WHO presser on cervical cancer 16 November 2020

[Other language spoken]

This is Fidela Shahid from the World Health Organisation.

Thank you for joining our press conference.

Today we will be talking about The Who global strategy to accelerate the elimination of cervical cancer.

We will be sending you the press release in English just after this press conference or even during this press conference.

We have also the translation in Russian and Chinese.

I hope to get the other translation to you in the course of the day.

Just note that this press conference is ender embargo for the date of tomorrow.

It's 0001 CT, meaning one minute after midnight, so the article should appear in newspapers as of tomorrow morning.

We have with us to speak about this very important global health issue, Doctor Princess Notamba Similela, she's ADG and special advisor on WHO strategic priorities.

Before we open the floor to your questions, I would like to give the floor to Doctor Similela.

We call her Doctor Nono to give us her opening remark.

Dr Similela, you have the floor.

Thank you for that, and good morning to all the colleagues who are here to listen to the update from the World Health Assembly.

The World Health Assembly at its 73rd meeting, which has just finished last week, adopted a strategy for the elimination of cervical cancer.

This is a big milestone in global health because for the first time the world has agreed to eliminate the only cancer we can prevent with a vaccine and the only cancer which is curable if detected early.

This is a huge milestone because 570,000 women died of cervical cancer in 2018 only.

I mean acquired cervical cancer in 2018 and over 300,000 of them died.

If we do nothing with this disease, the number of cases will increase and the number of deaths will also go up by 21% by 2030.

We have an opportunity as the global health community to end the suffering from this cancer if we adopt the targets that have been set in the strategy.

The first one is primary prevention.

Ensure that all girls are vaccinated before they turn 15 years of age and that women who are eligible for screening between the ages of 30 and 45 are screened twice in their lifetime with a **** performance test.

And we want 90% of the women who are found to have cancer to be treated and those that have invasive cancer, 90% of them must be treated.

We believe that this is doable because the world has the tools and we have the knowledge of how to prevent and cure this disease.

So we are aiming to ensure that countries have the vaccine they need.

There are vaccines available.

They should be made accessible even to low income countries.

At the moment, the balance between higher economies and low income countries is skewed towards **** income countries.

So we are asking the world to collaborate with low and middle income countries to access this HPV vaccine.

There is also new technology that is based on artificial intelligence which can be used to screen women for cervical cancer and if these technologies are used we would be able to get a diagnosis of cervical cancer within 15 to 20 minutes.

At this point in time, 10 around from the laboratories can be anything up to a month or longer and women don't get the the results because most of them don't stay or live nearest to the facility.

But with this new technology, we can get a diagnosis in 20 minutes and the woman can be treated immediately on site, making it possible to have one visit in one day and to be immediately cured of this precancer lesion.

We know also that the challenge for developing countries has to do with a shortage of specialists, not enough oncologists, not enough appropriately qualified personnel to help with this cancer.

But we are saying that if countries invest in cervical cancer whilst they are doing their universal health coverage, they will also benefit for the management of other cancers.

So we are excited by this landmark event because it really will bring a huge difference to the lives of women, extending their well-being and enabling them to contribute to development in their communities and to the economies of their own countries.

We will be launching the strategy tomorrow.

There is an event that we have set aside where we will have **** level speakers.

We have the First Lady of Rwanda, a country that has done very well with vaccination, has actually surpassed the 90% target.

And we would have the first lady of South Africa to speak.

We'll have our own DG here who will address those that will be will be listening.

And we will have women who have survived cervical cancer from all across the globe joining this milestone event, sharing their experiences with being diagnosed with cervical cancer with other people who might be afraid to go into the clinics for screening and testing.

We know that this disease is very stigmatised, that it's very difficult for women with cervical cancer to talk about it.

And in the way that it shows, you know, you start getting a smelly discharge, you start rotting from inside.

It's a painful cancer to have and they don't want to speak about it.

