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Background   Falciparum  and endemic Burkitt lymphoma (eBL) are co-endemic in Africa, but the malaria experience in eBL patients is unknown. A lower prevalence of  falciparum  has been reported in eBL patients, but those results are anecdotally attributed to pre-enrollment anti-malaria treatment.    Methods  We studied 677 eBL patients and 2920 community controls aged 0–15 years enrolled in six regions in Uganda, Tanzania, and Kenya during 2010–2016.  Falciparum  was diagnosed using thick blood film microscopy (TFM) and antigen-capture rapid diagnostic tests (RDTs). Guardians of the children answered a 40-item structured questionnaire about their child’s pre-enrollment lifetime malaria history and treatment, demographics, socioeconomics, animal exposures, fevers, and hospitalizations. We utilized exploratory factor analysis to reduce the 40 questionnaire variables into six factors, including Inpatient malaria and Outpatient malaria factors that were surrogates of pre-enrollment anti-malaria treatment. The six factors accounted for 83–90% of the variance in the questionnaire data. We calculated odds ratios and 95% confidence intervals (OR 95% CI) of association of eBL with  falciparum  positivity, defined as positive both on TFM or RDTs, or only RDTs (indicative of recent infection) or TFM (indicative of current  falciparum  infection) versus no infection, using multivariable logistic regression, controlling for group of age (0–2, 3–5, 6–8, 9–11 and 12–15 years), sex, and study site and the afore-mentioned pre-enrollment factors.    Results  The prevalence of  falciparum  infection was 25.6% in the eBL cases and 45.7% in community controls (aOR = 0.43, 95% CI: 0.40, 0.47;  P  < 0.0001). The results were similar for recent  falciparum  infection (6.9% versus 13.5%, aOR = 0.44, 95% CI: 0.38, 0.50;  P  < 0.0001) and current  falciparum  infection (18.7% versus 32.1%, aOR = 0.47, 95% CI: 0.43, 0.51;  P  < 0.0001). These aORs for any, recent and current  falciparum  infection did not change when we adjusted for pre-enrollment factors (aORs = 0.46, =0.44, and = 0.51, respectively) were significantly lower in stratified analysis for any infection in children < 5 years (aOR = 0.46; 95% CI: 0.29, 0.75) or ≥ 10 years (aOR = 0.47; 95% CI: 0.32, 0.71).    Conclusion  Our study results reduce support for pre-enrollment antimalaria treatment as a sole explanation for the observed lower  falciparum  prevalence in eBL cases and open a space to consider alternative immunology-based hypotheses.    Supplementary Information  The online version contains supplementary material available at 10.1186/s13027-021-00377-0.

infectious agents and cancer

Inverse association of falciparum positivity with endemic Burkitt lymphoma is robust in analyses adjusting for pre-enrollment malaria in the EMBLEM case-control study