. Huibers
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Prinses Maxima Centrum voor Kinderoncologie, Utrecht, Netherlands
Search for more papers by this authorAtupele Mpasa
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Search for more papers by this authorStella Wachepa
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Search for more papers by this authorSteve Martin
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Search for more papers by this authorPeter Wasswa
Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
Search for more papers by this authorMaurice Mulenga
University of North Carolina Project-Malawi, Lilongwe, Malawi
Department of Pathology, Kamuzu Central Hospital, Malawi Ministry of Health, Lilongwe, Malawi
Search for more papers by this authorShiraz Khan
University of North Carolina Project-Malawi, Lilongwe, Malawi
Department of Pathology, Kamuzu Central Hospital, Malawi Ministry of Health, Lilongwe, Malawi
Search for more papers by this authorSatish Gopal
National Cancer Institute Center for Global Health, Bethesda, Maryland, USA
Search for more papers by this authorTamiwe Tomoka
University of North Carolina Project-Malawi, Lilongwe, Malawi
Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
Department of Pathology, Kamuzu University of Health Sciences, Blantyre, Malawi
Search for more papers by this authorYuri Fedoriw
University of North Carolina Project-Malawi, Lilongwe, Malawi
Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
Search for more papers by this authorCorresponding Author
Katherine D. Westmoreland
University of North Carolina Project-Malawi, Lilongwe, Malawi
Department of Pediatric Hematology Oncology, University of North Carolina, Chapel Hill, North Carolina, USA
Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
Search for more papers by this authorYolanda Gondwe and April Evans Co-first authors.
ABSTRACT
Background
In 2011, a partnership between Kamuzu Central Hospital (KCH) and the University of North Carolina (UNC) led to the opening of the first diagnostic pathology laboratory in Lilongwe, Malawi's capital.
Procedure
A retrospective case series of malignancies diagnosed at the KCH–UNC pathology laboratory between 2011 and 2020 in pediatric and adolescent patients aged 0–18 years.
Results
Between 2011 and 2020, 12761 specimens were received from 5137 pediatric and adolescent patients. A malignant diagnosis was confirmed in 1498 (29%) of patients, with a median age of 10 years (interquartile range (IQR) 5–14) and 810 (54%) males. The most common malignancy was lymphoma (38%, 571/1498), including both non-Hodgkin lymphomas (NHLs) (86%, 387/571), with Burkitt lymphoma accounting for 80% (309/387) of NHLs, and Hodgkin lymphoma (HL) (22%, 125/571). Next were sarcomas (22%, 325/1498), including Kaposi sarcoma (KS) (34%, 111/325), rhabdomyosarcoma (21%, 68/325), and osteosarcoma (19%, 61/325). Then carcinomas (9%, 139/1498), with the majority (53%, 73/139) being squamous cell carcinoma. Next were acute leukemias (6%, 95/1498), including acute lymphoblastic leukemia (66%, 63/95) and acute myeloid leukemia (32%, 30/95). These were followed by Wilms tumor (WT) (6%, 90/1498), retinoblastoma (4%,66/1498), neuroblastoma (2%, 32/1498), hepatic tumors (2%, 31/1498), and germ cell tumors (1%, 22/1498).
Conclusions
The most common pediatric tumors diagnosed in the KCH–UNC pathology laboratory were NHL, HL, KS, and WT. Given the challenges of under-diagnosis, obtaining tissue biopsies, and reliance on clinical diagnosis, we suspect there is an underrepresentation of many pediatric cancers, including acute leukemias, brain tumors, and WT. Pathology diagnostic services and techniques need to be expanded further to aid the categorization of carcinomas and sarcomas.
Conflicts of Interest
No commercial support was provided for this study. This work was completed while Dr. Satish Gopal was employed at the University of North Carolina at Chapel Hill. The opinions expressed in this article are the authors' own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the US government.
Open Research
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Supporting Information
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Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
References
- 1L. M. Force, I. Abdollahpour, S. M. Advani, et al., “The Global Burden of Childhood and Adolescent Cancer in 2017: An Analysis of the Global Burden of Disease Study 2017,” The Lancet Oncology 20, no. 9 (2019): 1211–1225, https://doi.org/10.1016/S1470-2045(19)30339-0.
