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World of Genomics: Belgium

Belgium, a small but mighty kingdom in Europe, is our next stop in our Word of Genomics tour. The contributions of this multicultural and multilingual country range from great writers and scientists to the inventor of the saxophone and the creators of the Smurfs and Tintin. Besides being acclaimed for its waffles, chocolate and beer, Belgium is also home to NATO headquarters and the EU commission. Here is your chance to see how Belgium organises their genomic landscape in our latest piece.

The population of Belgium

The Kingdom of Belgium is one the smallest but most densely populated countries in Europe. The country is bordered by the North Sea to the northwest, the Netherlands to the north, Germany to the East, Luxembourg to the southeast, and France to the south.

Belgium is divided into three main linguistic communities: around 60% of the population are in Flanders in the North (the Flemish region) where they speak Flemish (equivalent of Dutch); around 30% the population are in Wallonia in the South (the Walloon region) where they speak French; around 10% of the population are in the capital city Brussels, which is officially bilingual but the majority speak French. In the East, there is a small German-speaking population.

Figure 1: Map of Belgium (Source: Canva)  

The modern history of Belgium begins with significant geopolitical unrest. It was under the rule of Spain, then the Austrian Habsburgs, then France and finally it was in a union with the Netherlands. Belgium declared independence in 1830.

During World War 1, Belgium wanted to stay neutral but was forced into the war when Germany invaded Liège. The country suffered greatly under German occupation. There were 40,000 military deaths and 60,000 civilian deaths. 1.5 million Belgians were displaced, with refugees fleeing primarily to Britain, France and the Netherlands. 60,000 Belgians were deported to Germany to work in labour camps and on the front lines. 

Belgium was plunged into war again in May 1940 when the Nazis invaded. There were 12,100 military deaths and 76,000 civilian deaths. Almost 25,600 Belgian Jews were deported to Germany and only 1,200 survived.

After World War 2, Belgium experienced an economic revival. During the 1990s, social distress was growing between the Flemish- and French-speaking regions. Due to an influx of refugees from Bosnia and Kosovo, Belgium also experienced an increase in its immigrant population during this time which further increased tensions.

Geographic and demographic information

Summary statistics

  • Land area: 30,688 km²
  • Gross domestic product (GDP):
    • Total: $599.88 billion
    • Per capita: $51,767.8

Population statistics

  • Population size: 11,587,882 (2021)
  • Birth rate: 10 per 1000 people (2020)
  • Death rate: 11 per 1000 people (2020)
  • Infant mortality rate: 3 per 1000 live births (2020)
  • Life expectancy: 81 (2020)
    • Male 2020 estimate: 79 years
    • Female 2020 estimate: 83 years
  • Ethnicities: The ethnic composition of Belgium is mainly Belgian (87.6%). The remaining composition is made up of people from France (1.5%), the Netherlands (1.4%), Italy (1.4%), Romania (1%), Morocco (0.7%), Poland (0.6%), Spain (0.6%), Portugal (0.4%), Bulgaria (0.4%), Germany (0.3%) and other countries (4%).

Healthcare system

Belgians, like their European neighbours, typically have good health and long-life expectancy. The healthcare system covers 99% of the residents. It is financed by a national compulsory health insurance scheme. Those that live and work in Belgium must register for social security and make payments into a health insurance fund called a mutuelle (in French) or ziekenfonds (in Dutch) at a particular tax rate: 3.55% from personal salary and 3.8% by the employer; or full 7.35% from personal salary if self-employed.

Public healthcare is subsidised but not free. The same subsidies available to the working population are available to residents who are unemployed, students, disabled or pensioners. Certain costs are covered under the health insurance scheme: 50-75% of doctor, hospital, and clinic costs, 20% of prescription costs and maternity costs.

The subsidised-but-not-free nature of the Belgian healthcare system means that many people also pay for private insurance. Under private schemes, medical costs are paid for upfront and reimbursements are claimed.

Since healthcare is not free, there are protection mechanisms in place to ensure accessibility. These are calculated depending on household income. For example, the ‘system of maximum co-payments’ places a cap on the annual amount of co-payments made and the ‘fixed payments’ plan financially supports people with high medical expenses due to chronic illness.

The future availability of GPs poses a challenge to the Belgian healthcare system. This is because of their increasing average age. The proportion of practising physicians 55 years of age and over was 44.3% in 2018 compared to 24.1% in 2000. The future availability of nurses in hospitals is also a challenge. There is a high patient to nurse ratio in Belgium. In 2019, the patient-to-nurse ratio was 9.4.  By international standards, patient safety in hospitals cannot be guaranteed when there are more than 8 patients per nurse.

