Policy responses for Belgium - HSRM

Belgium


Policy responses for Belgium

3.2 Managing cases

Contact and triage

The first point of contact for all people with symptoms is the general practitioner (GP) (see section 3.1 on primary care). A federal telephone line (free number 0800/14689) was set up early in February, but it was mainly intended to provide information to the population.

Initiatives are also taken by the federated entities. In Brussels, for example, a telephone line has been made accessible for marginal populations (i.e. homeless people, foreign populations and migrants, etc.), to direct them to the local GP circles where a doctor will answer the call.

Despite the information and recommendations spread through the media, many people were still going directly to hospitals. Therefore, informal physical triage initiatives were undertaken (often located in tents outside the emergency department of hospitals or in general practice wards). As of March 23rd, the National Institute for Health and Disability Insurance (NIHDI) and the FPS Public Health took a series of implementing measures in order to give maximum support to the work of health care providers in those triage centres. They were inventoried in a database in order to get an overview of the global offer and to be able to get rapidly in contact with them. Payments are made to doctors for providing patient examinations and to nurses and paramedics (for more details, see section 4.2 and the section on Primary care).

Treatment

In March, Sciensano published a document called “Interim clinical guidance for adults with suspected or confirmed COVID-19 in Belgium” (https://epidemio.wiv-isp.be/ID/Documents/Covid19/COVID-19_InterimGuidelines_Treatment_ENG.pdf). This document was first developed by a small task force on the basis of therapeutic protocols elaborated in the two reference institutions (UZ Antwerpen and Hôpital St Pierre Brussels) and then revised in fast track by a larger group of physicians and scientists from different specialties/disciplines including experts from Sciensano and the Federal Agency for Medicines and Health Products (FAMHP). It is a “living guideline” which will be regularly updated by the scientific committee each time new relevant scientific data emerges.

This document provides recommendations for supportive care and adjunctive antiviral/ immunomodulatory treatment for suspected/confirmed COVID-19 cases, according to disease severity. Apart from the supportive treatment for mild to moderate symptoms (no dyspnoea) in non-risk patients (paracetamol (usual dosage) and NSAIDs with caution if really required), these recommendations are for hospital use only. Complementary paediatric guidelines were added on March 31st (http://gbs-vbs.org/fileadmin/user_upload/Unions/PED/Belg_Recomm_COVID_ped_31mar_FR.pdf).

The same document also provides a summary of (in vitro/in vivo) efficacy data of selected drugs (remdesivir, chloroquine phosphate, hydrochloroquine and lopinavir/ritonavir) on COVID-19. Many other antiviral/immunological treatments have been/are being investigated, including (list not exhaustive) ribavirin, fabiravir, favipiravir, oseltamivir, darunavir/cobicistat, interferon, mycophenolate, tocilizumab, teicoplanin, convalescent plasma, etc. (see Landscape analysis of therapeutics WHO, https://www.who.int/blueprint/priority-diseases/key-action/Table_of_therapeutics_Appendix_17022020.pdf?ua=1). Any of these drug candidates should ONLY be evaluated in clinical trials and ideally in a coordinated way in Belgium.

The clinical guidance document insists that the use of investigational or off-label medications to treat patients suspected or confirmed COVID-19 should be restricted to hospital use and should not divert health professionals from the optimal supportive care that still provides the highest probability of favourable outcome.

The Belgian centre for Pharmaco-therapeutic Information (www.cbip.be) publishes updates for all physicians about what they should watch out for (possible interactions with hydroxycholoquine) and the drugs that are NOT to be prescribed (e.g. azithromycine).

Clinical trials

Some clinical trials have been organised in hospitals and research institutions. Beginning in April, the COV-AID trial (with UZ Gent as sponsor) was set up to assess the effectiveness and security of interleukin 1 and 6 inhibitors (siltuximab, tocilizumab and anakinra) for patients in respiratory distress. This trial is funded by the KCE Trials programme (for publicly funded non-commercial clinical trials).

Beginning in May, a trial investigating whether plasma from cured COVID-19 patients could be used to make the course of COVID-19 less severe was launched in 14 hospitals in collaboration with the Belgian Red Cross and Sciensano.

The Institute for Tropical Medicine in Antwerp also launched a study on hydroxychloroquine as a treatment in outpatient management (health professionals), in order to assess whether it has an effect on the duration of contagiousness of the virus.

Information on all COVID-19 clinical trials funded by the KCE trial programme (currently 4) can be found here: https://trials.kce.be/dashboard/index.html 

Hospital surge capacity

In December 2020, an evaluation of the hospitals surge capacity was published (mainly based on the first wave). The main challenges hospitals faced and the measures taken are summarized in this report: https://kce.fgov.be/en/assessing-the-management-of-hospital-surge-capacity-in-the-first-wave-of-the-covid-19-pandemic-in (see also section 2).

Additional measures were also implemented to be better prepared in case of a saturation of hospital services:
• An algorithm has been published for GPs, determining how moderate to severe cases of COVID-19 can be managed at home in the event of a saturation of hospital services: https://kce.fgov.be/en/outpatient-care-for-covid-19-patients-in-the-context-of-saturation-in-belgian-hospitals 
• Intermediate structures were created to temporarily accommodate patients with COVID-19 after their hospital stay or after an examination in a triage centre, until they can return home. This concerns COVID-19 patients whose cannot return to their usual place of residence for different reasons: they cannot isolate themselves from other family members, there is no necessary hygiene, they cohabit with people at high risk of infection, or rehabilitation care needed after their stay in the emergency service is not possible at home. The decision to refer a patient to an intermediate structure is taken either on hospital discharge, at the triage centre, or at the emergency service. An inventory of all possible locations (from hotels, holiday centres, day care centres, rehabilitation centres etc.) was made. These infrastructures had to be easily accessible, equipped with water and energy and connected to a sewerage system
• Concerning the workforce, a new law (enforced on 13 December 2020) was passed authorizing persons who were in principle not legally qualified to perform nursing acts in the context of the COVID-19 pandemic are now allowed to do so (under strict conditions) as of 6 November 2020. These acts must be carried out under the supervision of a coordinating nurse but do not necessarily require his/her physical presence.
• On 23 October 2020, it was also decided that the Belgian army would provide the following support: (i) provision of medical and paramedical personnel where needed; (ii) intervention in medical transports (i.e. provision of military ambulances, C130 planes, helicopters, etc.); (iii) increase in the treatment of major burns by military hospitals to relieve pressure on other hospitals (i.e. possibility to transfer patients with major burns in order to open up more beds for COVID patients); and (iv) the management of prisoners affected by the virus, where the capacity for isolation within prisons has been exceeded.
• 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 hospitalization (see section 3.1).


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)
https://www.inami.fgov.be/nl/covid19/Paginas/vergoedingen-triagecentra.aspx (Dutch) / https://www.inami.fgov.be/fr/covid19/Pages/retribution-soutenir-postes-triage.aspx (French);
• 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).