- 2D. M. Parkin and C. Stefan. Editorial : Childhood Cancer in Sub-Saharan Africa: 7–11.
- 3I. Magrath, E. Steliarova-Foucher, S. Epelman, et al., “Paediatric Cancer in Low-Income and Middle-Income Countries,” The Lancet Oncology 14, no. 3 (2013): e104–e116, https://doi.org/10.1016/S1470-2045(13)70008-1.
- 4C. G. Lam, S. C. Howard, E. Bouffet, and K. Pritchard-Jones, “Science and Health for all Children with Cancer,” Science 363, no. 6432 (2019): 1182–1186, https://doi.org/10.1126/science.aaw4892.
- 5Z. J. Ward, J. M. Yeh, N. Bhakta, A. L. Frazier, F. Girardi, and R. Atun, “Global Childhood Cancer Survival Estimates and Priority-Setting: A Simulation-Based Analysis,” The Lancet Oncology 20, no. 7 (2019): 972–983, https://doi.org/10.1016/S1470-2045(19)30273-6.
- 6N. Bhakta, L. M. Force, C. Allemani, et al., “Childhood Cancer Burden: A Review of Global Estimates,” The Lancet Oncology 20, no. 1 (2019): e42–e53, https://doi.org/10.1016/S1470-2045(18)30761-7.
- 7D. Cristina Stefan, “Patterns of Distribution of Childhood Cancer in Africa,” Journal of Tropical Pediatrics 61, no. 3 (2015): 165–173, https://doi.org/10.1093/tropej/fmv005.
- 8C. Stefan, F. Bray, J. Ferlay, B. Liu, and D. M. Parkin, “Cancer of Childhood in Sub-Saharan Africa,” Ecancermedicalscience 11 (2017): 1–95, https://doi.org/10.3332/ecancer.2017.755.
10.3332/ecancer.2017.755 Google Scholar
- 9M. J. Horner, S. Chasimpha, A. Spoerri, et al., “High Cancer Burden among Antiretroviral Therapy Users in Malawi: A Record Linkage Study of Observational Human Immunodeficiency Virus Cohorts and Cancer Registry Data,” Clinical Infectious Diseases 69, no. 5 (2019): 829–835, https://doi.org/10.1093/cid/ciy960.
- 10K. D. Westmoreland, N. D. Montgomery, C. C. Stanley, et al., “Plasma Epstein-Barr Virus DNA for Pediatric Burkitt Lymphoma Diagnosis, Prognosis and Response Assessment in Malawi,” International Journal of Cancer 140, no. 11 (2017): 2509–2516, https://doi.org/10.1002/ijc.30682.
- 11K. D. Westmoreland, C. C. Stanley, N. D. Montgomery, et al., “Hodgkin Lymphoma, HIV, and Epstein–Barr Virus in Malawi: Longitudinal Results From the Kamuzu Central Hospital Lymphoma Study,” Pediatric blood & cancer 64, no. 5 (2017): 1–9, https://doi.org/10.1002/pbc.26302.
10.1002/pbc.26302 Google Scholar
- 12M. J. Horner, A. Salima, C. Chilima, et al., “Frequent HIV and Young Age Among Individuals with Diverse Cancers at a National Teaching Hospital in Malawi,” Journal of Global Oncology no. 4 (2018): 1–11, https://doi.org/10.1200/JGO.17.00174.
- 13N. D. Montgomery, N. G. Liomba, C. Kampani, et al., “Accurate Real-time Diagnosis of Lymphoproliferative Disorders in Malawi Through Clinicopathologic Teleconferences: A Model for Pathology Services in Sub-Saharan Africa,” American Journal of Clinical Pathology 146, no. 4 (2016): 423–430, https://doi.org/10.1093/ajcp/aqw118.
- 14T. Tomoka, N. D. Montgomery, E. Powers, et al., “Lymphoma and Pathology in Sub-Saharan Africa: Current Approaches and Future Directions,” Clinics in Laboratory Medicine 38, no. 1 (2018): 91–100, https://doi.org/10.1016/j.cll.2017.10.007.
- 15K. Fleming, “Pathology and Cancer in Africa,” Ecancermedicalscience 13 (2019): 2–5, https://doi.org/10.3332/ecancer.2019.945.
