Introduction Each year, an estimated 1700 children should be diagnosed with cancer in western Kenya, with leukaemia making up nearly one-third of cases. However, far fewer are actually diagnosed, highlighting significant delays or errors in diagnosis. Flow cytometry, which the WHO considers essential for leukaemia diagnosis, remains underused across sub-Saharan Africa due to high costs, outdated equipment and a lack of trained personnel. In Kenya, decades-old cytometers have been adapted for leukaemia detection, but these systems are now outdated. Newer platforms, such as simplified single-tube multiparametric assays, provide a scalable and sustainable alternative. This study presents a protocol to evaluate the accuracy of diagnosis and the potential for implementing a streamlined flow cytometry assay using peripheral blood, supported by a regional educational initiative.Methods and analysis This prospective, mixed-methods implementation study has three aims: (1) to assess the concordance between the Beckman Coulter ClearLLab 10C gold standard 4-tube assay and the streamlined ClearLLab LS 1-tube assay using paired bone marrow and peripheral blood samples; (2) to evaluate the feasibility of peripheral facility referrals and transport logistics with couriered peripheral blood samples from referring sites across western Kenya; and (3) to measure training effectiveness and knowledge gain through a multimodal educational programme using the Project ECHO (Extension for Community Healthcare Outcomes) model. Up to 300 patients at Moi Teaching and Referral Hospital in Eldoret, Kenya, will be enrolled in Aim 1. A separate sample of 100 patients from peripheral facilities will be included in Aim 2. Surveys, knowledge assessments and structured interviews will be used to evaluate training impact under Aim 3. Diagnostic concordance, sensitivity, specificity and knowledge gain will be measured through appropriate quantitative and qualitative methods.Ethics and dissemination The protocol has received approval from institutional ethics committees at Moi University, MTRH and Indiana University. De-identified data will be analysed and shared through peer-reviewed publications, stakeholder presentations and educational platforms.

PURPOSEAccessing timely childhood cancer care is a significant challenge in low- and middle-income countries. Primary health care workers are key patient navigators through specialized care referral systems. Understanding their perspectives on childhood cancer is critical in improving access to care.METHODSA cross-sectional study was conducted from January to June 2023 in Bungoma County, Kenya. The in-charges of 144 level 2 and 3 facilities completed a semistructured questionnaire on childhood cancer perspectives, traditional, complementary, and alternative medicine (TCAM), referral barriers, and health insurance. Descriptive statistical analysis was performed. For baseline data, frequency distributions were calculated. Mann-Whitney test, chi-square test, and Fisher's exact test were performed for comparisons of perspectives and health beliefs.RESULTSOf 144 facilities, 125 (86%) were level 2 and 19 (13%) were level 3. Only 14% of the facilities offered full insurance from the National Health Insurance Fund. Most in-charges believed that cancer was caused by chemical exposure (98%) or maternal drug use (90%), whereas 25% cited supernatural causes. Financial barriers were the main obstacle to accessing childhood cancer care (90%), with 69% believing that families could not afford health insurance. TCAM use was common, with 50% of respondents supporting its combination with chemotherapy. The participants concluded that referral barriers included financial constraints, lack of insurance, and family fears.CONCLUSIONWe found that delays in childhood cancer care in Western Kenya arises from a combination of provider misconceptions, culturally embedded TCAM use, rigid referral systems, financial inadequacy, lack of insurance, and family fears and beliefs. This study contributes uniquely by focusing on primary health care facility in-charges, whose perspectives directly shape the navigation pathway through the referral system.