So we hope that with this strategy, countries will really be up to scratch, embrace this like they have embraced it at the World Health Assembly and start putting services in place so we can stop the death of young women and girls.

We're looking forward to working with all the Member states in our quest to achieve this elimination.

We want countries, as I said, to aim for 90% girls under 15 vaccinated, 70% eligible women identified and treated, 90% of women with invasive cancer treated.

If they are too advanced, they should receive palliative care.

It is a right for the women to receive this treatment so that they don't die a painful death.

We know that if countries invest in these interventions, that is an estimated 3.2 dollar return to the economy.

But when you calculate the social impact, you actually get $26 for every dollar invested.

When women are able to return to work, take care of their families and they are able to do their job even if they don't work, the fact that they are well, the fact that they can look after their children is already an added bonus for that family and the community where they live.

So we know that at the moment the world is struggling with this COVID-19 pandemic and we recognise that some of the tools that governments have brought to bear on this pandemic will be useful for screening for cervical cancer.

The very same laboratory platforms that they are using right now for HP for for testing for coronavirus are the same platforms that we require for testing if women have HPV.

We also will have an opportunity for women to collect the specimen themselves at home, making the visit to the doctor unnecessary if they don't feel comfortable being examined by a medical practitioner.

So there are many developments that are coming on board that we feel are going to change the landscape of cervical cancer.

Only if countries adopt these interventions and women demand these services will we will we be able to really move to the cervical cancer elimination goal.

Thank you very much.

Thank you, Doctor Simila.

I can see that we have 20 in the in the press conference, the floor, the floor is open for question.

Please raise your hand if you want to ask Doctor Simila any question.

[Other language spoken]

Lisa Sline, Voice of America has raised her hand.

Lisa, the floor is yours.

[Other language spoken]

Nice to see you, Doctor.

[Other language spoken]

That that part of your name is is easy.

[Other language spoken]

I'm sorry, just for attribution, are you also called Princesses Princess a title or is it a name?

I'm excuse my, my, my ignorance.

[Other language spoken]

I, I'd like to know what the cost of the the the test and the treatment is.

You say that it is affordable.

[Other language spoken]

And it is let let's see, because I, I, is it actually affordable for countries to get this?

And I'm wondering whether the developed countries at this point have essentially overcome a lot of cured or treated a lot of the cervical cancers because I believe that probably the the the testing and the medication has been fairly widely used in developed countries.

I'm not sure about that.

If you could answer it.

And then you were speaking about you hope that countries would overcome their reluctance to to adopt this new strategy.

What reluctance do they have?

[Other language spoken]

I mean, if if it is something that is affordable and easy to do, what is their objection to doing this strategy?

[Other language spoken]

I just explained that at this, the 73rd World Health Assembly, all 194 member states supported the adoption of this strategy.

So there, there is no reluctance.

Maybe my voice was not clear.

There is no reluctance because everybody understands that the tools are available.

The know how is there.

It's probably a cancer that we know a lot more about than many other cancers and that's why I was emphasising that if we can improve access for low and middle income countries, we really can be on the road to elimination.

You are correct in in talking about access and the scale of the problem across low and middle income countries and **** income countries.

It's true that most countries that are **** income countries have done a good job.

They had the technology quite some time back.

Many of them were using cytology.

And in fact the latest observation which they themselves have pointed out is that the the new HPV tests seem to be much better than even the cytological smears that they were using before.

They have seen a plateau in the number of cases using cytology and then they are starting to pick up higher rates now.

So they are excited about the recommendation that countries must use an HPV test as a primary screening tool so that we are able to then treat only the women who are HPV positive.

That will be cost effective.

And in terms of the, the, the affordability and accessibility of these tools, we've been working with implementing partners on the ground to do some market shaping work.

And in fact, we've been able to get the HPV tests down to an affordable price as well as ensuring through GAVI that the HPV vaccine itself costs much less for low income countries than it does in **** income countries.

So we we've put the mechanisms in to support those countries that don't have access to these new technologies.

