From May 4th 2020 the definition of ‘possible cases’ was enlarged (see section 1.4) and GPs were asked to start prescribing a test to any person presenting with these enlarged symptoms and to notify all these ‘possible cases’ via an electronic form which has been integrated into their electronic software packages. However, individual contact tracing occurs only after confirmation of the case with a positive laboratory result (unless the GP explicitly mentions that there is a highly suggestive clinical and epidemiological link to a confirmed case). All people living with the patient have to isolate at home for 14 days. From May 7th, the call centres for tracing could also request the testing of people identified as contacts of a COVID-positive person.
From May 8th 2020, the priority for testing was changed. People who should be PCR-tested are, in order of priority:
• Any ‘possible case’, with special attention to caregivers (people who provide care and/or assistance) and people in residential facilities;
• People who have had a high-risk contact with a case of COVID-19 (see section 1.4) .
Then if the testing capacity is sufficient:
• Any person requiring hospitalisation;
• Any person entering a residential facility for the first time.
From June 9th 2020, people returning from a red zone are also tested (see also section 6).
From October 21th 2020, because the testing capacity was exceeded, priorities for testing were changed and asymptomatic high-risk contacts and any people returning from a red zone are automatically put in quarantine for 10 days and are no longer being tested (except for health professionals).
From November 23th 2020, because the testing capacity was no longer exceeded, asymptomatic high-risk contacts and people returning from a red zone can again be tested. A focus has also been placed on collective care institutions. In case of clusters (two or more linked cases) in collective care institutions, the responsible physician must decide on the most appropriate testing strategy in consultation with the health authorities of the federated entities.
In March 2021, the indications for testing are as follows:
• All persons defined as a ‘possible case’ (symptomatic) and symptoms last for > 5 days or requiring immediate hospitalisation (or symptomatic persons whose rapid test was negative but suspected to be a false negative);
• Asymptomatic persons who had a high risk contact with a confirmed case;
• Persons requiring hospitalisation (also day-hospitalisation);
• New residents in nursing homes or other residential settings;
• Travellers coming back from a red zone;
• Cluster (2 or more linked cases) investigations in group environments (schools, nursing home, companies, etc);
• Repeated periodic testing of health care personnel in a nursing home / home for older people, of home care nurses, or of companies with essential workers: pilot protocols have been developed and have to be followed.
New initiatives have also been developed for university students to be tested after ‘risk contact’ when asymptomatic. The student can access this testing site on their own accord and will be followed up by a contact and tracing service from the university.
The samples can be taken by the GP himself (if he is equipped to do so) or in the former ‘triage centres’ (i.e. specific sites organised by GPs, hospitals, municipalities, etc.). These ‘triage centres’, also called ‘sampling centres’ are coordinated by the GPs circles (local associations). On May 7th, the Interministerial Conference decided that 120 sampling centres should remain operational (i.e. one sampling centre per 100,000 inhabitants) with each federated entity being responsible for ensuring an adequate distribution of centres on its territory. Sampling centres can organise their collection in several places and in different forms (drive-in, mobile teams, etc.) to increase accessibility.
The GP can consult the results of tests performed on a results server, even if the sample was taken by someone else, and he receives an automatic notification for all the patients whose medical records he holds. He can also deliver ‘quarantine attests’ to the members of the family and high-risk contacts of a positive patient (even if asymptomatic). These attests are to be given to the patient either in person or by post or e-mail, depending on the nature of the consultation (physical or telephone contact). They do not have to be signed by the doctor if they are sent by e-mail, but must then contain an identification of the physician. The patient is responsible for forwarding it either to the employer or to the sickness fund. Asymptomatic patients in quarantine are allowed to telework.
Moreover, from November 23th 2020, asymptomatic high-risk contacts and people returning from a red zone receive a code to be tested without a GP prescription and must make an appointment via an online platform to a triage and sampling centre. Via this platform and their code, they can also obtain test results or download a quarantine certificate. This procedure aims to reduce the administrative burden on GPs and allow them to focus on symptomatic patients.
Algorithms summarizing the possibilities are available on the Sciensano website: https://covid-19.sciensano.be/sites/default/files/Covid19/d%C3%A9claration%20obligatoire%20et%20suivi%20des%20contacts.pdf (French); https://covid-19.sciensano.be/sites/default/files/Covid19/verplichte%20melding%20en%20contact%20opvolging.pdf (Dutch).