Background: Globally, approximately 515,000 infants with Sickle Cell Disease (SCD) are born every year. Approximately 80% of these cases occur in Sub-Saharan Africa (SSA) annually, including 14,000 newborns in Kenya. In SSA, 50%-80% of children will die before the age of 5 years due to a lack of comprehensive SCD care compared to 3% in better-resourced settings. The Academic Model Providing Access to Healthcare (AMPATH) SCD Program started in 2010 as a partnership between Moi University, Moi Teaching and Referral Hospital (MTRH), and Indiana Hemophilia and Thrombosis Center (IHTC) with a goal to improve access to comprehensive SCD care by increasing capacity through training, clinical care, research, and advocacy. Findings: The program has trained over 5,000 healthcare workers on different aspects of SCD through face-to-face instruction, virtual training and one-on-one mentorship programs. Early infant screening and support for access to medications like hydroxyurea and antibiotics have been key in improving clinical care. The program has also participated in several research projects and has been a strong advocate for the provision of comprehensive SCD care by the health facilities within the high SCD burden areas in Kenya and the Ministry of Health. Conclusion: The strategies implemented by the program can serve as a template for establishment of SCD care programs in similar resource-limited settings.

Pediatric hematologic malignancies, particularly leukemia and lymphoma, represent a major and growing contributor to childhood cancer mortality in low- and middle-income countries (LMICs). In sub-Saharan Africa, more than 100,000 children develop cancer annually, with survival rates estimated at 20–30

Survival outcomes for pediatric Burkitt lymphoma (BL) substantially vary depending on geography (50-90%), which also serves as a proxy for the prevalence of Epstein-Barr virus (EBV) within the tumors. Although BL is considered an immunologically "cold" tumor with few tumor-infiltrating lymphocytes (TILs), their functional status has not been fully evaluated, especially for EBV-positive disease. Here, we characterize the exhaustion and activation profiles of T cells in the tumor microenvironment (TME) of EBV-positive BL using orthogonal methods, single-cell gene expression analysis, spectral flow cytometry, and immunohistochemistry staining (IHC). We found that CD8+ TILs displayed a mosaic of immune inhibitory gene expression encoding, PD1, TIGIT, LAG3 and HAVCR2/TIM3. IHC validated the expression of PD1 and TIGIT on CD8+ TILs, as well as their respective ligands, PDL-1, PVR, and Nectin-2 on malignant B cells. Despite exhaustion-associated signatures, CD8+ TILs retain cytotoxic potential, expressing granules (i.e. Granzyme A, Perforin) and cytokines (i.e. IFNγ) and demonstrate an increased uptake of metabolites such as glucose, arginine, and methionine. In peripheral blood, pediatric BL patients exhibited a significantly higher abundance of PD1+TIGIT+ CD8+ T cells compared to healthy children. Notably, these circulating T cells from BL patients express significantly lower levels of TOX, suggesting they are not irreversibly dysfunctional. Together, our results indicate that CD8+ T cells both in the TME and in circulation of children with BL are not terminally exhausted but remain poised for functional re-invigoration. These findings support the potential integration of immune checkpoint inhibitors into combination chemotherapeutic regimens to improve outcomes for these children.

CONTEXT.—:Chronic myeloid leukemia (CML) is a myeloproliferative disorder characterized by proliferation of the granulocytic cell line. The incidence of CML in Kenya is estimated at near 2000 cases annually. The disorder is associated with a poor prognosis without treatment. Tyrosine kinase inhibitors are approved for treatment in adults and children with confirmed disease. Diagnostic testing for CML in the public setting in Kenya is limited and not covered by the Kenyan National Health Insurance Fund. OBJECTIVE.—:To establish a clinical fluorescence in situ hybridization assay for the diagnosis of CML in the Academic Model Providing Access to Healthcare (AMPATH) Reference Laboratory in Eldoret, Kenya. DESIGN.—:Peripheral blood and bone marrow smears were split between the AMPATH Reference Laboratory and the Indiana University Cytogenetics Laboratory for concordance studies. RESULTS.—:Seventeen specimens from patients with a provisional diagnosis of CML were studied by fluorescence in situ hybridization in both the AMPATH and Indiana University Cytogenetics laboratories. The analysis for 1 specimen could not be completed by both laboratories, and the results for 1 other specimen were discordant. The interpretations of 15 of 16 specimens (93.7%) were concordant. Normal specimens were also studied to establish the normal range for the assay. CONCLUSIONS.—:We report the establishment of diagnostic testing for CML in the AMPATH Reference Laboratory and the Moi Teaching and Referral Hospital in Eldoret, Kenya.

