Policy responses for Belgium - HSRM

Belgium


Policy responses for Belgium

3. Providing health services effectively

The section on PROVIDING HEALTH SERVICES EFFECTIVELY describes approaches for service delivery planning and patient pathways for suspected COVID-19 cases. It also considers efforts by countries to maintain other essential services during periods of excessive demand for health services.

3.1 Planning services

Ordering and delivering

At the beginning of March 2021, three COVID-19 vaccines are available in Belgium: Comirnaty® (Pfizer/BioNtech), Moderna® and AstraZeneca® vaccines.

The vaccination schedule for these three vaccines consists of two doses (only one dose is not recommended by the Belgian Superior health council), administered with a recommended interval of 21 days (that can be extended to maximum 35 days if needed) for Comirnaty®, 28 days for Moderna®, or 12 weeks for AstraZeneca®.

The vaccine of Pfizer/BioNtech (Comirnaty®) is delivered by the firm in hospital hubs. Hospital hubs were designed by the Federal Agency for Medicines and health Products (FAMHP) and must be equipped with Ultra temperature (ULT) freezers. Maximum quantities that can be delivered (quotas) in each hub is defined by the Federal State, according the number of vaccines available. These quotas are communicated by the FAMHP. Other vaccines (Moderna® and AstraZeneca®) are delivered by the firms in a central HUB of Medista, a highly specialized medical supply chain company that operates in a strictly controlled environment. Medista was designated by the FAMHP to receive and store vaccines as well as the equipment required for vaccination (syringes, needles, dry ice, etc.).

Under the supervision of the FAMHP, Medista is also responsible for distributing the vaccines to centres that have vaccine storage facilities, i.e. from the hubs to hospitals, collective care institutions (including nursing homes and homes for the elderly), and vaccination centres.

Based on the number of vaccines available, the federal state communicates to each federated entity their maximum quota of vaccines. Each federated entity is then responsible for distributing this quota between hospitals, collective care institutions and vaccination centres.

The national vaccination plan

The Belgian vaccination strategy consists of three phases:

● Phase 1a (few vaccines and stocks, multi-dose vials, complex storage conditions of frozen vaccines): centralised administration of vaccines to high-priority target groups, according to the following sequence:
○ Residents and staff (including volunteers) in nursing homes and homes for the elderly followed by collective care institutions.
○ Health care professionals working in hospitals and health care and support professionals working in ambulatory care.
○ Other hospital professionals and health professionals working in other health services such as in preventive programmes.

● Phase 1b (wider range of vaccines and stocks, multi-dose vials, less complex storage conditions): centralised administration of vaccination extended to:
○ People aged 65 years and over, either indistinctly or by descending age categories depending on the availability of vaccines (decision managed by the federated entities).
○ People aged 45-64 years old with a well-known risk factor, later extended to 18-64 years for some co-morbidities.
○ People occupying a critical function within an essential social or economic profession (criteria not yet defined).

● Phase 2 (very wide range of vaccines and stocks, both multi-dose and single dose vials, simple storage in the fridge): vaccination generalised to all adults (18 years and over), including low-risk groups, via both centralised and decentralised channels.

The timeline is currently as follows:
• Residents of nursing homes and staff of nursing homes : Starting January 2021 (with a pilot phase that started on 28 December2020)
• Hospital health care professionals: starting end of January 2021
• First line health care professionals: starting February 2021
• Collective health care facilities and other hospital personnel starting February 2021
• Over 65 years of age: starting March 2021
• 18/45-64 years old with comorbidities : starting March 2021
• People with critical functions in essential sectors: starting April 2021
• General population: starting June 2021

Invitation process

Vaccination is done on a voluntary basis and is free. Belgian federated entities are responsible for initiating the vaccination process in respect with this national vaccination plan.

A computerized centralized booking system is in place since February 15th 2021. The sending of invitations is initiated from the booking application, which creates a vaccination code. An activated vaccination code that has not yet resulted in the registration of one or more vaccination moments remains valid until 31 December 2021.

Individual invitations can be sent by post, text message and/or email. The invitation includes a link toward the booking application and a phone number for people unable to use the online booking application, as well as general and organizational information. People are also invited to contact their GPs, pharmacists, or a call centre managed by the federated entities in case of questions. People have then the option to confirm, refuse or move their appointment, either online via the centralized booking system or by phone. The appointment for the second dose is made at the same time.

