Preventive care

The term preventive care denotes a type of care aimed at avoiding the occurrence of a disease (primary prevention, e.g. using vaccination), or at identifying a disease as early as possible in order to initiate treatment without delay and thereby reduce its mortality or severity (secondary prevention, e.g. cancer screening programmes).

Preventive care is to be distinguished from curative care, which is only initiated when a disease has manifested itself with the onset of symptoms.

In the broadest sense, prevention is a responsibility of both the individual (keeping a healthy diet, exercising, giving up smoking, etc.) and public authorities (organising screening campaigns, vaccinations, health education, etc.). In this report, we will only analyse prevention measures organised by the health system.

In Belgium, the area of preventive care falls into the scope of the federated entities, with some procedures remaining under the responsibility of the Federal State. For example, the Regions are in charge of organising cancer screening programmes, but the INAMI/RIZIV will reimburse the  examinations (cervical smear test, mammograms).

A country’s prevention policy requires the establishment of long-term strategies, since benefits will only become measurable after many years.

The Preventive Care section in this report contains 3 categories of indicators which have been selected in order to assess how well the Belgian health system achieves its prevention goals:

Summary of the indicators on preventive medicine
(ID) indicatorScoreBELYearTargetFlaWalBruSource

EU-15 mean

Vaccination coverage
P-1 Polio (%,4th dose) orange stable 93.0 2016 95 93.6 92.9 91.1 (e) Sciensano NR
P-12 Diphtheria, tetanus and pertussis
vaccination in children (%, 4th dose)
orange stable 92.7 2016 90-95 93.0 92.9 91.1 (e) Sciensano NR
P-2 Measles vaccination in children (%, 1st dose) green improving 95.7 2016 95 96.2 95.6 94.1 (e) Sciensano -
Measles vaccination in
adolescents (%,2d dose)
red empty 85.1 2016 95 93.4 75.0 75.0 (e) Sciensano -
P-3 Pneumococcus vaccination
in children (%, 3th dose)
green empty 93.6 2016 - 94.9 92.9 90.1 (e) Sciensano NR
P-4 Influenza vaccination (% pop aged 65+) (a) red deteriorating 54.7 2016 75 59.5 49.8 48.5 IMA-AIM 49.1 (1)
Incidence infectious diseases preventable by vaccination
P-5 Incidence of measles (new cases/million pop) (b) orange deteriorating 31.6 2017 (epidemic year) inf. 1 6.3 80.8 20.1 Sciensano 18.1
Cancer screening (c)
P-6 Breast cancer screening
(% women aged 50-69)
red stable 61.8 2016 75 67.4 53.9 52.9 IMA-AIM 69.1 (1)
P-7 Breast cancer screening - organised
programme (% women aged 50-69)
red improving 33.2 2016 75 50.7 6.8 10.9 IMA-AIM -
Over-screening cancer
QA-7 Breast cancer screening
outside age target group (% women aged 41-49)
red stable 35.4 2016 - 26.3 49.0 46.7 IMA-AIM -
Oral health – contacts with dentist
P-11 Regular contacts with dentist (d) (% pop aged 3+) red improving 54.1 2016 - 58.4 48.1 47.7 IMA-AIM -

(a) Exclusing population residing in homes for the elderly and nursing homes, (b) Incidence of measles has a large variability depending of the occurrence of epidemics. 2017 was an epidemic year in Wallonia and Brussels, (c) Within the last two years for breast cancer screening, (d) Regular contacts with dentist is defined as patients having had at least at 2 contacts on 2 different years over a three year period, (e) data from 2012, (1) OECD Health Statistics 2018, NR: Not Relevant.

Primary Prevention - Vaccination

Vaccination is one of the most powerful and most cost-effective forms of preventive care. Not only does it protect immunised people individually, but it also ensures a certain degree of collective protection for the population.

