Belgium shaken by prospect of coronavirus second wave

Belgium has learned an important lesson from the first wave of coronavirus — that the country is particularly vulnerable to a second.

The relief that Belgians got from their lockdown easing in June has now given way to a nervousness that the resumption of some measure of summer normality will be short-lived. After reported coronavirus infections averaged around 100 cases a day in June, they jumped in mid-July, sometimes over 500-600 a day.

That’s more than just a warning sign, according to experts. Steven Van Gucht, the virologist who chairs the government’s scientific committee on coronavirus, told journalists Monday that a “second wave” has already begun.

Emmanuel André, a microbiologist and associate professor of medicine at KU Leuven, has also sounded alarms, and began pressing for a tightening of social measures three weeks ago. “We’ve lost days, and this has made the problem much bigger, resulting in decreased individual freedom and an increased impact on the health of our people,” he said.

Belgium is far from unique in experiencing a resurgence of the virus. But what’s particularly concerning for experts and policymakers alike is that Belgium appears to be particularly vulnerable. The country is densely populated and positioned at the heart of Europe, marked by cross-border travel, meaning it can easily acquire new infections from within and beyond its borders.

“It’s important that the number of hospitalizations now stabilizes — otherwise it can go very quickly in the wrong direction” — Steven Van Gucht, chair of the Belgian government’s scientific committee on coronavirus

Policymakers aren’t sitting on their hands, though. On July 27, the government ordered tighter restrictions on social gatherings and more expansive rules on mask-wearing.

That’s in line with what André had sought. He recently quit his post as government coordinator for testing and tracing amid disagreements over pandemic strategy — while remaining part of the government’s expert advisory group — after his call for a renewed tightening of restrictions in mid-July was initially ignored.

Meanwhile, Antwerp went even further and imposed a nighttime curfew. A key aim: Reducing the size of social events like parties and weddings, which authorities believe fueled the recent surge of cases.

“It’s important that the number of hospitalizations now stabilizes — otherwise it can go very quickly in the wrong direction,” said Van Gucht, at Monday’s press conference.

Viral hot spot

With all eyes on the infection rate in the weeks ahead, some leading officials are also still feeling burned. They’re mindful of the reputational risk of Belgium returning to its contested status as a top virus hot spot in Europe.

To date, Belgium — with a population of around 11.5 million — has recorded more than 9,800 deaths attributed to COVID-19, mostly from the peak in March and April. That relatively high per capita fatality rate was a key reason cited in June by the Economist Intelligence Unit (EIU), when it parked Belgium at the bottom of 21 wealthy countries it surveyed for how well they responded to the pandemic (indeed, below the United States).

That ranking prompted a sharp rebuke from Health Minister Maggie De Block, who wrote in POLITICO that the EIU’s calculus overlooked factors such as the country’s now well-known accounting for coronavirus deaths, which covers everything from established COVID-19 cases to suspected ones where there was no test. Such an approach yields a mortality figure that — obviously — is higher than one that looks solely at deaths where COVID-19 was confirmed.

She also noted the rapid flattening of the country’s infections curve and its robust hospital capacity throughout the crisis.

The report “is a textbook example of what happens when you attempt to create a ranking using a small number of variables chosen for their availability, rather than for their relevance, with arbitrary cutoff points and time periods, and a complete lack of data curation,” she wrote.

Belgian policymakers and experts still stand by this accounting. They note that many other countries have since switched to the country’s methodology for counting COVID-19 deaths.

“You can’t choose your methodology for political reasons,” Van Gucht said. “We chose to count based on probability because at first a lot of people weren’t getting tested.

“In other countries, you saw a gross underestimation, especially in care homes,” he added. “But we decided to measure what’s going on in the field, not just in hospitals.”

André pointed out that the practice of using a more inclusive mortality measure isn’t unusual in public health. “At the start of an outbreak, when it’s a pathogen you don’t know and testing isn’t widespread, you need to assume that deaths are under-reported,” he said. “This is something you always do in disease surveillance.”