10.3332/ecancer.2019.945 Google Scholar
- 16S. Gopal, R. Krysiak, N. G. Liomba, et al., “Early Experience After Developing a Pathology Laboratory in Malawi, With Emphasis on Cancer Diagnoses,” PLoS ONE 8, no. 8 (2013): 6–13, https://doi.org/10.1371/journal.pone.0070361.
- 17S. Gopal, R. Krysiak, and G. Liomba, “Building a Pathology Laboratory in Malawi,” The Lancet Oncology 14, no. 4 (2013): 291–292, https://doi.org/10.1016/S1470-2045(13)70109-8.
- 18T. Tomoka, N. D. Montgomery, C. Kampani, et al., “Developing and Expanding Pathology Services to Support Clinical Care and Research Efforts in Malawi,” Blood Advances 1 (2017): 5–7, https://doi.org/10.1182/bloodadvances.2017GS102161.
- 19A. J. Brownlee, M. Dewey, M. B. Chagomerana, et al., “Update on Pathology Laboratory Development and Research in Advancing Regional Cancer Care in Malawi,” Frontiers in Medicine (Lausanne) 11 (2024), https://doi.org/10.3389/fmed.2024.1336861.
- 20R. Mzikamanda, N. Mwango, C. Mcatee, P. Wasswa, and N. Ozuah, “Impact of Early Mortality and Treatment Abandonment on the Prognostic Value of Minimal Residual Disease and Immunophenotype in Pediatric Acute Lymphoblastic Leukemia in sub-Saharan Africa,” Pediatric Blood & Cancer 70, no. S8 (2023): S259–S259, https://doi.org/10.1002/pbc.30748.
10.1002/pbc.30748 Google Scholar
- 21N. Mwango, R. Mzikamanda, N. Ozuah, P. Wasswa, and C. Mcatee, “Early Mortality and Blood Product Utilization in Children With Acute Myeloid Leukemia in Lilongwe, Malawi: In Support of Eary Intensity-Adapted Protocols,” Pediatric Blood & Cancer 70, no. S8 (2023): S279–S279, https://doi.org/10.1002/pbc.30748.
10.1002/pbc.30748 Google Scholar
- 22D. M. Holmes, A. Matatiyo, A. Mpasa, et al., “Outcomes of Wilms Tumor Therapy in Lilongwe, Malawi, 2016–2021: Successes and Ongoing Research Priorities,” Pediatric Blood & Cancer 70, no. 5 (2023), https://doi.org/10.1002/pbc.30242.
- 23T. Israels, C. Moreira, T. Scanlan, et al., “SIOP PODC: Clinical Guidelines for the Management of Children With Wilms Tumour in a Low Income Setting,” Pediatric Blood & Cancer 60, no. 1 (2013): 5–11, https://doi.org/10.1002/pbc.24321.
- 24S. Chasimpha, M. J. Horner, C. Dzamalala, and S. Gopal, “Historical Evolution of the Malawi National Cancer Registry: A Collaborative Effort to Develop and Sustain an Impactful Cancer Control Resource in a Low-Income Country,” Journal of Global Oncology 3 (2017): 3s–3s, https://doi.org/10.1200/JGO.2017.009530.
10.1200/JGO.2017.009530 Google Scholar
- 25D. Forman, F. Bray, D. H. Brewster, et al. Cancer Incidence in Five Continents Vol. X. IARC Publication No. 164; 2014. Accessed March 10, 2023. file:///C:/Users/yolan/Downloads/CI5volX_Full.pdf.
- 26N. K. El-Mallawany, M. Mutai, I. Mtete, et al., “Beyond Endemic Burkitt Lymphoma: Navigating Challenges of Differentiating Childhood Lymphoma Diagnoses Amid Limitations in Pathology Resources in Lilongwe, Malawi,” Global Pediatric Health 4 (2017), https://doi.org/10.1177/2333794X17715831.
- 27N. K. El-Mallawany, W. Kamiyango, J. Villiera, et al., “Proposal of a Risk-Stratification Platform to Address Distinct Clinical Features of Pediatric Kaposi Sarcoma in Lilongwe, Malawi,” Journal of Global Oncology 4 (2018): 1–7, https://doi.org/10.1200/JGO.17.00054.