Every patient being tested is invited to record his or her contacts over the past few days using a form available on the eHealth platform: https://www.ehealth.fgov.be/file/view/AXICTBY_l9vUUfvGGeqj?filename=Invulblad%20contacten%20FR.pdf (French); https://www.ehealth.fgov.be/file/view/AXICTJIQl9vUUfvGGeqk?filename=Invulblad%20contacten%20NL.pdf (Dutch). This form facilitates the tracing if the patient turns out to be COVID-positive.
Serological testing (used for diagnosis in special cases only)
In May 20th 2020, Sciensano published instructions for serological testing. People allowed to be serologically tested are the following:
1. In inpatients who meet the ‘possible case’ definition AND have a chest CT suggestive of COVID-19 but a negative PCR. Serology will be performed a minimum of 7 days after symptom onset.
2. In outpatients or inpatients with a suggestive and prolonged clinical picture for COVID-19 but a negative PCR test or who could not be tested within 7 days of symptom onset. Serology will be performed a minimum of 14 days after the onset of symptoms.
3. In a context of differential diagnosis, in the case of atypical clinical presentation. Serology will be performed a minimum of 14 days after the onset of symptoms.
4. To review serological status among health care staff and staff working in hospitals/services or communities at high risk of exposure to COVID-19 (COVID service or nursing homes) as part of local risk management.
Along with these instructions, it was stressed that the effective antibody levels needed to provide protection against the virus were not known, nor the duration of the protection. Nor is it known whether people with antibodies were still contagious. Therefore, the presence of antibodies should not be seen as a guarantee of protection and the preventive measures remained valid regardless of the test result.
Warning was also given about the risk of fraud with regard to the CE marking. Only the tests recommended by the FAMHP or Sciensano were recommended (ELISA method or equivalent - immuno-chromatographic tests are not indicated).
Rapid antigen tests
From the beginning of December 2020, the following people can be tested by a rapid antigenic test:
● Symptomatic patients (with symptoms from 5 or fewer days) in emergency departments, sampling/triages centres, or GPs' offices (especially advised when the pandemic is increasing or at the height of the wave and the laboratory capacity is stretched).
● People identified as low-risk contacts, as part of the cluster investigation (from at least 2 cases) in non-care collectivities (such as in schools, nurseries, policy departments, fire brigades, and other key sectors and businesses) but not for asymptomatic patients in clusters in nursing homes (PCR test). Specific protocols are established for each sector. For these indications, a negative result does not need to be confirmed with a PCR test.
In March 2021, rapid antigen (Ag) tests were also indicated for repeat periodic testing of health care personnel in a nursing homes/homes for older people, home care nurses, or companies with essential critical workers: pilot protocols have been developed and have to be followed.
NB: The use of rapid Ag tests for one-off spot screening is currently not recommended, but may be useful in certain contexts, e.g. for screening visitors aged ≥ 12 in nursing homes. There are many different rapid Ag tests on the market with varying reliability. Only tests of which at least 3 independent studies have shown sufficiently high sensitivity ≥80% and specificity ≥97% should be used.
Self-administered salivary test were used during the summer 2020 by the students of the University of Liège (at the initiative of the University, who deposited a patent for those tests). In November, they were then implemented in nursing homes in Wallonia, in the context of a pilot project. Rapid investigation teams go into schools and health care settings for outbreak investigations.
Genetic sequencing of SARS-COV-2
A subsample of the positive COVID PCR tests is automatically followed up for new variants. In December 2020, the laboratories that have been sequencing SARS-CoV-2 samples for some time joined together in a sequencing platform, which now comprises 11 laboratories. The sequencing platform carries out so-called 'core' surveillance, i.e. in-depth genetic analysis of a number of PCR-positive samples representative of the entire population. The goal is to sequence approximately 5% of positive samples, with the proportion of samples sequenced in the core surveillance currently ranging from 14% to 0.2% depending on the province. The sequencing platform also carries out "active" surveillance, i.e. advanced genetic analyses are carried out in certain contexts (certain travellers returning from red zones, a selection of epidemic outbreaks, certain cases of reinfection/infection after vaccination, etc.)