Background:Childhood cancer has an annual incidence of 150-160 cases per million children worldwide but remains vastly underdiagnosed in low- to middle-income countries such as those in Sub-Saharan Africa. The Moi Teaching and Referral Hospital (MTRH) serves a population of 25 million people, including 10 million children. The average number of pediatric cancer diagnoses was 216 cases annually in 2017-2019, which was well below the anticipated 1500 cases based on epidemiology data. The remaining 75%-80% of pediatric cancer cases remain undiagnosed, and these patients are not likely to survive. Prior outreach and needs assessments demonstrated a lack of medical knowledge related to pediatric cancer as a primary barrier to improved referrals, diagnoses, and ultimately, cure. Objective:This study aimed to address disparities in medical knowledge contributing to low diagnostic rates of cancer in children. We implemented Project ECHO (Extension for Community Healthcare Outcomes)-a validated virtual guided practice and telementoring model-to connect multidisciplinary specialists at MTRH with staff in medically underserved communities in western Kenya for training, technical assistance, and mentorship. Methods:Sessions were freely available on Zoom twice monthly and featured an expert-led didactic topic followed by a learner-led, case-based discussion. The discussion used dialogue education to promote learning and engagement among participants, with mentorship from the expert team. Information on ECHO participation was tracked, and electronic surveys were sent to the participants at the end of the pilot year. The ECHO program was run in parallel with the pediatric oncology cancer registry to monitor trends in diagnostic rates within the referral region. Results:The ECHO program launched successfully in January 2020 with a curriculum focused on pediatric oncology for health care providers. A total of 22 sessions were conducted, with an average of 23 learners per session. A total of 148 participants attended at least one session, with the majority (n=80, 54.1%) attending multiple sessions. The year-end analysis in January 2021 demonstrated that 286 new pediatric patients were diagnosed with cancer at MTRH, representing a 33% increase over the 3-year average. Conclusions:The Project ECHO platform created a dynamic virtual platform to continue to engage stakeholders across western Kenya. The implementation of this telehealth education platform in Kenya represents an effective model for increasing the recognition and earlier referral of childhood cancer in low- to middle-income countries.

Graduate medical education programmes in paediatric haematology/oncology (PHO) are necessary to train specialists to provide high-quality care for children and adolescents with cancer and haematologic diseases. In this study, we used the Education Program Assessment Tool (EPAT). The study consisted of three components: (1) mapping the PHO workforce and training programmes in Africa; (2) using the EPAT to evaluate the current PHO programmes in Africa and (3) using a design-thinking approach to develop priority interventions to expand PHO training capacity in Africa through a collaborative co-design process. There were 236 fellowship-trained paediatric haematologists/oncologists in 37 countries in Africa. 17 countries (32%), with a total population of 42 million under 14 years of age, had no paediatric haematologists/oncologists. The continent has an average of 205 new paediatric cancer cases per specialist. 22 PHO training programmes completed the EPAT. The average score was 72% (SD 9%). Programmes showed varying strengths in the elements of comprehensive training, with the highest EPAT scores in experiential learning domains. A priority-setting exercise established interventions to strengthen PHO training in Africa, including a PHO curriculum, a leadership skill development process and a path for the creation of exchange opportunities. The PHO workforce and training capacity are highly variable in Africa. Through international collaboration and a systematic evaluation of workforce density and training programme strengths, alignment on key regional priorities and the creation of a shared model of cooperation to enhance training programmes for Africa can be achieved.

Currently less than 2% of Kenyans with severe symptoms receive palliative care (PC). Moreover, PC services are concentrated in urban settings and most rural healthcare providers have limited PC expertise. Project ECHO® Palliative Care for Western Kenya was developed as part of a hub-and-spoke model for improving primary PC in rural Kenya. The programme is based at Moi University and Moi Teaching and Referral Hospital, a public, tertiary care facility with a catchment of 25 million Kenyans, the majority of whom live in rural settings. Self-reported assessments by primary care providers found the Project ECHO® Palliative Care for Western Kenya programme improved PC knowledge and clinical skills, increased professional confidence and decreased professional isolation. The training sessions led to an increase in collaborative care management between primary care providers and PC specialists outside of the educational sessions. While a positive finding, it does present challenges to an already small cadre of PC specialists in Western Kenya. A monthly education programme is a useful tool for expanding primary PC services, but optimal clinical care will require increasing the number of speciality PC providers. Effective PC will be most effective when primary and speciality PC are developed in a coordinated fashion.

