Mobile Menu

World of Genomics: Belgium

Original article written by Anjum Aktar, November 2022. Updated by Aleisha Collins, January 2024.

Nestled in the heart of Europe, Belgium shines as a country of profound historical significance, cultural diversity and breathtaking landscapes. Its heritage encompasses renowned figures like surrealist artist René Magritte and Adolphe Sax, the creator of the saxophone. 

As we continue on our World of Genomics journey, Belgium emerges as a pivotal destination. With a constellation of cutting-edge research institutions and trailblazing breakthroughs, this country plays a crucial role in driving the global progress of genetics and personalised medicine.  

The Population of Belgium

Belgium, host to the headquarters of both the European Union (EU) and the North Atlantic Treaty Organization (NATO), is multicultural and multilingual at its core. In light of this, it has three official languages. The country’s residents speak French, Dutch or German, linguistic differences that have fuelled remarkable divisions across the country that even the royal family must navigate.  

The nation is also home to a notoriously complicated political scene. There is a complex system of government because each region (Flanders, Wallonia and Brussels-Capital) and community (Dutch, French and German-speaking) has its own set of rights and obligations. Linguistic and political divisions have frequently produced coalition governments, with Belgium experiencing several periods without a fully operational government as a result of protracted political impasses. Additionally, between 2010 and 2011, they went through a 541-day political crisis, which led to one of the longest stretches without a functioning government in modern times. Despite this, Belgium has managed to maintain relative stability in its political system, however, these complexities have the potential both to help and to harm the country’s healthcare system.  

Geographic and demographic information 

Summary statistics 

  • Land area: 30,688 km² 
  • Gross domestic product (GDP): 
  • Total: $578.6 billion (2022) 
  • Per capita: $49,582.825 (2022) 

Population statistics 

  • Population size: 11,669,446 (2022) 
  • Birth rate: 10.2 per 1000 people (2022) 
  • Death rate: 9.7 per 1000 people (2021) 
  • Infant mortality rate: 3 per 1000 live births (2021) 
  • Life expectancy at birth: 
  • Total: 81.89 (2021) 
  • Male: 79.5 years (2021 estimate) 
  • Female: 84.4 years (2021 estimate) 
  • 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

Belgium ensures universal health coverage for its population and while public healthcare is subsidized, it is not entirely free. Notably, the same subsidies that are available to the working population extend to unemployed residents, students, disabled individuals and pensioners. To guarantee accessibility, protection mechanisms are in place, calculated based on household income, though many Belgians also opt for private insurance to supplement their coverage. In 2019, out-of-pocket payments across households accounted for 18.2% of expenses, primarily covering non-reimbursed services, official co-payments and additional billings. Under private schemes, medical costs are paid upfront, and reimbursements are subsequently claimed.  

Care accessibility in Belgium is generally good, with proximity, relatively short waiting times (although this may be changing) and the freedom to choose any healthcare provider. Despite this, at least 1% of the population (about 115,000 people) lacks social health insurance coverage, rising to around 2% in the Brussels region and among younger adults. On a related note, the share of households with catastrophic health spending in Belgium is currently among the highest in Western Europe, as reported by the World Health Organisation in February 2023. Catastrophic health spending means a household can no longer afford to meet basic needs – food, housing and heating – because of having to pay out of pocket for health care. The report testifies that nearly 260,000 households in Belgium experienced catastrophic health spending in 2020. This equates to 5.2 per cent of households, though alarmingly, the number goes up to 8% for households headed by unemployed people and 12% for households in the poorest fifth of the population.  

The future availability of GPs also 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. There is also a high patient-to-nurse ratio in Belgium. In 2010, one nurse was, on average, responsible for 10.7 patients, this was amongst the highest in Europe and nearly a decade later in 2019, the patient-to-nurse ratio had dropped slightly to 9.4 patients per nurse.  By international standards, patient safety in hospitals cannot be guaranteed when there are more than 8 patients per nurse

Belgium’s health system does have several strengths, including clear objectives of universality and solidarity and is supported by several federal institutions. The country’s federal structure enables regional adaptation and tailored approaches to meet healthcare needs in various areas, fostering competition and potential innovation in healthcare delivery. Furthermore, the distribution of powers and resources among regions may result in more equitable access to healthcare services across the nation. 

