In this World of Genomics instalment, we’re taking a trip to Luxembourg. The second richest country in the world, and the only nation with a Duke as the Head of State, Luxembourg is famous for its huge banking industry and its ancient summer festival, Schueberfouer. Lovers of a fine wine will find themselves at home here, with Luxembourg’s take on the alcoholic beverage closely rivalling that of its neighbour, France.
Home to one of the European Union’s institutional seats, this small but powerful nation should not be overlooked. Revered for its excellent healthcare system, Luxembourg is committed to research and innovation, particularly in personalised medicine. Let’s take a look at what the country’s genomics landscape.
One of the world’s smallest countries, the Grand Duchy of Luxembourg is situated in northwest Europe and borders Belgium, France and Germany.
Luxembourg is a nation with a complex history. Part of the Roman Empire from 53BC and occupied by the Franks from the 5th century, Luxembourg was established in 963. Initially ruled by Counts and Countesses, the nation became a Duchy in 1354.
Luxembourg was ruled by the Spanish Hapsburgs from 1555 but was conquered by the French in the latter part of the 17th century. Shortly after this, the land was returned to the Spanish, before passing to the Austrian Hapsburgs less than 20 years later. Following further domination by the French and a union with the Netherlands, the Grand Duchy of Luxembourg became an independent sovereign nation in 1862.
With so much foreign influence over the centuries, it is no surprise that Luxembourg is home to a diverse population. Today, the country relies on immigration to address labour shortages, as the native population is small and training opportunities are lacking. The modern Grand Duchy is therefore home to a large number of foreign residents – only around half of the country’s population are native Luxembourgers.
Geographic and Demographic Information:
- Land area: 2586.4 km2
- Gross domestic product (GDP):
- Total: $86.71 billion (2021)
- Per capita: $ 135,682.8 (2021)
- Population size: 639,070 (2021)
- Birth rate: 10 in 1000 (2020)
- Death rate: 7 in 1000 (2020)
- Infant mortality rate: 2 in 1000 (2020)
- Average life expectancy: 82 (2020)
- Male: 79 (2020)
- Female: 84 (2020)
- Ethnicity: 52.6% Luxembourger, 15.2% Portuguese, 7.6% French, 3.7% Italian, 3.2% Belgian, 2.0% German and 15.7% other.
Luxembourg spends significantly more on healthcare per capita than the EU average. A compulsory social health insurance scheme has operated in the country since 1992, which covers healthcare, sickness leave and long-term care for the elderly and disabled. Patients may sometimes pay up front for treatment, but costs are typically reimbursed in full. 99% of residents are covered by this social health insurance scheme, which is funded through taxes and social security payments. Children are covered by their parents’ health insurance until they are either 18 or 27 if they remain a full-time student. This public insurance system is responsible for around 84% of all health expenditure.
Around two-thirds of Luxembourg’s population also take out additional voluntary health insurance that is paid for out-of-pocket. This voluntary insurance covers treatments or related expenses which are deemed non-essential, such as private hospital rooms and dental treatments. Residents who are unemployed or otherwise vulnerable are entitled to social welfare that covers essential healthcare.
The Luxembourgish healthcare system has a very good reputation and the country has a relatively low number of preventable deaths. Outpatient care in the country is excellent, which subsequently decreases the need for unnecessary hospital stays. Overall, there are very few unmet medical needs in the country, making Luxembourg’s health system one of the best performing in the EU.
However, Luxembourg has a lower number of medical personnel than many other EU countries. This is in part due to a lack of training opportunities in the country. Luxembourg has no dedicated medical school, and as such relies on an influx of staff from other nations. However, there are a relatively high number of mental health professionals and mental health care in Luxembourg is highly regarded.
The most common causes of death in Luxembourg are ischemic heart disease, stroke and lung cancer.
Alcohol consumption is one of the top behavioural risks for death and disability in Luxembourg. Over a third of Luxembourgish adults regularly partake in binge drinking episodes, and alcohol use as a whole is higher than both Organisation for Economic Co-operation and Development (OECD) and EU averages. Unhealthy diets are also common, contributing to Luxembourg’s rising obesity rates. Only around half of the population eat fruit or vegetables daily. However, the most significant behavioural health risk is tobacco use. Over a fifth of Luxembourg’s population smoke, and this is the nation’s top risk factor for death and disability. In 2017, the country expanded smoking bans to cover playgrounds and raised the age at which individuals could buy tobacco to 18.
Luxembourg is faced by the problem of an ageing population – over 65s will represent over a fifth of the total population within the next 30 years. Subsequently, the number of people requiring long-term care is rising. Long-term care can be provided in a specialised facility or at the patient’s own home. The number of indiviuals choosing the latter option has risen significantly in recent years.
Despite outpatient care in the country being generally well regarded, Luxembourg has faced criticism for high levels of antibiotic use. The amount prescribed is far higher than the OECD average and concerns over antimicrobial resistance have highlighted a need for change. The Luxembourgish government has implemented a National Antibiotic Plan, running until 2024, to reduce use of these drugs, find suitable alternative treatments and raise awareness of the risks.
Genomic Medicine Capabilities
The majority of pre-natal screening tests for chromosomal abnormalities are covered by the social health insurance scheme, although it is not compulsory for pregnant individuals to undergo non-invasive pre-natal testing (NIPT). NIPT will be recommended by a doctor based on the mother’s medical history and age.