Health priorities

Obesity and alcohol and tobacco consumption are high in Belgium. The Belgian government have been proactive with public health initiatives to tackle these.

To promote healthy eating, the ‘Nutri-score’ was introduced on food packaging in 2018. The score ranges from A (best score) to E (worst score) on a green to red background. Although the system is voluntary, the five biggest retailers in Belgium committed to display Nutri-Score from 2020. A study in 2021 showed that Belgian consumers found this labelling system effective in conveying the nutritional quality of food products. 

In 2018, 15% of the Belgian population smoked daily. This was lower than the EU average. The government have several policies in place to reduce tobacco consumption: smoking is banned in public places, bars, restaurants, workplaces, schools and vehicles with minors; under 18 year olds have been banned from purchasing tobacco products since 2019; tobacco packaging has been plain and standardised since 2020.

Similarly, there are restrictions on advertisements for alcohol products. Belgium also have a national campaign against drink-driving called the ‘BOB campaign’, which started in 1995 by the traffic safety institute VIAS. It has been renewed every year since because of its success. The campaign emphasis the role of the designated driver who stays sober to ensure the safety of the passengers. It is now run twice a year and those who get a negative reading for breathalyser tests receive a ‘BOB’ keyring. In 2022, VIAS found that the number of drunk drivers had reached its lowest in 5 years.

In 2019, the leading causes of death were tumours and circulatory system diseases. This was followed by respiratory system disorders, such as chronic obstructive pulmonary disorder, and neurological disorders, such as dementia.

Belgium has an aging population. Given this, there are different aspects of care for the elderly in place. This includes development of home- and community-based care so patients can stay at home for as long as possible.

Genomic medicine capabilities

There are eight approved genetic centres in Belgium that are linked to academic hospitals. Within each hospital, there is a ‘centre for human/ medical genetics’. These are funded by regional governments, research grants and the national healthcare insurance system. The centres provide genetic services, which include diagnostic testing and analysis by geneticists.

Genetic testing is widely available and includes tests for cystic fibrosis, BRCA genes, and Duchenne muscular dystrophy. There is also no specific legislation for direct-to-consumer (DTC) genetic tests, which are usually based on saliva tests done at home. A recent study showed that the Belgian public had little interest in DTC tests and preferred tests that were performed in a healthcare setting. Since 1988, a specific reimbursement system has been in place for genetic tests. This is only applicable if the test was performed at one of the eight approved centres.

Non-invasive prenatal screening in Belgium is excellent. It is successfully incorporated as a standard part of prenatal genetic care. This also includes genetic counselling for pregnant women before and after testing. Belgium was the first country to implement and fully reimburse genome-wide NIPS as a first-tier screening test that was available nationwide.

Newborn screening is also implemented in Belgium. Recently, screening for spinal muscular atrophy (SMA) was added to the screening process after a three year pilot programme. As a result of the screening programme, 10 newborns were diagnosed with SMA and all benefited from treatment.

Belgium also have biobanking research structures in place. Since 2013, Belgium has been a member of the Biobanking and Biomolecular Resources Research Infrastructure – European Research Infrastructure Consortium (BBMRI-ERIC). Two main Belgian biobank networks are involved: the Belgian Virtual Tumour bank project assigned to the Belgian Cancer Registry (BVT-BCR) and Biothèque de la Fédération Wallonie-Bruxelles (BWB). The BVT-BCR (established in 2009) connects 11 hospitals that collect residual tumour tissue and associated clinical data, which is stored in a centralised online database. The BWB collect and store samples from various disease types and have a virtual catalogue. 

The aim of joining the BBMRI-ERIC was to ensure good research quality, transparency, and foster collaboration. The network currently consists of nineteen biobanks that are affiliated with public organisations like hospitals and universities. However, accessing samples and data is still difficult because each biobank network has its own set of rules and guidelines.