Regularly updated guidelines for health care professionals and for residential care can be found on the websites of Sciensano and on the websites of the Federated entities:
• Sciensano (2020). Coronavirus. Brussels: Sciensano (https://epidemio.wiv-isp.be/ID/Pages/default.aspx,) ;
• https://www.inami.fgov.be/fr/covid19/Pages/retribution-soutenir-postes-triage.aspx (French) / https://www.inami.fgov.be/nl/covid19/Paginas/vergoedingen-triagecentra.aspx (Dutch)
• Flemish Agency for Care and Health (2020). Uitbraak coronavirus COVID-19. Brussels: Flemish Agency for Care and Health – Agentschap Zorg en Gezondheid (https://www.zorg-en-gezondheid.be/covid-19, Accessed April 2020);
• AVIQ (2020). Coronavirus 2019. Charleroi : Agency for a Quality Life-Agence pour une vie de Qualité (https://www.aviq.be/coronavirus.html, Accessed April 2020) ;
• Iriscare (2020). COVID-19. Brussels: Iriscare (http://www.iriscare.brussels/fr/professionnels/, Accessed April 2020);
• Ostbelgienlive (2020). Coronavirus: Fragen und Antworten. Eupen: Ostbelgienlive (http://www.ostbelgienlive.be/desktopdefault.aspx/tabid-6711/, Accessed April 2020).
• https://organesdeconcertation.sante.belgique.be/fr/documents/covid-19-communiques-de-la-cim (French) / https://overlegorganen.gezondheid.belgie.be/nl/documenten/covid-19-persberichten-van-de-imc (Dutch)
The first hundreds of cases were systematically tested for COVID-19, but from March 11th, PCR tests had to be prioritised due to possible shortages. Hence, the Risk Assessment Group and the Risk Management Group (see section 5 on Governance) developed a testing strategy. Only severe cases and health care professionals with fever were tested. As of March 13th health care professionals with light symptoms are no longer being tested.
Since April 1th, more definite rules on who should be tested have been set by the Risk Assessment and Risk Management Group (https://www.inami.fgov.be/fr/covid19/Pages/priorites-repartition-materiel-protection-tests.aspx):
• Any person whose clinical condition requires hospitalisation AND for whom the clinician suspects COVID-19 infection.
• Any health professional (physician, nurse, nursing home staff and paramedic) in contact with people at risk, who meets the ‘possible case’ definition AND has a fever. (the term "fever" was removed on April 16th)
• The first cases (up to a maximum of five people) that meet the ‘possible case’ definition in a collective institution (e.g. nursing home, prison, etc.)
GPs can request testing in the abovementioned situations, or if the patient is in a residential setting (maximum of five patients per setting; if there are more, testing is not necessary anymore). Otherwise, testing is decided at the hospital level. On March 4th, hospitals and GPs' circles were invited to discuss the organisation of sample collection together, with a view to possibly coordinating practical arrangements in the organisation of sample collection. Hospitals and GPs' organisations were asked to keep the authorities informed of agreements on the organisation of sample collection, any changes and any problems that may be identified in this respect.
On April 23rd the rules about who should be tested have been slightly enlarged. It became “who could be tested”, and the text was formulated as follows:
• Any person requiring hospitalisation, including day hospitalisation (for the first time). If the test result is negative and the patient is still hospitalised, the test may be repeated only once on day 5, as a negative result could also mean that the person is infected but still in the incubation period.
• Any person entering a residential facility for the first time (e.g. nursing homes, homes for the disabled, youth centres, prisons, etc.). If the test result is negative, repeat the test only once on day 5, as a negative result could also mean that the person is infected but still in the incubation period.
• Any ‘possible case’ in residential facilities (e.g. homes for older people and nursing homes, homes for the disabled, youth centres, prisons, etc.). As soon as two cases are possible in the same structure, the testing strategy within the structure will be adapted according to the local situation by the infectious disease prevention and control services of the local authorities (federated entities).
• Any caregivers (persons providing care and/or assistance) who meet the ‘possible case’ definition.
While waiting to be able to test any person with relevant symptoms, the available capacity was thus focused on refining the management of the COVID risk in the residential facilities (including hospitals).
Results of testing have to be transmitted daily before 11am to Sciensano by each general hospital, using an online form (https://surveys.sciensano.be/index.php/523543?lang=fr) for epidemiological analyses. Mandatory notification from primary care was lifted on March 18th (except for residential institutions).
Information on testing capacity is provided twice a week by the authorities, in order to focus the majority of efforts on finding materials and solutions for people in the field.
It is important to note that since mid-March, some hospitals systematically use thoracic scan as diagnostic measure. Also, tests are not charged to the patient; the NIHDI pays directly for all tests where the indication meets the case definition.
Biosafety guidelines for labs testing COVID-19 (were made available on the Belgian Biosafety server (https://www.biosecurite.be/biosecurite-sars-cov-2).