The vaccination indicators selected in this report are subdivided into:

  • Child and adolescent vaccination (polio, diphtheria/tetanus/pertussis, pneumococcus, measles) (P-1 to P-3)
  • vaccination of elderly people (influenza) (P-4)
  • Incidence of diseases that are preventable by vaccination (example of measles) (P-5)

Child and adolescent vaccination (P1 to P3)  

Four indicators have been selected in order to assess the vaccination status of the Belgian population of children and adolescents:

  • Percentage of children aged 18 to 24 months having received full vaccination against polio (4 doses) (P-1-1)
  • Percentage of children aged 18 to 24 months having received full vaccination against diphtheria/tetanus/pertussis (4 doses) (P-1-2)
  • P2 : Percentage of children and adolescents having received full vaccination against measles (2 doses) (P-2)
  • P3 : Percentage of children aged 18 to 24 months having received full vaccination against pneumococcus (3 doses) (P-3)

Vaccines against poliomyelitis, diphtheria, tetanus and pertussis are part of the vaccinations recommended by the European authorities. In addition, Belgium has signed the global commitment to eliminate measles, which implies an vaccination coverage of 95% for the first and second dose of measles vaccine.

Since vaccination is a regionalised responsibility, vaccination rates are measured via regional surveys on vaccination coverage organised by the Regions and Communities. These surveys are conducted every 3-4 years (every 5-6 years in Brussels). The ‘national’ rate is then calculated using a weighted average of the 3 regional rates.

RESULTS
  • vaccination against poliomyelitis (P-1-1): the critical threshold recommended by the WHO (90%) has been reached in all three regions, but not the national threshold of 95% recommended by the Belgian Superior Health Council.
  • vaccination against diphtheria-tetanus-pertussis (P-1-2): the percentage of children having received the full scheme is 93%. This rate is stable and slightly above the WHO recommended threshold (90%), but it remains slightly lower than the critical threshold for pertussis, for which there are still multiple small-scale epidemics.
  • vaccination against pneumococcus (P-3): the national coverage rate is satisfactory.
  • vaccination against measles (P-2): for the first dose, the WHO recommended coverage rate (95%) was reached in Flanders and in Wallonia in 2016 (there has been no new survey for Brussels). For the second dose, coverage is too low in all three regions, particularly in Wallonia and in Brussels. It is possible, however, that differences in calculation methods may lead to under-estimated figures for Wallonia and Brussels.
  • For a long time, the vaccination coverage was lower in Wallonia and in Brussels than in Flanders, but the latest figures demonstrate that this gap is narrowing in Wallonia (no survey has been conducted on newborns in Brussels in 2015-2016). The only exception is the second dose of measles vaccination (MMR2), which is still much lower in Wallonia.
Table 1 : National vaccination coverage rates (weighted average) by disease, Belgium 2009-2016
Source=official national estimates (Institute of Public Health), computed from the weighted average of the regional survey results

Year

2009

2012

2016

Surveys used for calculation
of weighted average

VL2008
 RW2009
 Bxl2006

VL2012
 RW2012
 Bxl2012

VL2016 
 RW2015
 Bxl2012
Bxl-Wall 2015-16
for MMR2 

Polio 4

93.0%

92.0%

93.0%

DTP 4

93.0%

91.9%

92.7%

Pneumococcus (PCV) 3

 

93.3%

93.6%

MMR 1

94.5%

95.6%

95.7%

MMR 2 

83.1%

85.0%

85.1%

Green: reaching the critical threshold and national target; Yellow: reaching critical threshold but not national target, or very close to critical threshold; Red: far from the target/threshold 

Table 2 : Regional vaccination coverage rates against selected diseases by region; 2012 and 2015-2016 regional vaccination surveys.
Source=official national estimates (Institute of Public Health), computed from the weighted average of the regional survey results

Vaccine and dose

Flanders 2012

Brussels 2012

Wallonia 2012

Flanders 2016

Brussels 2015

 Wallonia 2015

polio 4

93.2%

91.1%

90.4%

93.6%

-

92.9%

DTP 4

93.0%

91.1%

90.4%

93.0%

-

92.9%

Pneumococcus (PCV) 3

96.5%

90.1%

89.2%

94.9%

-

92.9%

MMR 1 / MCV 1

96.6%

94.1%

94.4%

96.2%

-

95.6%

MMR 2

92.5%

75.5%
(2008-
2009)

75.5%
(2008-
2009)

93.4%

75.0%   
(2015-
2016)

75.0%    
(2015-
2016)

Green: reaching the critical threshold and national target; Yellow: reaching critical threshold but not national target, or very close to critical threshold; Red: far from the target/threshold

Link to technical datasheet and detailed results

Vaccination of elderly people against influenza (P-4)

Vaccination against seasonal influenza is considered as the most efficient preventive measure to reduce the frequency and severity of influenza virus infections. In Belgium, this vaccination is currently recommended (among others) for all elderly people aged 65 years and over, and for all people living in nursing facilities.