Background: Kenya faces significant gaps in multiple myeloma (MM) management, with available data (likely underreported) indicating 800 new cases and 677 deaths (2022). Late diagnosis, fragmented care pathways, and limited access to advanced therapies drive poor outcomes, exemplified by the AMPATH Multiple Myeloma Program (AMMP)—Kenya's sole integrated care initiative—reporting a median overall survival of just 29 months, starkly contrasting with >10-year survival in high-income settings. To dismantle systemic barriers, a landmark 2024 workshop convened national stakeholders to address diagnostic, therapeutic, and policy gaps impeding equitable care. Objectives: To (1) enhance multidisciplinary education on precision diagnostics/therapeutics, (2) develop implementation frameworks for Western Kenya's 23 counties, and (3) establish actionable pathways for bispecific antibody (BsAb) access. Methods: Participants: 117 attendees including: Frontline providers (hematologists, nurses, pharmacists) from all 23 counties of Western Kenya with direct MM management experience. Regulatory agencies: KEMSA, Directorate of Health Products & Technology (MoH), NCCP, NHIF, PPB, NCI-K. Design: 2-day hybrid workshop: Day 1 (Education): Didactic sessions on FISH cytogenetics, flow-adapted MRD, and BsAbs (teclistamab/elranatamab), anchored to AMMP data (n=221). Day 2 (Implementation): Interactive breakouts co-designing strategies for diagnostics scale-up, BsAb safety protocols, and regulatory pathways. Evaluation: Pre/post-knowledge assessments (111 paired responses; 95% response rate) analyzed via chi-square (p<0.05 significant). Key Findings: Diagnostics: Retrospective AMMP data (n=221) showed that 29.4% of patients had spinal cord compression at diagnosis, highlighting systemic diagnostic delays. FISH cytogenetics remains inaccessible, but AMMP is working to adapt existing lymphoma-capable flow cytometry for validation. Flow-based MRD detection (sensitivity 10⁻⁵) was identified as a transformative yet underutilized tool. While its implementation requires funding for reagents and validation studies, it could optimize therapy duration in resource-limited settings. Therapeutic Landscape and Barriers: Bispecific antibodies (BsAbs), such as teclistamab and elranatamab, emerged as prime candidates due to their >60% overall response rate in triple-class-exposed multiple myeloma. Their subcutaneous administration and lower CRS risk (compared to CAR-T) make them suitable for Kenyan infrastructure. However, critical barriers remain, including no regional BsAb experience, prohibitive costs, and a lack of pharma-regulatory partnerships for access roadmaps. Implementation Framework: The proposed framework includes structural, safety, and patient support strategies. Hub-and-spoke networks will leverage AMMP's ECHO tele-mentoring program. For safety, BsAb initiation will be inpatient with ICU backup, alongside mandatory infection screening (HIV/TB/HBV). Patient support includes “treatment buddy” systems and Swahili-language IEC tools. Regulatory Hurdles: Stakeholders (KEMSA, PPB, NCCP, NHIF now SHA) identified slow novel drug registration and reimbursement uncertainty by health insurance as major challenges. There is currently no clear pathway for BsAb procurement or trials, despite workshop consensus on their urgency. Workshop Impact and Next Steps: Post-workshop assessments showed significant knowledge gains (p<0.05) in FISH utility (Δ +42%), MRD principles (Δ +38%), and BsAb mechanisms (Δ +47%). Additionally, 96% of participants affirmed the workshop's relevance to Kenyan practice, while 94% gained critical insights into BsAbs. The unprecedented inclusion of regulators enabled direct dialogue on access barriers. Future Directions: Adaptive strategies—such as corticosteroid-first CRS protocols, task-shifted diagnostics, and pharma co-investment in African-centric data—now define a replicable care model for resource-constrained settings. Leveraging AMPATH's infrastructure as a launchpad, the 2025 follow-up aims to convert momentum into binding agreements with regulators, payers, and manufacturers. Progress will be tracked through measurable reductions in diagnostic delays and outcome inequities across Western Kenya, with accountability anchored to a dedicated 2025 implementation summit. While systemic challenges persist, this first-of-its-kind convening has crystallized a path to translate policy dialogue into tangible patient survival gains.

