COVID-19 IMMUNITY PASSPORT: PRACTICAL AND ETHICAL CHALLENGES

During this pandemic period, one of the controversial concept, that some governments have suggested including Germany, Chile, Italy, the US, the UK is the use of immunity passport –ie, a document that certifies an individual has been infected, recovered and is purportedly immune to SARS-CoV-2 by performing a blood test. Imagine a future where our job and all sorts of normal social activities will be based on blood testing. A positive antibody test and a negative virus test will help the individual to get an immunity pass and will be relaxed from physical restrictions and can return back to normal life. Given that the person is proven immune to the disease and can’t get re-infected and so no potential public health risk. This has been proposed in order to begin reopening of the economy around the world.

Chile become the first country to provide certificates and officials in Italy and Germany are also considering it. In China, “heath code” apps are used to decide the movement of people. India’s own contact tracing app Aarogya Setup is designed to keep track of the users and alert them when they come in contact with COVID-19 patients, but it will not restrict the people’s movement. Obtaining the immunity pass will provide some privilege to the recovered patients, but have a negative impact on the healthy, non-immune people who managed to stay safe and ward-off virus.

Some of the health, experts are debating the idea of giving this passport because this will only work if people really are immune to re-infection. Reports from South Korea and China suggested some recovered patients getting re-infected. Most of the studies show people who recovered develop antibodies to the virus, but some of them have very low levels of neutralizing antibodies in their blood. No evidence suggesting how long the developed immunity last to guarantee future protection.

One of the major issue highlighted by WHO include unsatisfactory results with the available rapid immunodiagnostic tests, which needs further validation to decide their accuracy and reliability. Low specificity cause false-positive results leading people to think they are immune when they aren’t, whereas low sensitivity cause false-negative results in people who have few antibodies. It is needed to differentiate between past infection from SARS-CoV-2 and those caused by the 6 known set of human coronaviruses. Two among them are viruses that cause MERS and SARS. People infected with anyone of these viruses may produce antibodies which will cross-react with antibodies produced in response to SARS-COV-2 infection. Remaining 4 viruses cause the common cold and circulate in the body. Then the volume of testing needed is unfeasible. Two tests per person are minimum required because anyone tested negative might later become infected and needed to be retested to be immune certified.

Another important aspect is to understand the proportion of a population that has been infected with SARS-COV-2. The term Positive Predictive value (PPV) which means “the probability that subjects with a positive screening test truly have the disease” is directly related to the prevalence of the disease in a population. For any given test (ie specificity & sensitivity remain the same) as prevalence decreases, PPV decreases because there will be more false positive for every true positive. So when the prevalence of disease increases, PPV increases because there will be less false-positive cases. This is an important concept. For an immune passport to work, there have to be enough potential passport holders to boost the economy.

Countries with the highest, COVID-19 infections rate may have the best reason to create immunity passport, but the number of recovered patients may not be enough to make the development of this program worthwhile. The WHO estimated that only 2-3% of the global population had recovered from the virus as of April 2020. Though it varies by region, no more than 5% of the population have antibodies (by contrast, around 70% of the population needs to have antibodies either through recovery or vaccination).

Countries like New Zealand, Australia. Taiwan, Vietnam that have successfully flattened the curve –had fewer cases and thus less incentive to initiate immunity passport.

Ethical challenges include monitoring private details which could be people’s travel history, locations and other health information. Marginalized groups (racial, religious and other minority groups) will face more scrutiny. In the US, digital incarceration has already increased. Shortage of testing suggests that the wealthy and powerful are more likely to obtain a test than the poor and vulnerable. Social and financial inequities would be amplified. People will be divided and labelled as immune-privileged and immune-deprived. Employers preferentially hire those having confirmed immunity. There will be a new form of discrimination, when employers, insurance companies and law-officers access private (mental health records and genetic information) details for their own benefit. People who managed to stay at home wilfully seek out infection –putting themselves at risk to get the benefits of passport holders. Sometimes they obtain documents illicitly through bribery, forgery.

There are “vaccination certificates” permissible under the International Health Regulations, which are already accepted by the WHO. They incentivize individuals to obtain vaccination against the virus whereas immunity passport incentivize infection.

Confronting with these challenges, till vaccination, government officials should invest available time, talent and money into areas like a test, trace and isolate. Health and personal data should be anonymised. All policies and practices must be guided by a commitment to social justice.

Miss Maria Thomas 5th Pharm.D