The selection of individuals and the procurement of contact information is done using different sources, such as the national register (e.g. for people aged 65 years and over), sickness funds data (e.g. for people with risked co-morbidities) or the Common Base Registry for HealthCare Actor (CoBRHA) (e.g. for health care workers).

Vaccines administration

The vaccination effort in phases 1a and 1b is centralized. Vaccines are delivered in hospitals for hospital staff, in collective care facilities (e.g. in nursing homes and homes for older people) for both residents and staff (including volunteer), and in vaccination centres for other people. People tasked to administer the vaccine are those allowed to do so under Belgian law, this may include besides health care providers also trainees, students, pensioners, volunteers, and other profiles. These people are allowed to provide vaccination following the law of 6th November 2020 (see also section 2.2). This law allowed, in the context of the COVID-19 pandemic, people without valid professional titles to perform nursing acts (including vaccine administration) under strict conditions, including having had prior training. This training is to be provided by a nurse or doctor, both in relation to the nursing activities performed and to health protection measures necessary to perform these nursing activities. The training must be adapted according to the knowledge and skills of people following them. The nursing activities must then be carried out under the supervision of the nurse coordinator, who must be accessible. This does not require the physical presence of the nurse coordinator.

Supplies to address adverse events during vaccination are provided by the place where the vaccination is done (vaccination centres, hospitals, collective care facilities).

To speed up vaccination, an increase in the number of vaccination centres is planned. The number/brand of vaccines available will also be increased (e.g. with the Johnson & Johnson vaccine). Moreover, when logistical obstacles will be reduced (i.e. very wide range of vaccines and stocks, both multi-dose and single dose vials, simple storage in the fridge), vaccination will probably also be allowed in GPs office or other decentralized centres (discussions ongoing).

Federated entities also plan to provide for "mobile actors" capable of reaching populations that are not able to go to a vaccination centre on their own (see below: access).

Vaccination financing, coverage and access

The financing of vaccination is shared between federated entities and the federal state/compulsory health insurance. The operation of large-scale vaccination centres involves the mobilization of many people with different backgrounds. These may include trainees, students, pensioners, health care providers and other volunteers, these people may be contracted in the following forms:
● on a volunteer basis;
● via an employment contract (e.g. ordinary or student work);
● via a provision of their employer (who therefore continues to pay the person);
● via self-employed workers.

Anyone aged 18 and over with a social security identification number (SIN) has access to the vaccine free of charge (no cost-sharing). This includes all persons residing in Belgium (the NISS corresponds to the national register number) or persons not residing in Belgium but having close and stable relations with Belgium, such as cross-border workers (these persons are identified by a BIS number). Some of these persons do not yet have a BIS number (e.g. because they had not yet needed one). In this case, the vaccinating doctor or a social secretariat can create a BIS number directly (but only if the patient presents a valid identity document with predefined minimum identification data).

The vaccination of people who do not meet these criteria (homeless people, undocumented migrants, etc.) is currently under discussion. Federated entities also plan to provide for "mobile actors" capable of reaching populations that are not able to go to a vaccination centre on their own. Two populations are particularly targeted: 
● people who are bedridden and cannot move or be moved in acceptable conditions (home vaccination);
● people in precarious situations that prevent them from going to vaccination centers for various reasons (vaccination directly with these people in the field or in collective facilities such as day/night shelters for homeless people).

Vaccination surveillance

A single software package, Vaccinnet+, is used to record all vaccinated people and allow all required activities related to surveillance and pharmaco-vigilance. People in charge of the vaccination are responsible for the uploading of data on vaccinated individuals on Vaccinnet, including information about the received vaccine (brand, lot number, date of vaccination, etc).

Sciensano is charged with the vaccine surveillance plan. In order to achieve post authorization monitoring and surveillance, COVID-19 testing data are coupled with the COVID-19 vaccine registry Vaccinnet, in addition to other national datasets.

The surveillance plan includes:

• National vaccine uptake and coverage: by vaccine brand, age, gender, geographical region, target group (Health Care Worker, >65y, 18/45-64y and co-morbidities, nursing-home residents), and by socio-economic indicators.
• Identification of breakthrough cases: i.e. Covid-19 confirmed cases occurring in fully vaccinated individuals. Primary objective: Incidence rates of break-through cases: by vaccine-brand, by age, gender, target group, by time since vaccination, by severity. Secondary objective: Conservation of samples of breakthrough cases for ulterior whole genome sequencing (identification of mutations).
• Vaccine effectiveness: the primary objective is to measure pandemic COVID-19 vaccine-effectiveness (CVE) against laboratory confirmed SARS-CoV-2 in patients of all ages, by vaccine-brand. The secondary objective is to estimate pandemic CVE against laboratory confirmed SARS-CoV-2: by target group (Health Care Worker, >65y, 18/45-64y and co-morbidities), by age-group, by gender, by risk-group (ex by specific co-morbidities), by time since vaccination and regularly over calendar time, by vaccine-dose (one vs two dose) if applicable, and by specific genetic variant, if feasible and documented.
• Vaccine safety in support of the FAMHP. The FAMHP regularly publish pharmaco-vigilance data on adverse reactions, both for the public and health professionals.

