Meet Fatima: our brand-new sister project to study vaginal health and HPV in Morocco

The Isala project is currently expanding worldwide, resulting in an international sisterhood of Isala-inspired citizen-science projects. The upcoming adventure will start in a North-African country, Morocco. As one of the project coordinators, I am delighted to write about this brand-new Isala sister! We chose to name it the Fatima project, inspired by Fatima Al-Fihriya. She was the first female founder of a university in Morocco. The Fatima project intends to provide the Moroccan society with evidence-based information on vaginal health and human papillomavirus (HPV) infection, more specifically tailored towards women living in rural areas. Get to know more in this blog!

The Fatima project aims to investigate the vaginal microbiota of healthy women and those carrying high-risk HPV genotypes. Why is this so important? One of our goals is to predict and monitor the occurrence and the risk of developing cervical cancer. Moreover, as part of the Isala sisterhood, in this project, we want to raise awareness on cervical cancer, increase scientific literacy and break taboos on this intimate topic in the Southern region of Morocco.

Get to know the human papillomavirus (HPV)

As you might remember from this Isala conversation starter, the human papillomavirus (HPV) belongs to the Papillomaviridae family, a very common family of viruses. This family includes 16 different genera. The alpha and beta genus are most often associated with human disease. In general, HPV does not cause any illness symptoms in most people, but some persistent types (called high-risk genotypes) can cause genital warts or cancer and affect the mouth, throat, or genital area. Since infection with HPV is mostly asymptomatic (meaning that no symptoms occur), it remains undetected too often. Moreover, these viruses are quite easily caught since they can be transmitted by any skin-to-skin contact of the genital area and via vaginal, anal or oral sexual intercourse (IARC 2012).

Cervical cancer: increasing awareness is highly recommended

HPV causes many different types of cancer, such as cervical, anal, vaginal and throat cancer. The most common type caused by this virus is cervical cancer, which involves the growth of abnormal cells in the cervix (Figure 1).

Figure 1: The female reproductive tract is characterized by abnormal cervical cells in women with cervical cancer.
Figure retrieved from:”.

The availability of vaccines against HPV makes cervical cancer a preventable disease. However, this type of cancer still remains the leading cause of female cancer deaths in Africa. In North Africa, both the incidence and mortality rate of cervical cancer are significantly high, particularly in Morocco, where it presents a major public health problem. Vaccination against HPV was recently introduced by the Ministry of Health in Morocco. Indeed, since the 22nd of October 2022, two vaccines were made available for teenage girls from the age of 12 years (HPV vaccination Ministry of Health in Morocco).

Unfortunately, the introduction of these vaccines against HPV did not prove that successful. Why is this the case? Well, mainly because of the taboo of the girls’ parents to talk about sexuality and sexual health with their teenage daughters and the lack of communication about the importance of this vaccination strategy to prevent the development of cervical cancer. For us, similar as the whole Isala sisterhood, it is therefore pertinent to create awareness on these intimate topics and break taboos on vaginal health. In this regard, our ultimate goal with Fatima is to empower women and girls to take their health into their own hands.

HPV and cervical cancer awareness in the Moroccan population

In the southern regions of Morocco (where my PhD project was conducted), the conditions of life are usually difficult to precarious, with almost no access to healthcare. According to the Moroccan Higher Commission of Plan (HCP) latest report (2022); ‘vulnerability captures the fraction of the population that was above the relative poverty limit but was at risk of falling below that limit if different factors affect their economic and social situation’. In Morocco, 12.4% of all women were considered to be vulnerable. This rate was expected to be higher in Southern regions.

It is known that Moroccan women from remote communities are most exposed to infectious disease (e.g., high-risk chronic HPV infections). Accordingly, previous reports highlighted the low level of awareness among women regarding the existence of cervical cancer screening in Morocco (11%) (Arechkik et al. 2022). Supporting this, we recently showed that this situation did not only concern women of a certain age, but also female students in higher education (Mansouri et al. 2022).

The low rate of HPV screening in Morocco might also be attributed to the lack of screening tests in the relevant public health care centers on a daily basis. Also, talking about diseases related to the genital area remains a taboo in Moroccan society, which unfortunately exacerbates the prognosis of cervical cancer. By establishing the Fatima project, we aim to raise awareness on available vaccines and yearly screenings, and to evaluate women’s perception of self-sampling.

HPV and vaginal microbiota

As you as Isala community are well aware off, the vaginal microbiota plays an important role in female health. We do not need to introduce to you that the vagina is commonly colonized by Lactobacillus spp. and that this is generally linked to a healthy vaginal environment. These vaginal lactobacilli are considered to be an important line of defence against pathogens, including these causing sexually transmitted infections (STIs) (Martin 2012; Petrova et al. 2015).

Vaginal lactobacilli are like small factories producing a lot of active metabolites such as lactic acid, bacteriocins, and biosurfactants that protect the cervicovaginal ecosystem from severe infections. Also, it was previously shown that Lactobacillus spp. are able to exert cytotoxic effects on cervical tumour cells in vitro, independent of pH and lactic acid production (Motevaseli et al. 2013).

As you can read on the Isala website, other bacteria can also populate the cervicovaginal microbiota, such as Prevotella spp., Gardnerella vaginalis and Atopobium vaginae. The replacement of vaginal lactobacilli by these other microorganisms might result in a change from a ‘healthy’ genital microbial community to a dysbiotic state, defined as bacterial vaginosis (BV), which is associated with an increased risk of acquiring STIs, or severe gynecological conditions such as preterm birth and pelvic inflammatory disease (Brotman 2011). However, a change from a ‘healthy’ vaginal microbial community to BV, concomitant with the presence of high-risk HPV infections, may lead to severe health outcomes, in particular the development of cervical cancer.

Now it became clear that the fight against cervical cancer includes several fronts. One of them is to investigate the protective role of the microbes residing in the vagina. Moreover, the vaginal microbiota composition might depend on many factors such as ethnic origin and the presence of STIs. An in-depth study of the bacterial communities present in the cervicovaginal environment is therefore important to predict cervical cancer risk, to develop targeted prevention strategies and to test new therapeutic strategies based on microbiome research. By establishing the Fatima project, these goals can hopefully be reached. We will definitely keep you up to date! 😊

Who am I?
Hi! My name is Leila Ferrera. I am a 29-year-old woman, half Moroccan half Spanish. I am a microbiology PhD candidate at the university Ibnou Zohr in Agadir, Morocco. Since my first microbiology course at university, I was fascinated and captivated by the power of microorganisms (bacteria, viruses…). These small yet complex organisms can be our invisible friends (and thus be beneficial for our health) or cause severe health problems.

I am committed to science and research, especially focused on women’s health. Therefore, in my PhD project, I aimed to study cervicovaginal microbiota. During my project, I came across the Isala website. The work of the Isala team seemed fascinating to me and I decided to reach out to Dr. Sarah Ahannach, being part of the Isala team from the beginning. Now I can tell you that I am one of the project coordinators of the Fatima project myself, which is Isala’s Moroccan sister project. Another Isala dream is coming true! 😊

Contact details:
Twitter: @FerreraLaila