Covid-19 vaccine passports: access, equity, and ethicsBMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n861 (Published 01 April 2021) Cite this as: BMJ 2021;373:n861
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The Covid-19 pandemic is nowhere close to over; Europe, parts of Asia, and South America are again under lockdown due to surges in cases. We are all desperate to resume “normal” lives. The medical journals and news-media is now flooded with ideas of “vaccine passports” and many cite opinion strongly in favor thereof. We would argue that these would be yet another measure that widens the gap between “haves” and “have nots” at regional, national, and global levels.
There are myriad problems and challenges with these passports. Which vaccines will make persons passport-eligible? For how long would such passports be valid? (We have no data on the duration of protection from these vaccines.) What will happen to passports when variants that reduce vaccine efficacy become dominant in a community? What about those with immunity due to natural infection - highly comparable or perhaps better than vaccine-induced immunity? (1-3) If measured antibodies are the basis for a passport, at what antibody level does a person not qualify? (4) And how can one equitably treat those with true contraindications such as anaphylaxis to similar vaccines?
An inequitable society cannot equitably provide passports. (5) The less privileged are less likely to have immediate access to vaccine, to be able to travel to get vaccinated, to be able to go to the show or the gym that the passport allows. When viewed in a societal context, a vaccine passport allows the privileged to resume their privileges.
The appeal of the concept of a vaccine passport is obvious. The realities make passports problematic. We cannot support them.
1. Hall VJ, Foulkes S, Charlett A et al. SARS-CoV-2 infection rates of antibody-positive compared with antibody-negative health-care workers in England: large, multicentre, prospective cohort study (SIREN). Lancet. 2021; (published online April 9.) https://doi.org/10.1016/S0140-6736(21)00675-9
2. Harvey RA, Rassen JA, Kabelac CA, et al. Association of SARS-CoV-2 Seropositive Antibody Test With Risk of Future Infection. JAMA Intern Med. Published online February 24, 2021. doi:10.1001/jamainternmed.2021.0366
3. Saadat S, Tehrani ZR, Logue J, et al. Binding and Neutralization Antibody Titers After a Single Vaccine Dose in Health Care Workers Previously Infected With SARS-CoV-2. JAMA. Published online March 01, 2021. doi:10.1001/jama.2021.3341
4. Krammer F . Correlates of protection from SARS-CoV-2 infection. Lancet. 2021; (published online April 9.) https://doi.org/10.1016/ S0140-6736(21)00782-0
5. Kuehn BM. High-Income Countries Have Secured the Bulk of COVID-19 Vaccines. JAMA. 2021;325(7):612. doi:10.1001/jama.2021.0189
Manish Joshi, MD,
Thaddeus Bartter, MD,
Anita Joshi, BDS, MPH
Competing interests: No competing interests
The conversation about COVID-19 vaccine passports has reached fever pitch, with many media outlets reporting that proof of vaccination may be required for entry into pubs, restaurants, entertainment venues, gyms, workplaces or to travel abroad.
This week the UK Prime Minister announced trials of a “Covid status certification" scheme to enable concerts and sporting matches to take place, as well as mass testing of all adults and children, twice a week, as a way to stamp out new outbreaks.(1)
European leaders have issued a statement calling for a Digital Green Certificate, “as a matter of urgency” to facilitate safe free movement inside the EU during the COVID-19 pandemic.(2)
In Israel, now that restrictions have eased due to its mass vaccination roll out, restaurants are re-opening and people can show their “Green Pass”, an app that lets you prove you’ve had the jab.(3)
France is trialling a vaccine passport for air travel for people travelling to the French Caribbean territories of Martinique and Guadeloupe, where they’ll be able to provide a COVID-19 vaccination certificate or negative test result.(4)
A New Zealand airline will also trial a digital vaccine passport this month on flights between Auckland and Sydney, with Australian airline Qantas, exploring comparable technology.(5)
All Nordic countries except Norway are working to launch digital vaccine passport apps to be used at ticket control terminals and passport security stations at airports.(6)
The hope is that vaccine passports will pave the way for economic recovery and restore people’s freedoms, but is it evidence-based and does it violate people’s right to choose?
The most obvious issue is that it is still unclear whether vaccination prevents transmission. Vaccinated people may still be able to unknowingly spread the virus.
That’s why, on 5 Feb, the World Health Organisation released a statement dissuading nations from using vaccine passports, stating that “there are still critical unknowns”(7) and recently, reiterated its opposition to them.(8)
In addition, demonstrating “proof of antibodies” on a vaccine passport is problematic, as people can be infected more than once, particularly considering that the virus mutates.(9)
Twice weekly testing of UK citizens using rapid 30 minute tests, has been criticised by experts as “beyond reckless.”(10) They say the tests are not accurate, and the evidence to support their use is very weak.(10)
Further, the PCR test used by many countries had 100% sensitivity and 97.8% specificity. This is a highly accurate test if used when infection is suspected. But it performs poorly when used as a screening test.
In Denmark, only 0.5% of those tested are positive for COVID-19. Thus, for every 1000 people who are tested, we will get these results:
This means that 81% (22/27) of those who are told they are ‘infected’ are actually healthy. A requirement for school attendance is a negative test twice a week, and in order to work at the Danish Technical University you must be able to present a Covid negative certificate, less than 72 hours old, to armed guards in the building.