The country has recently committed to the COP26 health programme, including a climate-resilient health system and a sustainable low-carbon health system. In coming years, major measures are likely to be introduced in Belgium, with the aims of continued healthcare improvement and maximised efficiency across the health system. Within these aims are targets to continue hospital, mental health care and national fee schedule reforms, whilst integrated care projects and the development of a national health research system are also to be focused on.  

Healthcare priorities

While Belgium is celebrated for its thriving and well-developed health sector, some indicators present a gloomier picture. Access to care, for instance, appears uneven: in 2019, approximately 4% of people in the lowest income quintile reported unmet medical needs, mainly due to costs, in contrast to only 0.2% in the highest income quintile.  

Some findings suggest that the optimal integration of care to manage chronic conditions is still lacking, as is health equity and inclusiveness. Developing a unified national healthcare strategy becomes challenging due to the presence of numerous regional governments, leading to fragmented healthcare policies and practices. Their very complex political structure and division of health responsibilities between the federal and federated governments slow down decision-making and policy implementation, particularly during crises. This political fragmentation also results in historical underinvestment in prevention and difficulties for patients navigating the healthcare system. Currently, health policymakers excessively emphasize public health and overlook healthcare governance, organization and financing. Additionally, strict and complicated governance frameworks exist, such as those for the payment of innovative drugs or medical innovations. Balancing the benefits and challenges of this complex political landscape remains a constant concern for policymakers in the Belgian healthcare system. 

Major contributors to mortality and ill health in Belgium are risk factors for health. Obesity and alcohol and tobacco consumption are high in Belgium. The government has 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. Thanks to initiatives such as these, smoking has significantly decreased over the past 20 years, and in 2018 only 15% of adults smoked daily. This was lower than the EU average. 

Similarly, there are restrictions on advertisements for alcohol products. Belgium initiated a national campaign against drink-driving called the ‘BOB campaign’, which was started in 1995 by the traffic safety institute VIAS. It has been renewed every year since because of its success. The campaign emphasises 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. As a result, drunk driving incidents have reduced in frequency, and in 2022, VIAS found that the number of drunk drivers had reached its lowest in 5 years.   

In 2018, close to the EU average, 16% of adults were obese, up from 12% in 2001. Teenagers aged fifteen are now more likely to be overweight and obese, up from 11% in 2002 to 17% in 2018. To promote healthy eating, the ‘Nutri-score’ was introduced on food packaging in 2018. Although the system is voluntary, the five biggest retailers in Belgium committed to displaying. A study in 2021 showed that Belgian consumers found this labelling system effective in conveying the nutritional quality of food products.  

While life expectancy in Belgium remains above the EU average, it experienced a temporary sharp decline in 2020 due to deaths caused by COVID-19. In response to the pandemic, the health system took innovative measures, mobilizing workers from outside the healthcare sector, implementing greater task shifting (‘skill mix’), rapidly allocating new payments to support healthcare providers, facilitating remote patient monitoring solutions and swiftly increasing ICU bed capacity. Among EU countries, Belgium faced one of the most severe impacts of the COVID-19 pandemic in terms of case numbers and deaths relative to its population size, especially during the first wave. 

Belgium, like many other countries, has an ageing population. Given this, there are different aspects of care for the elderly in place. This includes the development of home- and community-based care so patients can stay at home for as long as possible. Belgium might face particular struggles compared to other countries due to its complex federal structure and political landscape. The need to navigate the regional divisions and coordination between federal and regional governments may complicate decision-making and hinder the implementation of cohesive national strategies to address the ageing population’s healthcare needs effectively. Additionally, the fragmentation of policies and resources across different regions may impact the consistency and effectiveness of healthcare services provided to the elderly population. 

Genomic medicine capabilities

Belgium’s genetic centres have been regulated by law since 1987, with four located in Flanders and four in Wallonia, all linked to academic hospitals. Each of the eight universities or university hospitals has its “centre for human/medical genetics,” supported by funding from regional governments, the national healthcare system and research grants.  

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. 