From May 4th, hospitals progressively stared to reopen non-urgent consultations (see 3.3 maintaining essential services).

After the first wave, a five-phase plan has also been prepared to ensure patients with COVID-19 are distributed and treated in the most optimal way, while ensuring that other care is provided as much as possible (see section 2.1).

Primary care

General practitioners (GPs) are to be contacted by phone by patients suspecting COVID-19 for a telephone triage (remunerated by the NIHDI since April 1st). The GP has to evaluate the severity of symptoms and to decide whether the patient should stay home or go to the hospital. Detailed procedures are available on the Sciensano website (how to take a nasopharyngeal sample, how to manage relatives, prudent use of antibiotics in case of bacterial superinfection, etc.) (https://epidemio.wiv-isp.be/ID/Pages/2019-nCoV_procedures.aspx). If symptoms are relevant and the GP wishes to make a clinical examination, he/she may carry it out himself if he has the protective equipment (surgical mask, gown, goggles and gloves) preferably at the patient's home. If he/she does not have the necessary protective equipment, he/she refers the patient to a triage centre or to the hospital. During the peak of the epidemic, there were up to 152 triage centres on the Belgian territory (some local initiatives of mobile teams for less mobile patients and residential care have also been set up).

If symptoms are severe, the GP has to make contact with the ambulance service and with the hospital for admittance. The GP's role is not to diagnose COVID-19, but to assess whether or not the patient's condition is deteriorating and, therefore, whether or not the patient should be hospitalised.

Pharmacists received detailed recommendations commonly issued by their professional associations (on March 11th) to help them maintain a safe place, while they continue serving the population (https://epidemio.wiv-isp.be/ID/Documents/Covid19/COVID-19_SOP%20recommandations%20pharmacie-pharmacien_FR.pdf).

Dentists, home care nurses, physiotherapists, and some other primary care professionals have received specific recommendations, the essence of which is that they must judge the importance of their care and apply it accordingly to maintain the continuity of care to the population without exposing their patients to unreasonable risks.

Another subgroup of the federal Risk Management Group, namely the Primary and Outpatient Care Surge Capacity Committee was created (on March 13th) to streamline and harmonise the organisation and availability of care outside the hospital, both before and after admission, in the different federated entities. This Committee gathered representatives from federated entities, hospital federations, GPs, the scientific COVID committee and the FPS Public Health.

Alternatives to face-to-face consultations

On March 16th, 2020, it was decided that physicians would be paid a fee for telephone consultations taking place in connection with the COVID-19 crisis (telephone triage and telephone consultations with other patients as part of the continuity of care).

Since April 1st, 2020, phone or video consultations are remunerated and totally reimbursed by the NIHDI for the following other health care professionals: psychiatrists, psychologists, dentists, speech therapists, physiotherapists, midwives, dieticians, occupational therapists and diabetes educators.

In December 2020, NIHDI created the possibility to conclude conventions to finance pilot projects on 24/7 telemonitoring of COVID-19 patients. The aim is to monitor COVID-19 patients before and/or after their hospitalisation as part of an integrated medical approach supported by digital applications, avoiding hospitalisations of patients with moderate symptoms or reducing the length of hospitalisations. A number of parameters and the systematic identification of the patient's symptoms must be collected by mean of digital applications and telemetry and monitored 24/7 by a medical team, under the responsibility of a designed coordinating physician. A secure electronic platform must be used to collect all patient data (either sent automatically or entered by the patient and/or a practitioner) and protocols must be defined. The convention can either be concluded with a hospital or with a team of health care providers (including GPs, medical specialists, and/or nurses). In order to guarantee the quality of care, the structure must be able to follow a minimum of 200 patients simultaneously. A per capita payment and an evaluation of these projects are foreseen (for more details: https://inami.be/fr/covid19/Pages/soins-distance-patients-covid19-domicile-telemonitoring.aspx).

