At this point in the coronavirus pandemic, how or when our lives might return normal is unclear. Vaccines are currently the only way to finally rid ourselves of this pandemic, but how do we ensure that those who are vaccinated can start going about their lives normally, while still maintaining restrictions for those who are at risk?

One way proposed way to do this is the identification and documentation of immunity through the so-called immunity passports. They are a potential tool to record and share immune status of an individual presumed to be resistant to further infection. But there are many practical and ethical hurdles.

The idea was first raised in the spring of 2020 when the pandemic first hit hard and everyone was thinking of ways to alleviate the damage. But after a period of intense debate, the idea of dividing the population into two groups with different privileges was deemed too contentious to be implemented. After all, vaccines were still a ways away then, and creating such a blatant path for discrimination seemed like it could lead down a dark road.

But now, with vaccines rolling out in many countries, immunity passports seem to be back on the table.

There’s actually nothing new about needing to prove you’ve had a vaccine. Some countries require evidence of a yellow fever shot before you can clear customs, and in some countries, children need to be vaccinated to go to school. So the principle is not new by any means — immunity passports have been a thing for a while now.

Under an immunity passport regime, those who test positive for SARS-CoV-2 antibodies would receive certificates allowing them to return to work, travel, go to restaurants and participate in a broader range of activities without the need for social distancing. They could take different forms, such as a wristband, smartphone application, or a printed certificate.

Countries like Greece and Denmark have already started active discussions over the use of these certificates in the near future, with talk of the COVID-19 vaccine becoming the ‘world’s most powerful passport’. Touristic countries in particular are looking for ways to ensure that they can receive tourists this summer without increasing their risk of a new outbreak.

Still, experts are warning about privacy risks and the potential for discrimination and abuse. Important immunological issues will also have to be considered, such as the degree of immunity induced and the duration of the immunity with the vaccine.

First steps across Europe

Starting this month, Iceland is now issuing “COVID-19 vaccination certificates” to all Icelandic citizens who receive the second jab of the vaccine against the virus. This makes it the first country in the Schengen Area to initiate the practice of issuing these documents to persons vaccinated against COVID-19.

“The aim is to facilitate the movement of people between countries so that individuals can present a vaccine certificate at the border and are then exempt from COVID-19 disease control measures in accordance with the rules of the country concerned,” the Ministry of Health notes in a press release on the move.

The President of the European Union Commission Ursula von der Leyen said she supports the idea of a common vaccination certificate, which can be established by the EU, and issued by the Member States to every person who gets vaccinated against COVID-19. Speaking with Portuguese media, she recently backed the idea.

The Greek Prime Minister Mitsotakis sent a letter to Von der Leyen, calling on the European Commission to introduce a Coronavirus vaccination certificate in order to facilitate travel between the bloc. He said only those who receive their vaccines should be permitted to travel from one EU country to another.

As in Iceland, others are also moving forward. Denmark’s Ministry of Health and the Elderly has said to be working on a “vaccine passport”, which will soon be available for all Danish citizens who get vaccinated. The document will serve them as a “vaccination passport” to travel to the countries where vaccination becomes mandatory for entry.

Israel has said it plans to issue a “green passport” to those who have been vaccinated, which will grant them easy access to restaurants and cultural events, and exempt them from quarantine rules or getting a virus test before travel. Spain is compiling a database of vaccine refusers, which it will share with the European Union.

A global digital certificate

Some of the major tech companies in the US and Europe and global health organizations have already joined forces to create a COVID-19 vaccination passport. This digital pass, called “CommonPass,” is already being used by several airlines as proof of negative coronavirus results before travel.

There are a lot of big players involved, including IBM, the Commons Project, and the Covid Credentials Initiative. They’re coming at the problem from different angles but are ultimately chasing the same goal: let people share required information about their health while protecting other private information

“Initially for international travel where people are getting tested in one country and upload those test results to Common Pass. Then they use them to demonstrate that they satisfy the requirement for the country they are flying to,” Paul Meyer, CEO of The Commons Project foundation, said in a statement.

CommonPass allows individuals access to their lab results and vaccination records, and consent to have that information used to validate their COVID status without revealing any other underlying personal health information. Lab results and vaccination records can be accessed through existing health data systems and national or local registries.

The app assesses whether the individual’s lab test results or vaccination records come from a trusted source, and satisfy the health screening requirements of the country they want to enter. It delivers a simple yes/no answer as to whether the individual meets the current entry criteria, but the underlying health information stays in the individual’s control.

This would help address the already-booming black market in fake COVID-19 test results, which is diminishing trust in printed records and driving demand for cheat-proof digital documents. In France, at Paris’ Charles de Gaulle Airport last year, a group of seven people was arrested for selling falsified digital certificates at around $200.