- 28N. K. El-Mallawany, C. L. McAtee, L. R. Campbell, and P. N. Kazembe, “Pediatric Kaposi Sarcoma in Context of the HIV Epidemic in Sub-Saharan Africa: Current Perspectives,” Pediatric Health, Medicine and Therapeutics 9 (2018): 35–46, https://doi.org/10.2147/PHMT.S142816.
- 29A. Silverstein, W. Kamiyango, J. Villiera, et al., “Long-Term Outcomes for Children and Adolescents With Kaposi Sarcoma,” HIV Medicine 23, no. 2 (2022): 197–203, https://doi.org/10.1111/hiv.13191.
- 30A. D. Harries, N. Ford, A. Jahn, et al., “Act Local, Think Global: How the Malawi Experience of Scaling up Antiretroviral Treatment Has Informed Global Policy,” BMC Public Health [Electronic Resource] 16, no. 1 (2016): 938, https://doi.org/10.1186/s12889-016-3620-x.
- 31N. K. El-Mallawany, J. Villiera, W. Kamiyango, et al., “Increasing Numbers of New Kaposi Sarcoma Diagnoses in HIV-Infected Children and Adolescents Despite the Wide Availability of Antiretroviral Therapy in Malawi,” Clinical Infectious Diseases 64, no. 6 (2017): 818–819, https://doi.org/10.1093/cid/ciw879.
- 32 UNAIDS. HIV Estimates with Uncertainty Bounds 1990–Present, https://www.unaids.org/en/resources/documents/2022/HIV_estimates_with_uncertainty_bounds_1990-present.
- 33C. C. Stanley, K. D. Westmoreland, B. J. Heimlich, et al., “Outcomes for Paediatric Burkitt Lymphoma Treated With Anthracycline-Based Therapy in Malawi,” British Journal of Haematology 173, no. 5 (2016): 705–712, https://doi.org/10.1111/bjh.13986.
- 34S. Depani, K. Banda, S. Bailey, T. Israels, G. Chagaluka, and E. Molyneux, “Outcome Is Unchanged by Adding Vincristine Upfront to the Malawi 28-day Protocol for Endemic Burkitt Lymphoma,” Pediatric Blood & Cancer 62, no. 11 (2015): 1929–1934, https://doi.org/10.1002/pbc.25612.
- 35T. Ngoma, M. Adde, M. Durosinmi, et al., “Treatment of Burkitt Lymphoma in Equatorial Africa Using a Simple Three-Drug Combination Followed by a Salvage Regimen for Patients With Persistent or Recurrent Disease,” British Journal of Haematology 158, no. 6 (2012): 749–762, https://doi.org/10.1111/j.1365-2141.2012.09236.x.
- 36E. Molyneux, E. Schwalbe, G. Chagaluka, et al., “The Use of Anthracyclines in the Treatment of Endemic Burkitt Lymphoma,” British Journal of Haematology 177, no. 6 (2017): 984–990, https://doi.org/10.1111/bjh.14440.
- 37J. Orem, Y. Mulumba, S. Algeri, et al., “Clinical Characteristics, Treatment and Outcome of Childhood Burkitt's Lymphoma at the Uganda Cancer Institute,” Transactions of the Royal Society of Tropical Medicine and Hygiene 105, no. 12 (2011): 717–726, https://doi.org/10.1016/j.trstmh.2011.08.008.
- 38P. B. Hesseling, E. Njume, F. Kouya, et al., “The Cameroon 2008 Burkitt Lymphoma Protocol: Improved Event-Free Survival With Treatment Adapted to Disease Stage and the Response to Induction Therapy,” Pediatric Hematology and Oncology 29, no. 2 (2012): 119–129, https://doi.org/10.3109/08880018.2011.644881.
- 39N. Mutalima, E. Molyneux, H. Jaffe, et al., “Associations Between Burkitt Lymphoma Among Children in Malawi and Infection With HIV, EBV and Malaria: Results From a Case-control Study,” PLoS ONE 3, no. 6 (2008), https://doi.org/10.1371/journal.pone.0002505.