And the technology I was talking about earlier that is based on artificial intelligence, it's been tested as we speak in several countries in sub-Saharan Africa in as well as well as in India.

So this work will inform scale up in many other countries because these technologies, you'll be able to load the software onto a smartphone and the Nas can take a picture of the cervix.

At the backdrop will be specialists who will support the frontline workhouse with a diagnosis.

But the algorithm that will be in this the app, the app that will be in the phone itself can also give you a diagnosis even if you don't have backup from a specialist.

So that we believe will really be a game changer in this field.

[Other language spoken]

Any other question?

Any other question, please.

I can see that we have 20, almost 20 journalists.

Isabel Sacco from Spanish News Agency.

Isabel, you have the floor.

[Other language spoken]

I would like to to ask on the, the initial figures that you mentioned, Doctor and the total number of worldwide cases.

And I would like to know if you can give us a breakdown of cases by region or by income.

I mean, what what is the number in **** income countries in Europe, in North America and in the rest of the world?

And if you have any number, Latin America, it would be useful for me.

Is this not what?

And what does this number means?

In the last 10 years, for example, it has been an increase, a decrease and has been stagnation of cases.

[Other language spoken]

And finally, why if you, you said that the cases could be increase could be an increase of 2521% by 2030 if nothing is done, I understood why this increase because of increase of worldwide population or because the rate of incidents will be greater, more important?

[Other language spoken]

All right, Thank you.

The number of cases globally is 700,000 cases and up to 311 between 311 and 400,000 deaths, 311 deaths worldwide in 2018.

The burden is clearly in sub-Saharan Africa where you have incidence rates of up to 67 in Eswatini and almost all the the countries in sub-Saharan Africa have a double digit number.

And then you have gradual numbers in Southeast Asia.

It follows the burden in in sub sub-Saharan Africa.

And then obviously in the Americas, North America you have low incidence rates there.

Some parts of Latin America you do have a **** burden and then places like Australia, it's fairly low single digit numbers.

Even in the US it's single digit numbers.

So the burden, the estimation is between less than six in **** income countries to more than 76 per 100,000 in **** in low income countries.

So you asked about why there will be an increase in the number of deaths.

The modelling work we used to underpin the strategy, it elaborates what happens if countries do nothing.

So if countries continue the way they're doing now, they don't introduce a vaccine, they don't introduce anything to treat and screen, they will be faced with a rise.

In the number of deaths because they will not be treating the the patients or the women that already are in the system.

And indeed, you do know that the African continent is the only continent that will be reporting higher populations beyond 2030.

So they'll be dealing with a double bed in there in that they'll have a bigger number of young people to get to with the vaccine and a larger population of older women who will be having cervical cancer who have not been treated.

And these numbers specifically address the burden in low and middle income countries.

There was really no, no pointed work done on upper income countries because as you as you mentioned the the rates there have really gone down because of the availability of screening and testing and the availability of treatment.

So we are really looking at the burden of disease that's higher in low and middle income countries.

It's also made doubly challenging by the Co infection with HIV.

What we have found through research is that women who are living with HIV are at higher risk of acquiring these HPV infections and the infection progresses very quickly to cervical cancer.

The rates there will be the the risk increases sixfold in women who are living with HIV.

That might explain also the **** numbers who are seeing in countries with a very **** incidence rate of HPV.

So that is why we're urging countries that have had **** incidence of survival of of HIV to bring in the tools so that they don't get a reversal of the gains they're made in getting arts into the country.

So that's that's what is important, that women are not, you know, spared from death due to HIV and then data succumb to the cervical cancer.

And that is another imperative that we have put clearly for the countries that are now here in the World Health Assembly that we're convening last week and a special focus on supporting middle income countries and low income countries to access these technologies.

Thank you, Doctor Simila.

I would like now to give the floor to Peter Kinney from Turkish News Agency Anadolu.

[Other language spoken]

You have the floor, Peter.

