About the study

Non-communicable diseases in Sub-Saharan Africa (SSA) constitute a major public health challenge. The disease burden attributable to cancer is rapidly rising, with a predicted 85% increase in incidence by 2030. In a region where 40% of the entire population is under the age of 15, cancer is more likely to present in younger patients in sub-Saharan Africa, as demonstrated by rising numbers of  paediatric or adolescent patients. Aggressive lymphoma accounts for almost 10% of all cancer diagnosis in the region, due to a strong association with Epstein Barr virus (EBV) infection. Diagnosing these lymphomas using tissue samples poses a significant challenge in SSA, as a single pathologist may be responsible for up to 3.2m patients within a given region. It can also be difficult to obtain tumour tissue samples from young children. Therefore, despite tissue biopsy remaining as the gold standard diagnostic test, a major hurdle to diagnosis is obtaining a result in a timely manner. Samples are often transported overseas for reporting in large established tertiary labs.


With the availability of digital pathology and low-cost blood DNA analysis, we have the potential to quickly and accurately screen, diagnose and monitor children and young adults with EBV-associated lymphoma (EBVL), without needing to take a tissue sample. A liquid biopsy test only requires an additional 4-10ml (1-3 teaspoons) of blood collected into a specialised blood tube. Given that all patients currently have standard of care (SOC) testing, including routine blood tests, this additional sample poses minimal if any risk to the patient.

Our project, Aggressive Infection-Related East African Lymphomas (AI-REAL), is a collaboration between clinical and academic institutions in Tanzania (Muhimbili National Hospital, Kilimanjaro Christian Medical Centre, Muhimbili University of Health and Allied Sciences), Uganda (St Mary’s Hospital, Lacor) and the UK (University of Oxford) that aims to assess the accuracy of two low cost novel technologies (for diagnosing EBVL in East African patients aged 3 to 30 suspected of having the condition:

  • Liquid biopsy – The detection of fragments of lymphoma-specific DNA shed into the bloodstream from tumours. This test requires the collection of 10ml (2 teaspoons) of blood. We already have early data from an Oxford University study of lymphoma patients that shows a high sensitivity and specificity for ctDNA as a diagnostic tool.
  • Mobile digital microscopy – A device that can reproduce high-resolution, diagnostic quality, whole slide digital images from blood smears and tissue biopsy slides to be assessed by pathologists remotely.

We will therefore assess the utility of a digital microscopy platform which we are already using for teaching and training in the region. This technology will enable local scientists of obtain diagnostic quality digital images of traditional histopathology glass slides that can be shared immediately for reporting.

Principal Investigators

Sam M. Mbulaiteye

MBChB, MPhil, MMed.

Dr. Mbulaiteye is a senior investigator (see here) in the Infections and Immunoepidemiology Branch (IIB) in the Division of Cancer Epidemiology and Genetics (DCEG) at the US National Cancer Institute (NCI). He conducts multidisciplinary epidemiological research to understand the role of infections, immunity, and genetic factors in the etiology of cancer, particularly Burkitt lymphoma and Kaposi sarcoma.

To achieve these goals, Dr. Mbulaiteye designed and conducted a large multi-country, multiyear case-control study of endemic Burkitt lymphoma called Epidemiology of Burkitt Lymphoma in East-African Children and Minors (EMBLEM) study (https://emblem.cancer.gov/) in six rural regions in Uganda, Tanzania, and Kenya between 2010-2016. EMBLEM collected well annotated samples to facilitate research for the discovery of biomarkers that may be used for earle detection, diagnosis, prognosis, or prevention of Burkitt lymphoma.

In addition, Dr. Mbulaiteye has established collaboration with the AI-REAL study as an investigator, a member of the Steering Committee, and as a mentor. He has provided full access to his collaborators at St. Mary’s Hospital Lacor in Uganda to the AI-REAL study and allowed full collaborative access to the EMBLEM facilities in Uganda.

The Aggresive Infection Related East Africa Lymphoma
Ensuring all patients have the opportunity to take part in our research.