Contextualizing outbreaks of COVID-19 in Belgium: A news media analysis

Introduction

When the spread of the new coronavirus becomes a global pandemic in the spring of 2020, Belgium is one of the most affected countries in the world. The COVID-19 virus spreads throughout the country since early March, but some areas are worse off than others. Official investigations were initiated by the health authorities, but to date no results have been divulged. The question remains: what cause the local outbreak of COVID-19 in Belgium. This investigation will review all hypothesis published in Belgian news articles between the outbreak and the end of the confinement period in order to identify and describe potential routes of transmission for the major outbreaks of COVID-19 in Belgium.

Figure 1: Timeline of COVID-19- related events and regulations

• 31 December 2019: Chinese health authorities report a cluster of patients with an unknown pulmonary disease in Wuhan City, China. A large majority of cases visited the Huanan Foodmarket, which was closed on 1 January 2020.
• 5 January 2020: First mention of the new mysterious lung disease in Belgian online media outlets; HLN [1] and RTL [2].
• 7 January 2020: Identification of the cause: the new coronavirus SARS-CoV-2, also known as COVID-19.
• 3 February 2020: The first Belgian COVID-19 patient. Phillipe Soubry has a confirmed diagnosis of COVID-19, upon his return from Wuhan, China.
• 29 February 2020: The second Belgian COVID-19 patient was confirmed upon return from Crépy-en-Valois, Oise Department in France.
• 11 March 2020: First Belgian deaths due to COVID-19: 1 death in Etterbeek and 2 deaths in Sint-Genesius-Rode.
• 13 March 2020: National containment measures are implemented: closure of schools and the catering industry; cancellation of all public events; telework recommended.
• 17 March 2020: Stricter social distancing; ban on non-essential travel and activities.
• 20 March 2020: Border closes for all non-essential travel.
• 4 May 2020: First step in gradual deconfinement strategy.

Method

Preliminary study period

We will review all relevant news articles published since 4 February 2020, which is the date of the first confirmed COVID-19 case in Belgium.[3] The end date of our study period is 4 May 2020, which marks the end of the confinement period in Belgium.

Analysis method

We identified four early clusters of COVID-19 infections using (a) cartography of the regional Spread of COVID-19 between 3 April and 17 May 2020 by Deboosere, Surkyn and Costa using data from Sciensano[4] and (b) the original data from Sciensano per municipality for which we performed a exploratory analysis of municipalities with 5+ cases in the period 1 March -2 April 2020.

The identified early outbreak areas are:

• Sint-Truiden and Alken: including municipalities Gingelom, Wellen, Nieuwerkerken, Kortenaken, Zoutleeuw, Geetbets, Halen and Borgloon.
• Mons-Borinage: including Soignies, Le Roeulx, La Louvière, Binche, Quévy, Frameries, Colfontaine, Dour, Hensies, Morianwelz, Comines-Warneton, Honnelles, Quaregnon and Boussu.
• Bouillon: including Neufchateau, Bertrix and Libramont-Chevigny.
• Vielsalm: including Gouvy, Lierneux, Manhay and Erezée.

Using this information, we performed a news media analysis of news articles in Belgian journals, magazines and news sites using the GoPress academic search engine. A list of all included news sources is provided in the appendix. We used the Media Analysis Grid technique to break down the data, defamiliarize items and explore emerging patterns.[5] It is a useful analytical strategy because it produces a timeline for publications and offers room for opposing hypotheses. All selected articles are available in the excel-document (Media Grid) as well as in pdf-version (Articles folder). Keywords for our GoPress Academia search included COVID*, Corona* and the names of the identified clusters and related municipalities. We considered articles in Dutch and French in our analysis. The selected articles were entered into the media grid and provided with key themes. We checked for potential discrepancies in the coding and construction of the analytic interpretations.

Results

Sint-Truiden and Alken area

29 Articles were selected for further analysis, offering one or multiple explanations for the outbreak in the Sint-Truiden/Alken area. The mayor of Sint-Truiden states in a number of news articles that there is no evidence of hotspots within the Sint-Truiden/Alken area. This indicates that multiple routes of transmission were relevant to the outbreak. In our analysis, we find four major explanations for the outbreak: the carnival celebrations, snow tourism in Italy, the social fabric of the community and factors related to the early onset of the epidemic.