Peter, are you with us?

[Other language spoken]

Thank you for taking my question.

Doctor Similella, at the beginning of your your speech, you said that cervical cancer is the only cancer that has a vaccine against it.

[Other language spoken]

Because vaccines seem to be a magical word at the moment.

Can you explain, are these vaccines safe or they're seen as safe?

And what was a development?

[Other language spoken]

OK, indeed, we know that cervical cancer is caused by infection with the HPV, human human papilloma virus.

And when it gets into the woman's cervix is this is a sexually transmitted infection.

So if anybody, females or women have sexual intercourse, it's it's a common infection, but most women clear it after a couple of weeks, a couple of months and they don't develop cancer.

It's because there are many types of HPV, over 100 types, but there are specific ones that proceed to cause cervical cancer and we call them HPV 16 and 18.

Now the vaccines that we have right now, there are three.

We have a vaccine that is manufactured by GSK and it has been in the market for some time and it is very effective and safe for protecting and preventing young women from getting cervical cancer.

We also have another vaccine which has four HPV types, so you move from a bivalent to a quadrivalent and then we have another one that is made by Mac, both of them, which has effect on 9 HPV types.

So that also protects against **** warts, genital warts and other infections in the genital region.

And it's available, you know, in many countries, especially the US, Australia, you know, the ones that are **** income.

So we do know this relationship, which is why we are arguing that we should not be having such huge mobility and mortality due to an infection with this virus because there is something we can do.

So the recommendation in the strategy says that girls under 15, if we get into a place where we've got sufficient supply, because we are facing a supply constraint with vaccines at the moment, we would want to see a point in time where more girls get vaccinated.

You know, so countries can can target, you know, from 10 years, 11 years, 12 years, depending obviously on the age of sexual debut in those countries.

But the most important thing is to get it to the girls as quickly as you can before they acquire this HPV infection, so that this the the vaccines have been tested.

We know that they are safe.

There is nothing that has been proven to cause a problem with any of these vaccines.

That is why we are comfortable as WHO to promote them and to assure the Member States that there is no harm in using this vaccine for young girls at a later point when there's sufficient supplies.

There are countries that are also vaccinating boys, as I said, you know, to prevent genital warts and and **** cancers.

[Other language spoken]

Doctor Similela, I would like now to give the floor to Nina Larsen from Azons France Press.

Nina, you have the floor.

[Other language spoken]

Thank you for taking my question.

So I, I also want to ask about the vaccine issue.

There's a lot of discussion right now on vaccine hesitancy.

Is that an issue, issue with this?

I mean, you say that the vaccines are, are considered very safe, but that doesn't always convince people.

Is that a major issue?

And also on you mentioned COVID and that some of the the systems that are being set up now can be used going forward perhaps in this area.

Could you say a little bit more about how COVID is impacting in a positive way like that, but also, I guess how the pandemic may have have taken a toll on, on efforts to, to to vaccinate and to test for HPV?

[Other language spoken]

Indeed we have seen a decline in screening services even in vaccination programmes in many countries worldwide, not just a low income or middle income countries.

I think with the shutdowns or the lockdowns, people could not access services and in some countries, you know, the health professionals themselves where they didn't have protective equipment, they were not comfortable and they would not go into the clinics.

So we do know that services have been severely affected and WHO has been working very closely with countries to re establish their services, put things back in place and actually to improve those services in, in view of their commitment also to universal health, health coverage.

I think the positives for this area of work from the COVID pandemic are there are many.

Of course, we we are worried about those women who are already having a lesion if they can't get into the clinics because they probably will progress.

But as I said, the laboratory infrastructure that countries have put in now gives them an extra step ahead.

So you know, what we are, we're echoing throughout our messages is that there mustn't be an unbundling of everything.

You know, they need to look at what are the things that can support even health services of any kind going forward.

So we have seen the laboratory platforms particularly in the low income countries and because they were able to put those in place quickly, we are already starting to flag this message that please don't unbundle.