The older people care sector

After an initial focus on hospitals and their intensive care units, it became clear that nursing homes and homes for older people were also being particularly affected by the epidemic. Approximately half of the recorded deaths have occurred in these facilities (but this may be a possible overestimation, see section 1.4 on Monitoring and Surveillance).

On April 15th, the Interministerial Public Health Conference approved a framework for possible support from the hospital sector to the older care sector. This framework foresees that hospitals can give support to institutions caring for older people by providing expertise (e.g. geriatric liaison, hygiene and control of infectious diseases, etc.), by making staff available (in addition to other possibilities for staff reinforcement), by helping them to procure equipment or products (e.g. supply of oxygen or certain medicines), and by supporting them in the screening process or by providing infrastructure (as long as their own basic hospital missions are not compromised). Similar requests arising from other communities (e.g. institutions for disabled people) will be dealt with the same way as for care facilities for older people. 

In preparation for transition towards the post-lockdown phase, great attention has been put on the testing of residents and staff in nursing homes and homes for older people. Testing began in mid-April but has progressed slowly because of logistical problems. Testing capacity has then progressively evolved, allowing the testing of all new residents and the investigation of clusters (see section 1.5).

Hospital care

Referral centres

At the very beginning of the outbreak in Belgium, two hospitals were designated as referral centres for the treatment of COVID-19 patients (St Pierre Hospital in Brussels and UZ Antwerpen). When the epidemic increased, all hospitals started admitting COVID-19 patients and, from March 14th measures were taken to create additional beds.

Increase hospital capacity: act first at hospital level

From March 14th all hospitals (general and university, psychiatric and rehabilitation settings) were required to activate their emergency plan (see section 2 on Ensuring sufficient physical infrastructure/Hospitals). They had to cancel all non-urgent consultations, investigations and elective interventions (with special focus on those potentially impacting intensive care capacities). Urgent consultations, investigations and interventions could be maintained as well as necessary treatments (i.e. chemotherapy, dialysis, etc.) and rehabilitation.

On March 17th, hospitals were further asked to do their utmost to create additional critical care capacity for both ventilated and non-ventilated patients. Empty units, medium care facilities and post-anaesthesia care units could be used for this purpose. Hospitals undertook an inventory of the capacity of CPAP devices and they had to be made fully operational, as well as equipment used for demonstrations, simulations or training. A maximum number of inpatient beds had to be immediately released, at a ratio of 3 to 4 inpatient beds per intensive care bed in order to be able to admit patients to non-critical units as much as possible in order to save the intensive care beds.

It was also stressed that patients who no longer required hospital care should leave the hospital as soon as possible. Residential facilities for older people and other residential care facilities had to reintegrate their residents after hospitalisation as much as possible.

When saturation is reached: Hospital & Transport Surge Capacity Plan (federal level)

All hospitals have to organise proactive agreements, at least at the local-regional level, regarding possible transfers when a hospital's maximum capacity is exceeded. As soon as 50% of the COVID-bed capacity is reached, partner hospitals in the same loco-regional network have to be notified. At 75% of capacity, transfers must be initiated. At this level of saturation at loco-regional level, the federal authorities take the necessary decisions regarding referrals in accordance with the agreements reached within the Hospital & Transport Surge Capacity Committee (subgroup of the federal Risk Management Group - see section 5 Governance).

In order to keep COVID-19 patients out of regular ambulances as much as possible, and to keep the availability of the regular system as high as possible, additional COVID-19 hotlines have been set up in each province. The inter-hospital transport of COVID-19 patients had to be organised by the hospitals themselves (at their own cost) with non-emergency (non-112) services, in consultation between the sending and receiving hospitals.

From early April, transition centres have been opened (or are in progress of being open) for patients who are no longer ill enough to stay in hospital but cannot yet go home following hospitalisation (e.g. in some empty, rapidly refurnished, hospitals). By mid-April there were four such centres in Flanders, two in Wallonia and one soon to open in Brussels.

Additional measures to avoid a saturation of hospitals are also described in section 3.2.

Emergency medical services

Within the Emergency Medical services several (EMS) measures were taken to face the crisis:
• In the dispatch centres, a new ‘COVID-telephonic-triage-protocol’ was initiated. This was created in order to determine if a 112-call is COVID-related or not;
• A dedicated COVID ambulance-capacity was created (36 ambulances). COVID-related calls are preferably managed by these dedicated ambulances;
• To maintain business continuity in EMS, an online ‘temp-office’ was created to fill in the gaps in EMS-schedules throughout the country (https://112support.belgambu.be/).