The WHO recommends a target vaccination rate of 75% for elderly people.

The proportion of elderly people (aged 65+ years) who were vaccinated against influenza during the past year is an important indicator for assessing preventive care accessibility. This indicator is calculated based on INAMI/RIZIV data regarding reimbursement of the vaccine.

RESULTS
  • In 2016, 54.7% of elderly people aged 65 years and over (not living in an MRPA/MRS facility) were vaccinated against influenza, which is much lower than the WHO target of 75%.
  • This figure has been consistently decreasing since 2009 (63.6%), particularly in Wallonia and in Brussels, but this decline can be observed in most EU-15 countries. Nevertheless, 2013 figures show that Belgium is above the EU-15 average.
  • Major differences can be observed depending on individual age: the coverage rate is only 40.1% for people aged 64 to 69 years, but it reaches 68.8% for people aged 80 years and over. 
  • The vaccination rates are higher in Flanders (60.6%) than in Wallonia (50.1%) and Brussels (47.8%).
  • For elderly people living in institutions, the conditions for purchasing the vaccine are different among the Communities, which does not allow for direct comparisons. However, a sensitivity analysis conducted on figures from Wallonia and Brussels showed much higher coverage (82%) in this population (which represents approximately 8.5% of the elderly population).
  • There is no accessibility problem with the influenza vaccine for people entitled to preferential reimbursement (BIMs/increased assistance beneficiaries).
Figure 1 - Coverage of vaccination against influenza in people aged 65 years and over, by region (2006-2016)
Data source: IMA - AIM
Figure 2 - Coverage of vaccination against influenza in people aged 65 years and over, by district (2016)
Data source: IMA - AIM
Note: People residing in institution are excluded from the analysis (see section limitation in the technical fiche for details).

Coverage of vaccination against influenza in people aged 65 years and over, by district (2016)
Figure 3 - Coverage of vaccination against influenza for elderly: international comparison (2000-2017)
Data source: OECD health data 2018
Coverage of vaccination against influenza for elderly: international comparison (2000-2017)
Figure 4 - Coverage of vaccination against influenza for elderly: international comparison (2013)
Data source: OECD health statistics 2015
Coverage of vaccination against influenza for elderly: international comparison (2013)

Link to technical datasheet and detailed results

Incidence of measles (P-5)

Measles is a highly contagious viral disease, whose complications are frequent (30%) and can be very serious: in 4 cases out of 1,000, they can cause brain lesions leaving permanent sequelae (measles-induced encephalitis), or even death. European countries have made a commitment with the WHO with the aim of eradicating this disease; the goal is to reduce the measles incidence rate to below 1 per million population.

Measles vaccination was introduced in Belgium in 1985. Since then, the incidence of this disease has been significantly reduced, but intermittent epidemics still occur. A fairly large epidemic occurred in 2011 and another in 2017, this latter mainly in Wallonia, and to a lesser extent in Brussels. These recurrences are likely due to some groups of people who are not, or not completely, immunised, including children whose parents refuse vaccination, but also adults who have never been vaccinated. This highlights the need to improve the vaccination coverage: continued targeted efforts are necessary, not only to reach the 95% coverage recommended by the Belgian Superior Health Council, but also to detect and vaccinate non immunised adults.