You can test many for many other diseases and then the social media is a big learning curve for us.

Simplify messages, try to get messages to women in a simple and easy manner.

You know, what we have seen from the COVID pandemic is that messages can go into the community and we want to use this momentum as well to get women out and push these self sampling tools that I spoke about into the communities and get women to be comfortable with self collection of a sample and then coming through if and only if they are recalled to the clinic by the by the the midwives or the nurses or the cheating physician.

So we think that although the services were negatively impacted and we probably lost a sizeable number of women given the mortality we've seen in one year.

But on the positive end, we're saying at least we can move forward now with better laboratory platforms as well as having learned lessons about how communities want to be engaged when there is a problem.

[Other language spoken]

Thank you, Doctor Similela, coming back to Lisa.

[Other language spoken]

I, I asked about the, the affordability of the vaccine.

[Other language spoken]

I mean something like that just to have something in mind.

And then I'd like to have a clarification on the treatment.

Are you saying that that women who are found to have cervical cancer can be cured and by following a certain treatment?

And is this a simple and affordable course of treatment?

[Other language spoken]

OK, So the let me start with the vaccines.

In view of the **** costs of the HPV vaccine, which is I'll tell you 2 prices in developing in developed countries and I'm talking US, Canada, Australia and many others, you can pay up to 100 a $110.00 for a dose of HPV vaccine now through Gavi's procurement system.

GAVI supports low income countries to acquire HPV and the price for GAVI is less than $5, somewhere between 4 point $4.80 but clearly not as **** as you see in **** income countries.

What GAVI has been struggling with is to negotiate a good price for middle income countries because GAVI cannot procure for countries at a certain GDP.

So we, we, we know that if there is a big demand from countries that can can drive down costs and there is ongoing discussions between WHO, Garvey, many other partners to negotiate a good price for middle income countries.

So we hope this the drive by the strategy will produce, you know, create a demand that the manufacturers can feel.

Here's a point where we can come in.

The good thing is that we've just been informed a couple of months ago that there's another new vaccine that has been brought into the market.

It's yet to be fully registered because the pre qualification team has been stuck here in in Geneva and they couldn't travel to China to look at the plant where this vaccine has been manufactured.

But Innovex, once it comes into play, we will have a fourth vaccine and there's two other manufacturers who are still coming up the pipeline.

So we have a healthy pipeline in so far as the vaccine is concerned.

We have a constraint right now because there was a bit of a header when we started.

Countries expressed a lot of demand and then the manufacturers came to the table and then there was just lack of uptake and not for reasons of vaccine hesitancy or anything like that, but it must have been the economic economics issue for those countries.

But more and more countries that are supported by Govi are introducing this vaccine.

And right now, as I say, the challenge is how to support middle income countries to get a fair price and not have to pay the very **** prices that are are charged to **** income countries.

So that's where the issue is right now.

Our offices in PAHO have their own revolving fund and they have negotiated their own prices for their region.

So we we are pursuing an option for million income countries and the negotiations are are moving in a good direction.

So we hope that it will be a good and fair price for all countries because the burden of disease is higher in the poorest countries.

Thank you, doctor Similena, I think Isabel has Isabel Sacco from FA has a follow up question.

[Other language spoken]

I would like to I don't get very well on the the the what you talked about the this app application for mobile phones that the the women can tested out the themselves.

I understood and then they can send.

I don't know where this the results and get the results back.

I mean, I don't get and and I don't know if this is something that exists already or something that is this is something that is you expect to to to have in the in the in the in the next future.

If you can explain this please.

And the sorry, sorry, yes, on the, on the vaccine.

So you mentioned before that there is a supply vaccine constraint.

So you mean that is not the constraint is not because of there is not enough capacity by the manufacturers, but there is a problem also by what is the problem in the in the supply constraint basically?

And finally, if I may, sorry, but if you can have, do you have any idea of the price that the middle income countries can get for a vaccine?