In Denmark, in the last week of March, 1.1 million PCR tests were carried out (population of 5.8 million). Consequently, an enormous number of healthy people will be declared ill; they will be isolated; and many contacts will be asked to be tested, too. This situation is likely to spiral into chaos.
Vaccine passports are not a novel idea. Travelling to certain regions requires you to prove that you have been vaccinated for yellow fever for example, but the requirements for COVID-19 vaccine passports will be more widespread, potentially giving rise to a two-tier society – those who can be vaccinated and those who cannot.
Some employers may make it a requirement to be vaccinated before hiring, or it could become a condition of continuing employment.(11) An Australian business for example, made receiving the flu vaccine a condition of employment(12) despite evidence showing that the effect of flu shots is poor; they increase the risk of getting infected with another flu strain; and it has never been shown that flu shots reduce transmission, admission to hospital, lung infections or death.(13)
Even though in Australia, COVID-19 vaccines are voluntary and free(14), refusal to be vaccinated, resulted in the dismissal of an Australian employee.(12) If more businesses adopt this position, it will impact people seeking employment, and it could entrench discrimination and health inequality.
There is enormous pressure by Governments and public health authorities to consent to these vaccines. Our biggest concern regarding vaccine passports is the potential violation of people’s freedom of choice. People are likely to be denied access to places or the opportunity to travel abroad unless they opt for the jab.
The proponents of vaccine passports say it is meant to incentivise people to be vaccinated, but it has created a bitter divide, with many arguing that it is treading a fine line between voluntary and mandatory vaccination.
The Biden administration recently announced that it would not endorse a national vaccine passport and that it was a matter for individual States.(15) The Governors of Florida(16) and Texas(17) have both moved to prohibit vaccine passports saying that they reduce individual freedom and will harm patient privacy.
Conversely, in the UK, political leaders continue to support the idea of vaccine passports,(1) and many UK citizens appear to agree. A recent survey of more than 8,300 people aged over 16 found that most were in favour of vaccine passports to travel abroad or to visit a relative living in a care home.(18)
We wonder, however, whether this comes at a time when Britons have ‘lockdown fatigue’ and may be willing to consent to anything in order to restore ‘normality’. This is a slippery slope and there’s no telling where this could lead if law-abiding citizens are expected to show documentation in order to eat out with their families or enjoy an afternoon at the pub.
1 BBC News Online 4 Apr 2021 https://www.bbc.com/news/uk-56634176
2 Statement of the Members of the European Council, Brussels. Online 25 Mar 2021 https://www.consilium.europa.eu/media/48976/250321-vtc-euco-statement-en...
3 The Economist. Online 27 Mar 2021 https://www.youtube.com/watch?v=RyWdIm57fpE
4 Lovell T. Healthcare IT News. Online 13 Mar 2021 https://www.healthcareitnews.com/news/emea/france-trial-digital-vaccine-...
5 Bosley M. The Guardian. Online 23 Feb 2021 https://www.healthcareitnews.com/news/emea/france-trial-digital-vaccine-...
6 O’Dwyer G. ComputerWeekly.com. Online 31 Mar 2021 https://www.computerweekly.com/news/252498670/Nordics-run-information-sh...
7 World Health Organisation; Interim position statement. Online 5 Feb 2021 https://www.who.int/news-room/articles-detail/interim-position-paper-con...
8 Bourke L. Sydney Morning Herald. Online 7 Apr 2021 https://www.smh.com.au/world/europe/who-urges-against-vaccine-passports-...
9 Michie S et al. The Conversation. Online 6 Apr 2021 https://theconversation.com/new-covid-variants-have-changed-the-game-and...
10 Lay K. The Times UK. Online 6 Apr 2021 https://www.thetimes.co.uk/article/plan-to-test-adults-twice-a-week-for-...
11 Bever L. Washington Post. Online 6 Mar 2021 https://www.washingtonpost.com/lifestyle/2021/03/06/workplace-covid-vacc...
12 Das C, Yin K. The Conversation. Online 4 Feb 2021 https://theconversation.com/can-my-boss-make-me-get-a-covid-vaccination-...
13 Gøtzsche P. Vaccines: truth, lies and controversy. Publication 5 Feb 2021 https://www.amazon.com/Vaccines-controversy-Peter-C-G%C3%B8tzsche-ebook/...
14 Australian Government Department of Health. Last updated 8 Apr 2021 https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/get...
15 The Hill. Online 6 Apr 2021. https://thehill.com/homenews/administration/546705-white-house-rules-out...
16 State of Florida, Office of the Governor Executive Order #21 – 81 https://www.flgov.com/wp-content/uploads/2021/04/EO-21-81.pdf
17 Mastrangelo D. The Hill. Online 6 Apr 2021 https://thehill.com/homenews/state-watch/546626-texas-gov-abbott-issues-...
18 Sky News. Online 31 Mar 2021 https://thehill.com/homenews/state-watch/546626-texas-gov-abbott-issues-...
Competing interests: No competing interests