RESULTS
  • In Belgium, the measles incidence rate has varied between 1 and 9 per million since the beginning of this monitoring (2003), except during the epidemic years (2011 and 2017) where it reached 55 and 31.6 cases per million, respectively (Figure 5).
  • The highest average incidence is in Brussels, followed by Wallonia, then Flanders. However, in 2017, the epidemic mainly affected Wallonia, which increased the incidence rate to 80.8 per million. In Brussels the rate was 20.1, and in Flanders 6.3.
  • Eradication of measles remains a challenge, both at the EU level and for Belgium (Figure 6). In order to meet this goal, a sufficient level of coverage (95%) must be reached for the 1st and 2nd vaccination dose, which is not yet the case, particularly for the second dose.
Figure 5 - Measles notification rate (per million) in Belgium since the 2011 epidemic, by region (2011-2017)
Data source: Annual reports on vaccine-preventable infectious diseases in children. Sciensano, Service “Epidemiology of Infectious Diseases”
Figure 6 - Measles notification rate (cases per million), EU-15 comparison (2008-2017)
Data source: ECDC

Link to technical datasheet and detailed results

Secondary Prevention – Cancer Screening

A cancer screening test is an examination aimed at detecting cancer (at an early stage) in people who have no symptoms and who seem to be in good health. This is very different from diagnosis, which is an examination (sometimes the same) performed in a person who shows symptoms (a ‘lump’ in the breast, blood in the faeces) and in whom cancer is suspected.  The purpose of screening is to reduce the overall mortality of the type of cancer concerned in the entire population, while early diagnosis is aimed at treating, and if possible extending the life of, the individual who is being tested.

Because screening concerns people who are (in principle) in good health, it is very important that the examination does not carry an excessively high risk, which would counter-balance the expected benefit at the overall population level. Therefore, a mammography exam or a colonoscopy – tests that involve a certain degree of risk, even minimal – cannot be used in the general population as long as there is no evidence that these examinations can help reduce the mortality rate in this population. For this reason, mammography exams are not recommended in women before the age of 50 years, nor is colonoscopy recommended for everybody as first line screening.

In this report, we have selected 3 indicators related to breast cancer screening

Breast cancer screening (P6-P7)

Breast cancer is the most common type of female cancer, and the main cause of death by cancer in women (approximately 20% of all deaths due to cancer in women).

Since the beginning of the 2000s, there has been a national breast cancer screening programme in Belgium for women aged 50 to 69 years. In this age group, each woman is invited every 2 years, to participate in this programme in an approved radiology/senology department, free of charge. The mammograms performed in the framework of this organised programme follow a standardised procedure defined by European quality standards. The age group of 50 to 69 years was set because this is the age when early breast cancer screening is most likely to lead to a healthy outcome. This organised screening programme is under the responsibility of the Regions, but mammography exams are reimbursed by INAMI-RIZIV.

In practice, it is also possible for women to get screened outside of the organised programme, using therefore the “diagnostic” path for screening purposes. This type of "screening" (called ‘opportunistic breast cancer screening’) generally consists in a clinical examination by a specialist, a mammography exam, and often an ultrasound exam. This more expensive examination is not done on an invitation, but at the individual’s own initiative. There is no evidence to demonstrate that it is more efficient than organised screening, particularly since it is not standardised and not subject to quality controls. It is reimbursed by INAMI/RIZIV as a diagnostic test.

Two indicators help measure the level of attendance to breast cancer screening exams:

  • The proportion of women aged 50 to 69 years who have had a mammography exam in the last two years regardless, whether or not as part of the organised screening programme (P-6)
  • The proportion of women aged 50 to 69 years who have had a mammography exam in the last two years as part of the organised screening programme (P-7).

It is interesting to consider these two indicators together, as the first provides a measurement of attendance to the organised screening programme , and the second measures the total coverage of women (in the recommended age group). A 75% coverage is usually recommended for this intervention to reach an acceptable cost-effectiveness level.    