[Other language spoken]

Let let me clarify the two things that you started with the two different technologies that I spoke about.

The first technology, the new one that I spoke about that has got that is driven by artificial intelligence that is being tested right now as we speak.

So how it works is that you've got images of the cervix that have been fed into an algorithm for the many, for many, many years.

So these these are these images.

Researchers at the NCI have pulled on these and they are working now on an algorithm because obviously when you are treating women with cervical cancer, you need to screen and look at what it looks like.

And then after that you then treat.

So I spoke about the two things you can screen with an HPV test and women can be able to do this with a self collection kit.

So the same thing that they put down your nose when they are doing the test for COVID, something like that.

But a woman would then be doing that herself.

Especially women who are familiar with where the cervix is, you know, women in the 5050 year olds and that age.

Who have probably used an intrauterine device before.

It's easy for for them to find the cervix, even younger girls.

You find the cervix, you put this swab in there, you twiddle it and then when it comes out, you load it into a tool or a container very much like the COVID one, the way, the way it looks.

And then these samples can be collected.

If you are doing a screening in the village, they can be collected at the end of the day and taken to the laboratory.

And then once they have been tested whether they are HPV positive or not, it's easy then to come back with a batch of results which can then be distributed to the to the different women, as it were.

There are self collection kits for other STIs.

This is also a sexually transmitted infection.

And what I was saying is that in some of the research sites, two things are going on.

They are testing this algorithm, which if it works, they will load onto a smartphone.

That's number one.

So you don't then need sophisticated tools.

You've got one simple picture that can then get translated by the algorithm and it tells you whether this is a precancer or not.

Now, these will be much cheaper.

In the projects that we are doing, we want to draw down the price, drive it down to less than $1.00 per screen and treat.

And that is possible because how cervical cancer grows, you have the earlier lesions which are easy to remove, then you start to get the deeper lesions, which are also not very difficult to remove, but might require a specialist.

And then once it's advanced, it advances first up on the uterus and then it starts to move, then onto the sides.

So if you catch it at that stage, it can still be curable because the oncology surgeons do what we call a radical hysterectomy.

Remove the uterus, remove the lower third of the vagina.

You take out this growth, you take out all the pelvic nodes, and the woman is cured.

That's what we meant.

If diagnosed early on time, it is a cancer that you can cut out even if it's spread to the lymph nodes.

You take those out, maybe followed by a course of chemotherapy and they go home.

But if it's far advanced, obviously that's why we have the third pillar where we're saying those that are advanced, they are still being treated, but given the treatment that is appropriate for the stage of disease they're at, so that those two things are slightly different.

And for the screening with this new technology and the treatment with an ablating instrument, we want those two together as a package to cost less than a dollar.

That's what we are aiming for at this point in time.

They are still in the implementation research phase.

That is why I'm unable to say this is what it's going to cost you today, but we are very positive.

[Other language spoken]

We have Paula Dupra Dobias for Swiss info.

Paula, you have the floor.

[Other language spoken]

Thank you for taking my questions, Ashley, for the new humanitarian this case, I just wanted to know most of the questions that I had I think have been answered, but there's there.

I wanted to know in terms of breakdown for countries, would it be possible to, to send some document?

I don't know if there's something that's already available that we could see in terms of which specific countries are are worse hit by by this this this issue.

Doctor Nono, let me try to get back to Doctor Similella.

Are you with us?

[Other language spoken]

Oh, I can see that Doctor Similella disconnected.

Paula, I will check and send you what we have in terms of breakdown by country.

[Other language spoken]

I can see that she she's disconnected.

I don't know what happened.

We are not in the same room.

[Other language spoken]

We'll send you just when we close the press release.

It's ready in English, Chinese, Russian.

I hope to get it in other languages in the course of the day.

As I said, this is there is an embargo for 0001 article should be posted published as of tomorrow after one minute, after midnight.