The carnival celebrations (“75ste Internationale Verloure Moondagstoet”) in Sint-Truiden on the 24th of February is the most frequent hypothesis for the outbreak.[6] Whereas most other carnival parades were cancelled due to bad weather, the parade in Sint-Truiden attracted a considerable number of visitors.[7] However, this hypothesis is also questioned. The much larger carnival celebrations in Aalst also proceeded as planned, but no outbreak was observed there. Nonetheless, the presence of a super-spreader at such an event may still explain the outbreak, according to Sciensano experts.[8] Super-spreaders are individuals who unknowingly infect more people than the average transmission rate (e.g. 20 people vs. 3 people). The president of the carnival society in Sint-Truiden does not consider the carnival as the main route for transmission of COVID-19 in the area. He stated on the 26th of March that all 300 members of the carnival groups remained healthy, except one person.[9] That person was a deejay at a carnival party with guests who had just been on a skiing holiday.

Snow tourism is a second much-cited explanation for the outbreak.[10] The Sint-Truiden/ Alken area has a relatively large population of people of Italian descent, who favour North Italy for their (skiing) holidays. In addition, group travels seem to be particularly popular in the area.[11] It is possible that the transmission of COVID-19 was accelerated during the long bus rides home to Sint-Truiden/Alken.

Another frequent explanation is the social behaviour in the area.[12] “The Limbourg feeling” or the togetherness among residents of the province is thought to produce a close social fabric. Although -to our knowledge- research has not established heightened social interactions in Limburg, the media grid analysis reveals that regular family visits and participation in social clubs are often-cited explanations for the transmission of COVID-19. On this subject, the closeness of the Turkish community in the area was also referred to.[13] Two news reports mentioned difficulties in the Turkish community with regard to cancelling family visits and following social distancing measures. However, the reports were also contradicted.[14] In addition, there was no significant excess in COVID-19 among patients of Turkish origin, according to the governor of Limburg.[15]

One of the most important explanations, in our view, is the early onset of the epidemic in the area. Having the bad luck of being the first outbreak seems to have triggered a number of other influential factors, that may have further accelerated the spread. Already on 2 March, a man with severe respiratory problems is admitted to the hospital in Sint-Truiden. At the time, diagnostic procedures targeted individuals who travelled to China or North Italy recently.[16] As a result, this man is not tested but is admitted for a couple of days because of the severity of his condition. Three days after discharge from the Sint-Truiden hospital, the man is admitted to another hospital’s emergency room and tests positive for COVID-19 there. Afterwards, two persons who had direct contact with him tested positive, but it is possible that more people were infected. As a precaution, 24 members of the Sint-Truiden hospital staff are placed in quarantine for a couple of days (sic). Local mayors take the necessary precautionary policy measures cancelling public events.[17] However, these measures are implemented after a short latency period (after the weekend) or with certain restrictions. On 7 March, a sold-out boxing gala takes place in the local gym hall.[18] That weekend, two events in Alken also went ahead as planned.[19] One party of the local youth association and one cheese and wine tasting. It is possible that people returning from ski holidays attended these events. Doctors from Alken reported afterwards that a number of new corona patients attended these events. On 12 March, the soccer match of the Sint-Truiden team takes place but with restrictions: visitors may watch the match from the stands and the business seats, but no beer, no lingering and no diners.[20]

As the outbreak progressed, many local doctors were infected with the coronavirus, potentially transmitting the virus to non-infected patients.[21] This increase in COVID-19 among primary caregivers can be explained by the large number of infected patients that turn to local doctors for help, but also by the interactions in triage centres and elderly homes. Furthermore, news articles point towards a shortage of protective materials (e.g. mouth masks, aprons) for the local doctors.[22] It is possible that the medical supply distribution strategy was taken by surprise by the pressing need for these materials among primary caregivers in the Sint-Truiden/Alken area.

Mons-Borinage area

16 articles were retrieved with more context on the outbreak in the Mons-Borinage area. In addition to the lower number of articles on this subject, less detailed information was offered per article. Still, we find some striking similarities with Sint-Truiden and Alken.