Primary care

General practitioners (GPs) are to be contacted by phone by patients suspecting COVID-19 for a telephone triage (remunerated by the NIHDI since April 1st). The GP has to evaluate the severity of symptoms and to decide whether the patient should stay home or go to the hospital. Detailed procedures are available on the Sciensano website (how to take a nasopharyngeal sample, how to manage relatives, prudent use of antibiotics in case of bacterial superinfection, etc.) (https://epidemio.wiv-isp.be/ID/Pages/2019-nCoV_procedures.aspx). If symptoms are relevant and the GP wishes to make a clinical examination, he/she may carry it out himself if he has the protective equipment (surgical mask, gown, goggles and gloves) preferably at the patient's home. If he/she does not have the necessary protective equipment, he/she refers the patient to a triage site/to the hospital. During the peak of the epidemic, there were up to 152 triage centres on the Belgian territory (some local initiatives of mobile teams for less mobile patients and residential care have also been set up).
If symptoms are severe, the GP has to make contact with the ambulance service and with the hospital for admittance. The GP's role is not to diagnose COVID-19, but to assess whether or not the patient's condition is deteriorating and, therefore, whether or not the patient should be hospitalised.

Pharmacists received detailed recommendations commonly issued by their professional associations (on March 11th) to help them maintain a safe place, while they continue serving the population (https://epidemio.wiv-isp.be/ID/Documents/Covid19/COVID-19_SOP%20recommandations%20pharmacie-pharmacien_FR.pdf).

Dentists, home care nurses, physiotherapists, and some other primary care professionals have received specific recommendations, the essence of which is that they must judge the importance of their care and apply it accordingly to maintain the continuity of care to the population without exposing their patients to unreasonable risks.

Another subgroup of the federal Risk Management Group, namely the Primary and Outpatient Care Surge Capacity Committee was created (on March 13th) to streamline and harmonise the organisation and availability of care outside the hospital, both before and after admission, in the different federated entities. This Committee gathered representatives from federated entities, hospital federations, GPs, the scientific COVID committee and the FPS Public Health.

Alternatives to face-to-face consultations

On March 16th, it was decided that physicians would be paid a fee for telephone consultations taking place in connection with the COVID-19 crisis (telephone triage and telephone consultations with other patients as part of the continuity of care).

Since April 1st, phone or video consultations are remunerated and totally reimbursed by the NIHDI for the following other health care professionals: psychiatrists, psychologists, dentists, speech therapists, physiotherapists, midwives, dieticians, occupational therapists and diabetes educators.

The older people care sector

After an initial focus on hospitals and their intensive care units, it became clear that nursing homes and homes for older people were also being particularly affected by the epidemic. Approximately half of the recorded deaths have occurred in these facilities (but this may be a possible overestimation, see section 1.4 on Monitoring and Surveillance).

On April 15th, the Interministerial Public Health Conference approved a framework for possible support from the hospital sector to the older care sector. This framework foresees that hospitals can give support to institutions caring for older people by providing expertise (e.g. geriatric liaison, hygiene and control of infectious diseases, etc.), by making staff available (in addition to other possibilities for staff reinforcement), by helping them to procure equipment or products (e.g. supply of oxygen or certain medicines), and by supporting them in the screening process or by providing infrastructure (as long as their own basic hospital missions are not compromised). Similar requests arising from other communities (e.g. institutions for disabled people) will be dealt with the same way as for care facilities for older people. 

In preparation for transition towards the post-lockdown phase, great attention has been put on the testing of residents and staff in nursing homes and homes for older people. Testing began in mid-April but has progressed slowly because of logistical problems.

Sources:
• FPS Public Health (2020). Coronavirus Covid-19. Brussels: Federal Public Service Health, Food chain safety and Environment (www.info-coronavirus.be, Accessed April 2020);
• Sciensano (2020). Coronavirus. Brussels: Sciensano (https://epidemio.wiv-isp.be/ID/Pages/default.aspx, Accessed April 2020);
• 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);
• Flemish Agency for Care and Health (2020). Schakelzorgcentra. Brussels: Flemish Agency for Care and Health – Agentschap Zorg en Gezondheid (https://www.zorg-en-gezondheid.be/schakelzorgcentra, 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);
• Personal communication with the FPS Public Health: Van der Auwera Marcel;
• Personal communication with the German Community: Lena Pankert;
• Press release of the Interministerial Public Health Conference on April 15th