And just reminding you also that we today is the executive board meeting and we have we will have also Doctor Tedros and other expert press conference today at 5:00 that I will be moderating.

I can see that we have Christian Olares, but Doctor Nono has disconnected.

[Other language spoken]

And if I don't have the answer, we'll provide you an answer in the course of the day.

[Other language spoken]

Yes, very well.

So my question was, if I understand correctly, this is a sexually transmitted disease, which means the girls see when they have sex first time or after that would be infected by the boys.

Would that not tell us that it would be a much better idea to treat the boys rather than the girls?

[Other language spoken]

I can see that.

Doctor Similella reconnected.

[Other language spoken]

You were disconnected.

And in the meantime, we have two questions, Paula.

She wanted to have some examples of breakdown of countries with cervical cancer.

And the second question was from Christiane Ulrich from DPA, German news agency.

Can you hear me, Doctor Nono?

[Other language spoken]

The second question was from DPA, the German news agency asking if this is sexually transmitted diseases, why we are not vaccinating boys, OK.

The focus for us in W2 this year was to deal with cervical cancer.

Cervical cancer was the disease that we wanted to really focus on and because of the focus on cervical cancer, we prioritise girls and women because the burden of disease is killed more by by them.

But we have not pronounced on vaccinating boys because at this point in time we know that we need to get the countries with the highest burden of cervical cancer to move forward with the vaccine.

Those countries that are vaccinating boys, they were asked to just hold a bit during the vaccine, supply some goods, some didn't, where we were asking by way of solidarity if we could make those vaccine doses available to lower income countries.

But can't you still vaccinate?

And indeed there will be a benefit for boys as well because they're especially the non available vaccine, best protect against inner wards and dental ulcers.

So it will be a good investment at that point.

[Other language spoken]

Can I just ask you if you can put your headset the, the, the voice is not very clear.

Sorry for that.

[Other language spoken]

So I was just answering the question on why we are not vaccinating boys and I'm saying that for 2018-2019, 2020 the forecast has been and will continue to be for the Hawaii bringing the bedroom of Slifer cancer down.

Countries are vaccinating oils in some of the **** income countries and there is a value to doing that because some of the vaccines especially the one that has a valency, the non Valiant 1 kills nine types of prevents against nine types of HPV infection including warts.

So that is a benefit for boys.

At this point, like I said, the focus was on just getting acquainted with moving the cervical cancer agenda forward.

[Other language spoken]

So no, actually it was just more I guess if it's possible to get more of a breakdown of where cervical cancer is, the cancer is most prevalent.

You mentioned in Latin America that certain countries had a **** incidence, but you know, either if it's possible to get directly verbally from you now or or otherwise if you have a document where you know, we could see that you know how the which countries are most affected that that would be great.

[Other language spoken]

Yes, Doctor Nono, OK, I'll give you a broad, a broad response on that.

But country by country, I can share that information with you all later.

So what we've got in our publication which is called Kobokan, we've got a range of countries and in those countries I can say like I said earlier, the the incidence rates range from six right up to 60s and 70s in Swati.

The countries that have a similar digit burden of disease are monastery in Europe and Americas and other regions of the world, Australia and some others.

And then you have South Asia as the second highest and then you have the developed regions coming through between China and India.

They contribute 1/3 of the global bedding of cervical cancer.

That is the situation right now.

So we've got to aim for those countries with big populations where we need to cover many more people because then we'll see an impact.

You know, if you roll out student treat in a country, very low population, not too many women, you won't see a heavy impact on this global number of of cervical cancer incidents.

So that's that's you can break it down by reason and break it down by country, but then it will be a long list of countries that I can send that to to you in a separate communication.

[Other language spoken]

We are up to the hour.

So I wanted to thank our friends from UN for their support to contact this.

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Doctor Similela, if you can send me the information that I can share with Paula and the others.

Thanks all.

No other question.

We will close this press conference.

Just reminding you of the embargo.

I will be sending you in.

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