Mons and the Borinage are well-known for carnival festivities. Only 2 articles mentioned carnival specifically, but considering the popularity in the area we believe this is a highly relevant issue.[23] Although specific information on the carnivals was not included in the news articles, we performed some additional investigations on the timing of these carnival festivities. Three carnivals took place in the period before the outbreak: the famous carnival of Binche (23/02/20-25/02/20), Frameries (29/02/20) and Morianwelz (01/03/20-03/03/20).[24]

Like in Sint-Truiden and Alken, there is a considerable Italian community in this area. Family visits and snow tourism in Italy are posited as possible explanations.[25] Not only the Italian community is mentioned in the news articles, but there are also references to the travel behaviour of other migrant communities (e.g. Spanish and French) in the Mons area.[26]

In addition, COVID-19 may have spread in the Mons-Borinage area because of caregiver transmission.[27] Contrary to reports from Sint-Truiden and Alken, the news articles do not mention local doctors. The emphasis lies on the high incidence of COVID-19 among health professionals in the local hospitals. Explanations include a shortage of protective materials and increased care for (and thus contact with) the large number of severely ill COVID-patients. Furthermore, the articles refer to insufficient hospital policies, including pressure to work when sick. Unless infected medical persopersonnelnal had a fever, they were kept on the job even with light COVID-symptoms. Protective materials were mandatory in these cases, but it is possible this rule could not be followed correctly as there was a shortage of these materials. The news articles also mention a concern for hospital staff and health professionals outside the COVID-wards. Chirurgical masks seemed to be reserved for those who needed to enter rooms with COVID-patients.

Lastly, the proximity of the French border is mentioned in one article as a possible explanation.[28] Despite the low news coverage of this aspect, the hypothesis of transmission originating from France is highly plausible. There was an outbreak of COVID-19 in the nearby French department of Oise in late February- early March.[29] The transmission of the virus could have occurred through French-Belgian family visits, popular events such as the carnival of Binche or cross-border consumption behaviour (tobacco is cheaper in Belgium) until the border was closed on 20 March.

Vielsalm

Only seven news articles were retrieved to contextualize the spread of COVID-19 in the Vielsalm area. Almost all articles explain the increased incidence of the presence of a retirement home (La Bouvière).[30] In addition, there are two centres for disabled persons, which are classified as a risk group for the coronavirus. Three articles mention that retirement homes were given priority in the test capacity.[31] A large number of tests in the high-risk elderly population in the retirement home could have caused disproportionally high incidence rates for the relatively small community of Vielsalm.  Despite the increased testing, one article mentions that not all corona-deaths were confirmed. Some deaths in the retirement home were classified as COVID-19 deaths, even though the real cause was not conclusively determined.[32]

Bouillon area

In the 10 retrieved articles on the outbreak of COVID-19 in the Bouillon area, the major explanations are the presence of three retirement homes [33] in the area and the priority testing of residents and staff[34]. Two explanations are worth mentioning, although they appeared only scarcily. On March 4th, there was an awards ceremony in Rochehaut, a sub-municipality of Bouillon.[35] One of the attendees was infected with COVID-19 after spending the holidays in Italy. The number of participants and the share of local residents remains unclear. Another article mentions a ball, an inauguration and a theatre show in the nearby town of Bertrix, in addition to a local service club’s charity diner in Fauvillers as potential transmission sources.[36] Second, many owners of a second home travelled to the Bouillon area during the first weeks of the confinement.[37] Perhaps, they unknowingly spread the virus when making essential errands (e.g. grocery store, pharmacy).

Conclusions

Time and timing seem to be key to understanding the major outbreaks of COVID-19 in Belgium. Although the virus was probably already in the country since January, news articles pinpoint the first Belgian cases not related to travelling abroad less than two weeks after the Carnival holidays. The spread of COVID-19 in Sint-Truiden and Mons was probably facilitated by a chain events with carnival festivities, snow tourism, family visits in Italy and normal social gatherings, as these two areas are known for their carnival traditions, large Italian communities and strong social ties. For Bouillon and Vielsalm, we find a relatively large number of retirement and care homes in the area. Priority testing of residents and staff may explain the increased incidence and mortality of COVID-19 here.

Relevant to all areas under investigation, we consider the importance of the timing and scope of implemented regulations. Early February-early March, regulations aimed at preventing COVID-19 from entering the country. Due to a small stock of testing materials, diagnostic procedures targeted persons with symptoms who recently travelled from Italy or China. The example of Sint-Truiden shows secondary cases could have been overlooked as a result. Policy measures related to cancelling public events were swiftly taken as a result of local outbreaks. However, local policymakers should aim to minimize the lag period between decision and implementation, as well as avoid large crowds at all costs. Our analyses also indicate that the shortages in protective materials and the timing of distribution of these materials potentially contributed to the spread among medical personnel and further transmission to patients and household members. All four investigated cases are relatively close to the border. Although a correlation seems only plausible for Mons and the surrounding area, the impact of the timing of closing the border may need further investigation.

Appendix: Overview of sources in Gopress Academic Database (161.29 KB) "pdf"