Starting in 1988, a specific reimbursement system has been in place for prenatal, cryogenic, molecular and biochemical tests, but only when conducted at approved centres. Since 2013, there has been stratified reimbursement for molecular genetic tests, genetic counselling and samples sent abroad. 

Quite recently, considerable attention has been paid to Genomic surveillance, which was not structurally implemented in Belgium during 2020; rather, it was carried out by individual research labs, which had to raise the necessary funds on their own to carry out this crucial task. To significantly increase the country’s genomic sequencing efforts (both in terms of intensity and representativeness), perform quality control among participating laboratories and facilitate coordination and collaboration of research projects and publications, a national genomic surveillance consortium was established in Belgium at the beginning of 2021. Belgian sequencing coverage had significantly increased by March 2022, allowing for quick identification and tracking of viral lineages. What’s more, the project found the first Omicron variant in the nation and offered insightful information on disease severity, novel infections and virus spread in various environments. 

Prenatal and newborn screening

Non-invasive prenatal screening (NIPS) in Belgium is excellent. Prenatal genetic screening is available in Belgium as part of routine prenatal care, a process that typically involves a combination of different tests and screenings. These may vary depending on factors such as the woman’s age, medical history and any identified risk factors. Belgium was the first country to implement and fully reimburse NIPS as a first-tier screening test offered to all pregnant women and offers NIPS virtually for free to all pregnant women. Fetal ultrasound is still performed to measure the nuchal translucency (NT) and identify foetal malformations, both indicators for additional genetic counselling and invasive genetic testing. When a foetal or maternal genetic lesion is detected, the obstetrician is informed and the pregnant woman is invited for genetic counselling.  

First-trimester anatomy screening is offered as a stand-alone offer, apart from aneuploidy screening. The first- and second-trimester screening for trisomy 21 (T21) is reimbursed for all pregnant women in Belgium. 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 provides a unique context; whereby genetic counselling is fully reimbursed for all and the geneticists as test providers collaborate closely with the obstetric community. There are still concerns about the potential impact of these tests, particularly regarding the emotional distress of pregnant women who may not have sufficient preparation for the difficult news of a severe disorder or personal health issue.  

Biobanks 

Belgium also has 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). The aim of joining the BBMRI-ERIC was to ensure good research quality, and 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. 

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 eleven 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.  

Notable projects 

  • BeSolveRD: A nationwide randomised control trial, which involved all eight Belgian genetic centres. The trial aimed 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 to provide 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 clinical-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 institutions 

  • 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):  The Belgian Medical Genomics Initiative (BeMGI) is a network of seven Belgian institutions. These are supported by the Interuniversity Attraction Poles (IAP) program of the Belgian Federal Science Policy Office (BELSPO). The project’s primary objectives revolve around harnessing genomic information to predict clinical outcomes and paving the way for the next generation of genomics research. Through its funding and collaborative efforts, BeMGI seeks to advance medical genomics and contribute to cutting-edge discoveries in personalized medicine, ultimately benefiting patients and healthcare practices. 
  • 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.  
  • GENOMED: An interfaculty consortium of four research groups and the Center of Excellence at the University of Antwerp. GENOMED namely supports the enhancement of genetic research in biomedical sciences by application of state-of-the-art technologies such as next-generation sequencing (NGS), induced pluripotent stem cells (iPSC) and gene editing (CRISPR/Cas). In the past few years, GENOMED has focused on exome sequencing, an area that has led to new gene discoveries. Despite this, it now anticipates that whole genome sequencing (WGS) will become the next standard genetic analysis and an essential step towards personalized medicine. 

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 (12/06/1933 – 23/01/2017): 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 the 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 (23/07/1863 – 08/10/1924): 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. 

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 has Molecular Tumour Boards (MTBs), which are expert advisory boards that support the translation of NGS into practical clinical applications 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 its 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 several fronts including population-based sequencing and developing standards for good sequencing practice. 

Belgium is well-positioned to achieve an adequate level of genomic sequencing coverage of positive cases thanks to the genomic surveillance consortium, which was established at the beginning of 2021. This will ensure a reasonable probability of identifying circulating virus lineages. 

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.

References