RESULTS
  • The total coverage of women (organised screening + opportunistic mammography exams) reached 61.7% in 2016. The highest rate was in Flanders (67.4%), compared to Wallonia (53.9%) and Brussels (52.9%).
  • The total coverage rate was higher for younger women within the relevant age group (50-69 years).
  • Coverage for the organised screening programme has been stagnating at country level around 33%, with major differences between regions: it has increased in Flanders (from 7.5% in 2001 to 50.7% in 2016), has reached a plateau around 10% in Brussels since 2007, and has even slightly decreased in Wallonia, where it was only 6.8% (Figures 7 and 8).
  • For both organised screening and total coverage, the most vulnerable women at the socio-economical level (BIMs/increased assistance beneficiaries) have a coverage rate that is lower than the rest of the population (24.9% versus 34.3% for the screening programme and 48.1% versus 65.1% for total coverage).
  • On an international scale, total coverage remains lower than the EU-15 average and the recommended screening rate of 75%. Only Finland, the Netherlands and the United Kingdom meet the 75% target, and Ireland is very close to target.
Figure 7 - Coverage of organised breast cancer screening in women 50-69 years old, by region
Data source: IMA-AIM
Figure 8 - Total coverage of breast cancer screening in women 50-69 years old, by region
Data source: IMA-AIM
Figure 9 - Coverage of organised breast cancer screening in women 50-69 years old, by municipality (2016)
Data source: IMA-AIM
Coverage of organised breast cancer screening  in women 50-69 years old, by municipality (2016)
Figure 10 - Total coverage of breast cancer screening in women 50-69 years old, by municipality (2016)
Data source: IMA-AIM
Total coverage of breast cancer screening  in women 50-69 years old, by municipality (2016)
Figure 11 - Coverage of breast cancer screening: international comparison (2000-2017)
Data source: OECD health data 2018
Coverage of breast cancer screening: international comparison (2000-2017)
Figure 12 - Coverage of breast cancer screening: international comparison (2015)
Data source: OECD health data 2018
Coverage of breast cancer screening: international comparison (2015)

Link to technical datasheet and detailed results

Breast cancer over-screening (QA-7)

The national breast cancer screening programme is intended for women aged 50 to 69 years, as recommended internationally (for women who do not have a known family history risk). There is currently no evidence that an extension of such a programme to younger women (41 to 49 years of age) would help reduce the number of deaths due to this type of cancer. The risks linked to an extension of the period where women are exposed to the radiation delivered during mammography exams are also unknown. Research is, however, under way to understand whether it would be appropriate to modify the age limits and modalities for breast cancer screening.

The indicator "percentage of women aged 41 to 49 years having been screened within the past 2 years" therefore provides a measurement of the extent of over-screening and inappropriate screening tests.

RESULTS
  • Despite the fact that breast cancer screening is currently only recommended from 50 years onwards, one third of women aged 41 to 49 years have screening tests.
  • This trend is more noticeable in Wallonia (49%) and in Brussels (47%), while it has begun to decrease in Flanders (26% in 2016, compared to more than 30% in 2007).
Figure 13 - Breast cancer screening coverage for women 41-49 years
Data source: IMA – AIM (EPS)
Note: contact is defined as two contacts in two different years in the last three years.

Link to technical datasheet and detailed results

Oral Health : Proportion of population which has regular contacts with a dentist (P-11)

Eating, talking, confronting other people’s looks, all this becomes more complicated when one does not have good teeth! But oral and dental health is also important for health in general, since bad teeth can promote the development of diseases (including cardiovascular diseases). Regular visits to the dentist’s help diagnose and treat dental problems before they become too serious, but also prevent them, either by making people aware of preventive behaviours (e.g. proper tooth brushing), or by performing prophylactic procedures (e.g. tartar removal, application of fluoride treatments).

In addition, it is known that socio-economically unfavoured people have less access to oral and dental healthcare and are not sufficiently informed about the importance of preventive behaviours in this area.

Measuring the proportion of the population (aged over 3 years) who have regular contacts with a dentist is therefore a good reflection of preventive care accessibility.

RESULTS
  • Just over half (54.1%) of the Belgian population has had at least two contacts with a dentist in two different years during the 2014-2016 period. This proportion has been increasing (47% in 2008). (Figure 14)
  • The highest attendance can be observed in the 5-14-year-old (66%) and 15-17-year-old (71%) age groups. The lowest attendance is observed in very young children (3 to 4 years, 14%) and in elderly people (75 years and over, 36%). 
  • The rate of regular attendance of dental offices is higher in Flanders (58%) than in Wallonia (48%) and in Brussels (48%). (Figure 15)
  • Comparing these data with those of other countries is difficult, as what is understood by ‘regular visits to the dentist’ is defined differently from one country to another.
Figure 14 - Regular contact with the dentist, by region (2008-2016)
Data source: IMA – AIM (Atlas)
Figure 15 - Regular contact with the dentist, by municipality (2016)
Data source: IMA – AIM (Atlas)
Regular contact with the dentist, by municipality (2016)

Link to technical datasheet and detailed results