Notable projects

  • BeSolveRD: A nationwide randomised control trial, which involved all eight Belgian genetic centres. The aim of the trial was to assess the use of whole genome sequencing in routine hospital examinations for diagnosing developmental disorders.
  • Belgian genetic test database:A public website that centralises information about genetic test services in Belgium.
  • HERA-BE incubator project (Health Emergency Preparedness and Response Authority – Belgium): A national infrastructure to exchange genomic data collected around infection disease typing for epidemiologic surveillance. The project aims to effectively monitor emerging outbreaks and strengthen public health responses during local outbreaks.
  • PRECISION initiative: Organised by the Belgian Society of Medical Oncology with the aim of providing patients with molecularly targeted therapies for metastatic solid tumours. The evaluation of targeted therapies for the treatment of cancers with actionable genomic mutations has begun, and a clinico-genomic database has been established.
  • 1+ Million Genomes – Belgium: In August 2020, Belgium became a part of the European 1+ Million Genomes initiative. This further progressed the development of a genomic data infrastructure for use in diagnostic screening and personalised medicine in Europe.

Notable organisations and companies

  • Nationwide genomic surveillance consortium: Established at the start of 2021 to organise the genomic surveillance efforts during the SARS-CoV-2 pandemic. This included increasing sequencing capacity by establishing a national network of seventeen laboratories, performing laboratory quality control measures and promoting collaboration for research projects and publications.
  • BeMGI (Belgian medical genomics initiative): A network of seven Belgian institutions that are working together to advance the use of cutting-edge genomic tools to better understand disease biology and integrate the use of genomic data to predict clinical outcomes.
  • BeSHG (Belgian society for human genetics): An official representative society for Belgian scientists in human genetics that supports genetic research and promotes national and international collaborations.
  • Genomics Core Leuven: An academic facility between KU Leuven and the affiliated academic hospital, UZ Leuven, which aims to make genomic services accessible for research and diagnosis. They provide expertise and protocols in different areas including various sequencing pipelines (single cell, RNA-seq, long read, whole exome) and technologies.
  • University Hospitals Leuven’s Centre for Human Genetics: The department is the biggest genetic diagnostic unit in Belgium. They have over 10,000 patient contacts and perform over 12,000 cytogenetic tests and around 50,000 genetic analyses every year. 

Notable individuals

  • Professor Joris Vermeesch: Professor Vermeesch has many roles including President of the BeSHG, Professor of Molecular Cytogenetics and Genome Research and Head of the Constitutional Cytogenetics Unit at the Center for Human Genetics in Leuven. As well as discovering several syndromes, he developed and implemented a molecular karyotyping technique for use in clinical diagnostics.
  • Professor Herman Vanden Berghe: Known as one of the “founding fathers of cancer cytogenetics” and a pioneer in human genetics, Professor Berghe founded the Center for Human Genetics at the medical faculty of the Catholic University of Leuven. He served as the Director for more than 30 years. One of his seminal findings included the discovery of the 5q deletion in a form of myelodysplastic syndrome.
  • Professor Anne de Paepe: Professor Paepe teaches human and medical genetics and serves as Pro-Vice Chancellor at Ghent University. She also serves as the university’s representative for the Centre for Medical Genetics (CMG). Her leadership helped the CMG develop into a multidisciplinary, internationally recognised centre for genetics with more than 150 collaborators.
  • Dr Frans Alfons Jansess: A Catholic priest based in Leuven who identified the crossing over of genes during meiosis. His work led to the development of the theory of genetic linkage.

The future genomics landscape

The future of Belgium’s genomic landscape is focused on the practical implementation of next generation sequencing (NGS) in precision oncology (specifically in haemato-oncology care). Since 2016, sequencing workflows have been developed and three benchmarking trials on different types of tumours have been conducted. A specific annual budget for NGS has been established and clinical laboratory standardisation is in progress. Guidelines for using NGS for haematological and solid tumours have been outlined. They detail the lab-based testing requirements, the bioinformatic analysis and how to report the clinical findings.

Belgium also have Molecular Tumour Boards (MTBs), which are expert advisory boards that support the translation of NGS into practical clinical application in precision oncology. There are also projects underway to launch national MTBs. MTBs are a key connection to the industry for access to off-label treatments and molecular guided therapies in clinical trials.

The growing reality of NGS in routine clinical practice highlights two main points of consideration for Belgium: the economic feasibility and education for patients and healthcare providers.

Belgium’s dedication to personalised medicine is also demonstrated by their participation in the 1+ Million Genomes (1+MG) Initiative. Since joining in August 2020, they have committed to the 1+MG Roadmap and a Belgian Mirror Group has been established. The group serves as a forum for consultation and advice, ensuring that the 1+MG action plan is carried out. Belgium supports the 1+MG initiative on a number of fronts including population-based sequencing and developing standards for good sequencing practice.