Covid-19 vaccine passports have recently made headlines and some countries are already planning their implementation. So what exactly are vaccine passports and what are their pros and cons?
By Emmi Weller, MSc. and Candela Iglesias Chiesa, MPH, PhD
Vaccination passports: not a new thing
A vaccination passport is a certification confirming that you have been vaccinated against Covid-19. Its goal is to allow vaccination passport holders to travel freely again without endangering personal safety and the health of others. While until now the discussion mainly revolved around its use for international travel, these vaccination passports could potentially regulate who can enter entertainment venues (e.g. cinemas, theatres, gyms) and public spaces. Israel has for example already issued “green cards” which enables holders to access hotels, gyms, theatres, and other public spaces again (1). Similarly, the European Union proposed a Digital Green Certificate and are aiming to implement it by June 2021 (2).
Vaccine “passports” are not a new invention, they already exist. In 1951, the member states of the World Health Organisation (WHO) adopted the International Sanitary Regulations, which contained one provision on the validity and use of vaccine certifications (3). Back then, vaccination passports against smallpox were useful to avoid the importation of the disease into countries that had a low number of cases, especially in a period where travelling by air became more common (4). Smallpox was ultimately eradicated in 1980 thanks to an immense international vaccination effort (5). Nowadays, only the yellow fever vaccine certificate remains approved for use by the WHO. If you travel to certain countries inside the yellow fever “belt” you might be requested to show one at the point of entry.
Why would we want a vaccination passport for COVID19?
In public health, we are always aiming to balance between the “public good” and personal liberties. Thus public health uses the principle of “least infringement”, which says that those who decide on policies should choose interventions that minimise restrictions on individual liberty and that are truly necessary to achieve the public health goal (i.e. saving more lives, decreasing transmission, etc). So how does this apply to vaccination passports?
Today most countries have in place strong public health and social measures that protect people from COVID19 infection and also restrict movement, some have work-from-home orders, others have closed cinemas, markets, etc, others have curfews. These are necessary to protect people’s health during a pandemic and ensure the healthcare system does not collapse. Countries have loosened or tightened these measures based on how much the virus is spreading and how the healthcare services are able to cope locally.
But when people are vaccinated they have a much lower risk of serious disease, and some data suggest, also of transmitting the virus if they do get infected. So continuing to restrict movements of people who have already been vaccinated might be disproportionate, and contrary to the principle of least infringement. Vaccine passports could offer a solution to this problem, by allowing authorities to distinguish those who have been vaccinated and loosen up certain measures for this group. Vaccination passports could allow certain people to travel again internationally, which could have several benefits:
It could allow families who have been separated by border restrictions to reunite again, for example. It could also facilitate work by international humanitarian health organizations whose teams may have had to restrict some travels to key areas where help is needed. It would help the tourism and leisure industry, two sectors that were hit hardest during the pandemic, as those who are vaccinated could restart tourism travels. Countries whose economies that are dependent on tourism, many of which are low or middle-income countries, could welcome tourists again, thus boosting their travel revenues and improving the local economy, without increasing COVID19 risk for the countries’ populations.
Lastly, vaccination passports could also be a way to incentivise vaccine uptake as people can see the mobility advantages of being vaccinated. The more people are vaccinated, the closer we are to getting this pandemic under control and the faster we can put an end to restriction measures. Vaccine passports could thus help avoid further negative economic, societal, and mental health impacts on our populations.
What are the potential negative aspects of a vaccination passport?
Vaccine passports for COVID19 remain controversial for numerous reasons (7, 8). Firstly, they raise concerns about equity. Access to vaccines has been extremely unequal across countries, with various high income countries buying enough doses to cover their populations more than once, and potentially completing vaccinations by mid-2021. While many low and middle income countries may have only enough to cover their healthcare workers by the end of 2021 and might have to wait one or two more years to fully vaccinate their populations.
Research has also shown that people from ethnic minorities or from low-income groups have been vaccinated at lower rates (even in countries with higher access to vaccines). Thus, having a vaccine passport would mostly allow those with more privileges and from richer countries to travel again, deepening existing inequalities both inside and across countries.
There are also key scientific questions still unresolved that underline the idea of vaccination passports: for a Covid-19 vaccine passports to be truly representative of a holder’s protection, more needs to be known about the long-term effectiveness of the different vaccines, the duration of immunity, how well do they prevent transmission (and not just disease) and most urgently, how well do vaccines protect against new variants. In fact, depending on these characteristics, a passport renewal might be needed (which used to be the case for the yellow fever passport, for instance), and some restrictions may still apply even for vaccine passport holders.
Other questions remain too: what do we do with people who have contraindications to vaccination? How do we successfully ensure privacy and data protection? How do we standardise vaccine passports internationally?
What are the alternatives to vaccination passports?
Because of the issues mentioned above, the world could choose not to use vaccination passports and maintain the tools we are using right now. But because of the positive aspects of vaccine passports, a better alternative might be a combination of different options, which may be a more equitable solution to only using vaccine passports.
Vaccine passports could could be used together with many of the measures that exist today, such as testing certificates, and in some cases, even the continued use of quarantines. Many countries are already requiring a negative Covid-19 test result to enter their territory, although, similarly to a vaccination passport, a negative test result does not necessarily mean that a person is not infectious anymore (6). Most countries have quarantines with different restrictions (home-based, in a regulated hotel or site) for people who want to enter. And these could still be a solution -albeit inadequate – for those who don’t have a vaccination passport. These measures nevertheless hamper short-term travelling and are therefore not a sustainable, long-term solution.
Clearly, vaccination passports can be useful tools in helping us reopen countries safely, but there is much to do to address the ethical and logistical challenges they pose today, and strong considerations to global vaccine equity to protect as many people as possible against Covid-19. In the end, the most important issue is ensuring a more equitable access to vaccines.
Sources:
- Ministry of Health Isreal. What is a Green Pass?. Available from: https://corona.health.gov.il/en/directives/green-pass-info/
- European Commission. Coronavirus: Commission proposes a Digital Green Certificate. Available from: https://ec.europa.eu/commission/presscorner/detail/en/ip_21_1181
- World Health Organization. (1951). International Sanitary Regulations. Weekly Epidemiological Record= Relevé épidémiologique hebdomadaire, 26(42), 403-404. Available from: https://apps.who.int/iris/bitstream/handle/10665/101391/WHA4_60_eng.pdf?sequence=1&isAllowed=y
- Fenner, F., Henderson, D. A., Arita, I., Jezek, Z., & Ladnyi, I. D. (1988). Developments in vaccination and control between 1900 and 1966. Smallpox and its eradication, 277-314. Available from: https://biotech.law.lsu.edu/blaw/bt/smallpox/who/red-book/Chp%2007.pdf
- CDC. History of Smallpox. Available from: https://www.cdc.gov/smallpox/history/history.html#:~:text=Almost%20two%20centuries%20after%20Jenner,achievement%20in%20international%20public%20health.
- Government of New Zealand. Travel to New Zealand. Available from: https://covid19.govt.nz/travel-and-the-border/travel-to-new-zealand/#who-can-travel-to-new-zealand
- Osama, T., Razai, M. S., & Majeed, A. (2021). Covid-19 vaccine passports: access, equity, and ethics. https://www.bmj.com/content/373/bmj.n861
- Hall, M. A., & Studdert, D. M. (2021). “Vaccine Passport” Certification—Policy and Ethical Considerations. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMp2104289
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