Apples to oranges

Some experts now point to recent data on excess deaths across Europe, which smooths out national differences in counting fatalities, to suggest that Belgium didn’t do as badly as initially reported.

The counting of excess deaths also takes into account deaths that were caused indirectly by the pandemic — for example, cases when other medical treatment was delayed or denied due to the stress on health systems forced by COVID-19.

More refined and recent analysis seems to bear this out. For example, the U.K.’s Office for National Statistics released a study on Europe in late July showing that England, in fact, had the highest age-adjusted mortality rate across the entire course of the pandemic, for both under and over those aged 65. Belgium, by contrast, had lower than average mortality for those under 65, and came in only fourth place in excess mortality for those over 65 (after England, Spain and Scotland).

More broadly, recent data “corresponds quite well with how we decided early on to count COVID-19 mortality,” said Van Gucht. “It also shows how much the pandemic hit us outside of hospitals — in the care homes, where people weren’t getting tested until mid-April.”

This accounting also explains the age divide in the virus’ victims, he points out.

“If your health care system becomes saturated, you see higher mortality among younger people, who can’t access hospitals for other urgent care,” he said, pointing to the “proportionally higher mortality in younger people” in the U.K.

“That didn’t happen in Belgium, where our ICU capacity never got higher than 60 percent,” he added.

One challenge that Belgium will still have to face in a second wave is how to handle its elderly in care homes. Many often enter these facilities with a directive that they not be hospitalized, notes André. Last spring, many care homes complied even as more and more residents got sick — leading to the virus’ spread.

As the official who oversaw the ramping up of testing in mid-April to cover care homes, André was acutely aware of this challenge. Only when they expanded testing in care homes were authorities able to find out how infections were spreading — as many staff and residents who were asymptomatic or mildly ill passed on the virus to others.

“We were able to find out what the drivers were,” he said. “This shows that it’s not how many tests you perform, but what you do with them.”

Keeping distance

One risk factor that explains Belgium’s vulnerability early on was its high population density compared to the rest of Europe and highly connected communities.

“Population density can explain a lot about Belgium’s recent experience — as well as its risk for a second wave” — Pierre Van Damme, an epidemiologist at the University of Antwerp

“Population density can explain a lot about Belgium’s recent experience — as well as its risk for a second wave,” said Pierre Van Damme, an epidemiologist at the University of Antwerp. “It’s also why we never could get the numbers all the way down earlier this summer when things were better. The virus was always circulating in society.”

“Population density makes Belgium extremely vulnerable,” agreed Boudewijn Catry, an epidemiologist at Sciensano, an institute that advises the government on public health.

Of countries in that ONS survey, Belgium has the highest share of its population in an urban area at 98 percent.

Why does this matter? Scientists broadly see the proliferation of larger social events, populated by younger people, as the main driver behind the recent spike. And these are more likely in urban centers.

Both Catry and Van Damme say that the risk of more infections coming from abroad, as Belgians return from holidays, is also still likely. A similar dynamic occurred in early March when vacationers returned from ski trips and carnival excursions and made the virus’ spread especially aggressive.

“At the start, we had hundreds of simultaneous introductions of the coronavirus,” said André. “In the Netherlands, it was just a couple of strains.

“Now that we know what we know about transmission through aerosols, it’s much more important to look at factors like density,” he added. “I don’t think it’s useful to compare Belgium to, say, a mountainous, less-populated country like Austria.”

Amid the caution, Van Damme sees general practitioners as a first line of defense — especially for younger people showing only mild systems.

“This is an area where Belgium is strong,” he said. “These are professionals who are very important for conducting cluster investigations, along with the more centralized source and contact tracing system. And they often have good ties to diverse communities, which is so crucial now.”

He also warns against ranking countries against each other, because “it will be important from a European perspective to address this as a European problem.”

“The virus is very intelligent,” he added. “It goes where people are vulnerable and where there’s a relaxation of measures. So we need a common policy.”

Barbara Moens contributed reporting.

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