COVID-19 immunity passports and vaccination certificates; scientific, equitable and legal challenges
This was a comment by Alexandra Phelan published May 4, 2020 in the Lancet.
There is clearly urgency for relaxing social distancing and isolation measures which have been imposed to control the spread of the coronavirus.
The potential vaccine against COVID-19 is many months away.
There is a caution here how population level, serology studies and individual tests are used.
It has not yet been established whether the presence of detectable antibodies to the SARS-CoV-2 confers immunity to further infection in humans. It is not known what level of antibody is needed for protection nor how long any such immunity lasts.
It will be important to have sufficiently representative serological studies to understand the proportion of the population that has been infected.
This data can inform decisions to ease physical distancing restrictions at the community level, provided that they are used in combination with other public health approaches. This data will of course depend on the accuracy and reliability of tests, particularly the number of false positives and false negatives, and these tests will require further validation.
As discussed in other reviews, the near patient tests on a cassette are felt to be very inaccurate with poor specificity and sensitivity.
However, two reliable tests made by Abbott Laboratories and Roche have been approved for use in the United Kingdom and they should come online within the next few days.
Clearly, any false positive result may lead to an individual changing their behaviour unwittingly. This may lead them to be susceptible to infection, potentially becoming infected and unknowingly transmitting the virus to others.
At the present time it is therefore felt that immunity passports are impractical given the current state of knowledge and technical limitations.
There are also considerable equitable and legal concerns. They would impose a restriction on who can and cannot participate in social, civic and economic activities. They may result in the perverse incentive for individuals to seek out infection, especially those who are unable to afford a period without work. These would compound existing gender, race, ethnicity and nationality inequalities. This behaviour would clearly pose a health risk to the individual and also to the people that they come into contact with.
In countries where there is no universal access to healthcare, those most incentivised to seek out infection might also be those unable or understandably hesitant to seek medical care due to the cost and possible discriminatory access. However, these incentives need to be understood in the context of the pressure governments are facing from businesses who seek to adopt policies that return employees to the workforce.
Companies would be the beneficiaries of those with apparent immunity within their workforce.
These immunity passports will help to alleviate the duty on governments to adopt policies that protect economic, housing and health rights across society by apparently providing a quick fix.
As a privilege, these passports would be ripe for both corruption and implicit bias. They would rely on antibody testing and existing socioeconomic, racial and ethnic inequalities might be reflected in their administration. For example, who is at the front of the queue for certification and the very burden of the application process.
It is possible that by replicating existing inequalities, the use of immunity passports might exacerbate the harm already inflicted by COVID-19 on a vulnerable population.
This potential discriminatory consequence of immunity passports might not be addressed by our existing legal system. This is a novel concept that immunity from disease or lack thereof is a health status. Anti-discrimination laws would need to cover health status generally as a protected class and would need to include those for whom infection would pose a high risk such as the vulnerable, older individuals, patients who are pregnant, have disabilities or those with comorbidities.
Under human rights law countries have obligations to prevent discrimination while progressively achieving the process of social and economic right. These immunity passports might risk enshrining such discrimination in law and undermining the right to health of individuals and the population through the perverse incentives that they create.
When international travel restarts, countries might require travellers to provide evidence of immunity as a condition of entry. Under the International Health Regulations 2005 countries are able to implement health measures that achieve the same or a greater level of health protection than the WHO recommendations. However, these measures need to have a rational basis, be non-discriminatory, consider the human rights of travellers and must not be more restrictive on international traffic than alternatives which are reasonably available.
Taking into account the current uncertainties about the accuracy and interpretation of individual serology testing, immunity passports would be unlikely to satisfy this health basis evidentiary burden and would be inconsistent with the WHO recommendations against interference with international travel that were issued when the WHO Director General declared COVID-19 a Public Health Emergency of International Concern. The WHO would need to consider the discriminatory impact of immunity passports in the context of their own human rights protections.
Some have compared immunity passports to those international certificates of vaccination such as the yellow fever certificate. However, there are significant differences between the two documents. Vaccination certificates incentivise individuals to obtain vaccination against the virus, which is clearly of social good. By contrast, immunity passports incentivise infection.
Under the IHR, countries can require travellers to provide vaccination certificates, but this is limited to specific diseases which currently only includes yellow fever. Once a vaccine is developed, COVID-19 vaccination certificates could be included in a revised WHO recommendation and this could be considered by member states.
Until a COVID-19 vaccine is available, the real way out of this crisis is built on the established public health practices of testing, contact tracing, quarantine of contacts and isolation of cases. Phelan argues that the success of these practices is largely dependent on public trust, solidarity and addressing rather than entrenching the inequities and injustices that may have contributed to this outbreak becoming a pandemic.
The London General Practice understands and acknowledges that at this time there is no clear understanding as to the level of antibody and whether this provides immunity in an infected individual.
However, The London General Practice is delighted that the UK have approved two validated antibody tests, the Roche and Abbott tests, which can only help to understand the level of antibody formation in infected individuals.
We are very happy to be able to offer the antibody test to our patients.
The London General Practice
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