The cost of newborn screening for a select number of genetic conditions is also reimbursed. Newborn screening in Luxembourg has been carried out since the 1960s, although there are still relatively few conditions investigated as standard. Cystic fibrosis screening via blood spot testing was introduced in the country in 2018, bringing the total number of conditions to five. If the results of a blood spot test are abnormal, samples are sent to the nation’s only screening laboratory at the National Centre of Genetics for further DNA testing. In the event that genetic testing returns a positive result, children are referred immediately for treatment.
The vast majority of genetic testing is undertaken at the National Centre of Genetics. Alongside pre- and neo-natal screening, the centre is also responsible for analysing cancer types in order to inform treatment decisions. This contributes to Luxembourg’s ongoing commitment to implement personalised treatments and genomic medicine into its healthcare system. The Centre also provides genetic counselling, and in 2018 over 900 patients attended an appointment. However, the genetic counselling field is also impacted by the aforementioned lack of domestic training opportunities. There are currently no training programmes within the country, and 2020 was the first time a trainee genetic counsellor was able to practice in Luxembourg, as part of a Master’s programme in France.
As of 2018, Luxembourg had no specific legislation regulating genetic testing. This means that the field is only governed by broader healthcare and data laws. Luxembourg is one of five European countries who have signed but have not ratified the 1999 Oviedo Convention. This convention governs many aspects of health and medicine, including consent for genetic testing and genetic counselling. However, without ratifying the convention, Luxembourg has no legal obligation to follow it.
1+ Million Genomes: Luxembourg is one of over 20 European countries contributing to the 1+ Million Genomes Project. This initiative aims to make genomic data accessible across borders, advancing genomic medicine and digital health data.
COVID+ Genomics: Overseen by the LNS and financed by the Ministry for Health, this project aims to build a genomic map of COVID-19 variants to reduce transmission and improve diagnostics and treatments.
NCER-PD: NCER-PD is a collaboration between multiple institutions that specialise in Parkinson’s disease research. The project aims to use genomics and other clinical data to identify early risk factors for Parkinson’s disease. It is aided by the bioinformatics core at the University of Luxembourg.
Predi-COVID: Predi-COVID is a project overseen by the LIH. All individuals diagnosed with COVID-19 in Luxembourg are invited to take part in the study, which aims to identify clinical and epidemiological biomarkers for severity through “deep-phenotyping.” Biological samples collected as part of the study will be stored at the Integrated Biobank of Luxembourg for use in further research.
Notable Institutions and Organisations
Integrated Biobank of Luxembourg (IBBL): The IBBL is part of the LIH. Biological samples and data are collected and stored by the IBBL for use in research.
Laboratoire National De Santé (LNS): The LNS is a public multidisciplinary institution founded in 2012 to advance scientific discovery and development in Luxembourg. The LNS conducts research in various biological fields and is home to the National Centre for Genetics. It also hosts two diagnostic centres and is involved in pre-natal screening.
Luxembourg Genome Centre (LuxGen): LuxGen was established in 2018, and expanded in 2021, as a centralised sequencing facility for both research and diagnostics. It is the only sequencing centre of its kind in Luxembourg and it provides scientists with access to state-of-the-art next generation technology. The LuxGen initiative places significant emphasis on personalised medicine and patient care.
Luxembourg Institute of Health (LIH): The LIH is a public research organisation which focuses on patient-centric research and precision medicine. Research focuses primarily on cancer and immune diseases, but also includes other conditions such as Parkinson’s disease. The institute collaborated with the LNS to set up the LuxGen centre.
University of Luxembourg: The University of Luxembourg is a relatively young institution, founded less than 20 years ago in 2003. It is the only public university in the country. The campus hosts research groups that investigate a variety of topics including cancer, drug discovery, immunology and genetics.
Rudi Balling: Balling is a prominent researcher in the field of developmental genetics. He founded the Luxembourg Centre for Systems Biomedicine at the University of Luxembourg, the unit responsible for research into biological areas such as gene expression and neuropathology. His work earned him the Luxembourgish Ordre de Mérite.
Jules Hoffmann: Jules Hoffmann is a Luxembourg-born biologist who won the 2011 Nobel Prize in Physiology or Medicine for his discovery of the Toll gene’s role in innate immunity. He currently holds the position of Research Director at the National Centre of Scientific Research in France.
Rejko Kruger: Kruger is director of the Transversal Translational Medicine unit of the Luxembourg Institute for Health. He is a Professor of Neuroscience and his recent work developing a personalised treatment for familial Parkinson’s disease earned him the award for Outstanding Scientific Achievement from the Luxembourg National Research Fund.
Future Genomic Landscape
Luxembourg may be a small country, but it is committed to better healthcare for all. The National Research and Innovation Strategy for Luxembourg, a roadmap developed in 2020, places a significant emphasis on personalised healthcare. As a result, research into precision medicine will receive significant funding in the coming years. Huge research efforts are already underway, with the LIH recruiting for multiple clinical trials.
Luxembourg is also a participant in the European Beyond 1 Million Genomes project, which aims to complement the 1 Million+ Genomes project by making genomic data more accessible across Europe. The University of Luxembourg will play a role in helping develop this vital infrastructure. Access to a broad range of data from different countries will be hugely important for small nations like Luxembourg, where the available national data may not be sufficient for large-scale genomic research.
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LNS Luxembourg. Cystic Fibrosis screening available to all newborns. Available at: https://lns.lu/en/cystic-fibrosis-screening-available-to-all-newborns/
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