Criticism on immunity passports

However, many in the travel and tourism sector (in particular in Europe) are also opposed to implementing immunity passports, insisting it will delay the reopening of the world for travel. They argue it will take a significant amount of time to vaccinate the majority global population, in particular those in less advanced countries, or in different age groups, which would discriminate against the ones not vaccinated yet (who would need to embark on the same test/quarantine system currently in place in most parts of the world). Gloria Guevara, the president of the World Travel & Tourism Council (WTTC), a forum for the travel and tourism industry, said only a very small share of the world population have so far taken the vaccine; thus, she believes, those who have not should be permitted to travel with negative results of COVID-19 tests.

Screening people by vaccination status could also prove hard when no country has made vaccination mandatory so far, and there are many cases in which people who might otherwise be eligible (for example, those who suffer from serious allergies) are discouraged from receiving the vaccine while more data is gathered.

Some can’t or don’t want to use smartphones for their medical records. This may be especially true for those hardest hit by the pandemic, including elderly and undocumented people. Given the challenges faced even by countries with significant resources, it’s hard to imagine every immunization clinic in the world handing out QR codes with their vaccines.

Experts think enforcing two-tier restrictions on who can and cannot socialize or go to work also raises legal and practical concerns, and that it could have the adverse effect of incentivizing people to seek out the infection to avoid being excluded. And as such existing inequalities could worsen. Not least the economic divide, potentially exaggerated by some being excluded from work when others aren’t.

“By replicating existing inequities, use of immunity passports would exacerbate the harm inflicted by COVID-19 on already vulnerable populations,” Alexandra Phelan, a member of the Center for Global Health Science and Security at Georgetown University, wrote in The Lancet. Because of this, she says, they would be ripe for corruption.

The benefits of immunity licenses could encourage forgery, illegal markets, or fraud by unethical physicians or testing facilities. This underscores the need for careful implementation through strategies like anti-counterfeiting designs, cryptographic or biometric features, and reliable chains of verification for tests, researchers wrote in a paper last year.

There’s also the problem of discrimination in job interviews or those who might not have the possibility to take a vaccine, widening already existing social gaps.

Liberty, an advocacy group focused on human rights and based in the UK, responded to the idea of immunity passports by warning they could risk further marginalizing those already most at risk. Sam Grant, Head of Policy and Campaigns at Liberty, said in a statement that getting out of the pandemic shouldn’t be done at the expense of marginalized groups.

“Even the introduction of a voluntary immunity passport to prove if you’ve had a vaccine could result in many being blocked from essential public services, work or housing – with the most marginalized among us hardest hit,” Grant said. “This has wider implications too because any form of immunity passport could pave the way for a full ID system”.

There’s also the practical question of how long these passport would be valid (which is not clear, as we don’t know how long immunity lasts). Then also, what do you do with people who had the disease and also have some level of immunity? There’s no clear answer as to how these people (who are presumably also immune) could be integrated to an immunity passport scheme.

Favorable voices

Andrew Bailey, professor of Philosophy and Associate Dean of Research at the University of Guelph, wrote a commentary piece on The Conversation last year supporting the idea of using immunity passports. Some of the reasons against them when the pandemic started are no longer valid, and some were never good reasons, he argued.

Bailey recalled that one of the concerns behind immunity passports when the pandemic started was inaccurate testing. Even the World Health Organization recommended against implementing the passports for this reason. But now antibody tests have become much more accurate, he argued, and immunity levels are slowly going up as vaccination is starting.

Another issue raised by Bailey is the concern that the passports would divide a population into two classes, one more privileged than the other. Nevertheless, he argued that this type of discrimination would make a big difference to public safety and would only be temporary, lasting only until there’s a larger immunity. Continuing to impose restrictions on people who are immune would also be unethical, he said.

“Immunity certification will carry benefits, both to the passport-holder and to those who depend on their services, but it will also be important to be clear about what demands are placed on passport-holders. Should employers be able to require them to return to the office, for example? Could certain essential workers, such as nurses or teachers, be mandated to be vaccinated?” he wrote.

Still, he argued governments and organizations should avoid worsening inequalities through immunity passports. For example, low-income people will need no-cost access to vaccinations, and this should include reducing or offsetting travel costs if they have to get to an inconvenient vaccination location and unpaid time off work. Also, those with precarious jobs shouldn’t be pressured to vaccinate and go back to work.

Will the passports become a reality?

It seems like a very plausible possibility, especially considering the steps already taken across the European Union and by tech companies and health organizations to create a single digital platform.

Still, if they are eventually implemented, several measures will have to be taken for them to be secure and accessible by everyone, avoiding widening current inequalities. Ultimately, we need a way out of this pandemic and implementing immunity passports is, while far from perfect, a useful tool in helping us overcome this difficult period.