Introduction Children in low- and middle-income countries face barriers to timely access cancer care. Between January and June 2023, an awareness campaign in Bungoma County, Kenya, aimed to address this issue. This study describes sociodemographic and clinical characteristics of children diagnosed with cancer after the campaign, explores health-seeking behaviors and delays, and compares cancer referrals pre- and post- campaign. Methods Parental interviews were conducted for all children newly diagnosed with cancer from Bungoma County at Moi Teaching and Referral Hospital between January 2023 and December 2024 using semi-structured questionnaires. Hospital registry data from January 2014 to December 2024 were analyzed to compare referrals pre- and post-campaign. Results Following the campaign, 30 children were diagnosed with cancer (40% female, median age 5.5 years). Diagnoses included hematological cancers (23%), solid tumors (60%), rare solid tumors (7%), and brain tumors (10%), with 57% of solid tumors presenting at advanced stages. Delays were substantial: median patient-, physician-, diagnosis-, treatment-, health system- and total delay were 30, 104, 114, 6, 114 and 146 days respectively. Barriers included use of traditional medicine, cultural beliefs, financial strain, travel costs, lack of insurance, income loss, and fear. Mean annual referral rate showed no notable change (14.5 [7.6] pre- vs. 15 [0.7] post-campaign). Conclusion The campaign did not increase cancer diagnoses, highlighting ongoing barriers in timely accessing childhood cancer care. Addressing these barriers is essential for improving access to childhood cancer care. Factors such as healthcare worker strikes, supply shortages, and treatment seeking at other facilities may have contributed to the lower-than-expected numbers.

Introduction International survivorship guideline consortia have developed strategies to prevent, detect and manage late effects of childhood cancer survivors. However, recommendations do not adequately reflect the everyday reality of paediatric oncology care in low- and middle-income countries. In this study protocol, a survivorship intervention programme, comprising an educational component and a follow-up component, is described. The Educational Programme aims to improve follow-up adherence of childhood cancer survivors through increasing survivorship knowledge of caregivers. The Follow-up Programme aims to map late effects by implementing a follow-up form at the outpatient clinic to be used by trained healthcare providers.Methods and analysis This non-randomised prospective clinical trial will be performed at a referral hospital in Western Kenya. 100 caregivers of children diagnosed with cancer, who will complete treatment within 2 months, will be enrolled and followed for 24 months after completion of treatment. A caregiver control group receiving usual care will be recruited, and sequentially, caregivers will be included in an intervention group to attend an educational group session where they receive educational materials (video, booklet and Survivorship Card). Primary study outcome will be survivors’ follow-up adherence. Survivors will be considered lost to follow-up after they miss a scheduled appointment and do not revisit the clinic for more than 6 months. Mixed models regression analyses will be performed to determine intervention effects on follow-up adherence and on caregiver survivorship knowledge uptake. Additionally, healthcare providers will be trained on follow-up care, whereafter a form will be introduced at the outpatient clinic to document late effects in paediatric survivors attending the clinic for the period of a year. Secondary outcomes will be late effects prevalence as documented in the follow-up form and caregiver and healthcare provider survivorship knowledge uptake. Implementation measures (reach, potential effectiveness, adoption, satisfaction and maintenance) will be evaluated for both programmes.Ethics and dissemination The Institutional Research and Ethics Committee has approved the study protocol. Findings will also be shared with governmental and non-governmental organisations that support children with cancer in Kenya to inform their target audiences and guide their policy development.Lessons learnt from this study could inform healthcare providers and policy makers on how to shape survivorship programmes in the Kenyan context and possibly implement similar programmes in other centres in Sub-Saharan Africa.Trial registration number NCT06680687.