Immunity Passports To Travel During The COVID-19 Pandemic: Controversies And Public Health Risks
Sep 15, 2023
ABSTRACT
As countries emerge from pandemic lockdown, many countries are relaxing international travel restrictions. Commercially available serologic tests for anti-SARS-CoV-2 antibodies are being performed. The concept of an ‘immunity passport’ has gained popularity, whereby evidence of SARS-CoV-2 antibody production would signal immunity to reinfection. For an immunity certificate to be validated for travel purposes, it should meet certain criteria. The introduction of such certificates faces multiple challenges. While there may be a future role for immunity passports in limited circumstances in the event that a protective vaccine becomes freely available, for now at least the risks of such an approach outweigh the perceived benefits.
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Keywords infectious disease, migration, public health
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To the editor
The rapid global spread of SARS-CoV-2 was initially facilitated by international travel. As society begins to emerge from months of stringent confinement, many states are relaxing international travel restrictions in an effort to stimulate their economies. Members of the public are beginning to entertain the prospect of a resumption of normal travel, albeit under unfamiliar conditions.1 As travel medicine practitioners, we are receiving abundant queries from members of the public about the current safety of air travel and their own medical fitness to fly.
Serologic tests for anti-SARS-CoV-2 antibodies are being requested. Many individuals are curious about the possibility of past infection based on historical symptoms but in the absence of a confirmed diagnosis. The concept of an ‘immunity passport’ has been advanced, whereby serologic evidence of SARS-CoV-2 antibody production indicates immunity to a second infection.2 In the case of international travel, such ‘risk-free certificates’ could reassure an anxious traveling public and potentially satisfy national border control requirements.
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Immunity passports already exist in public health and travel medicine.
Certified evidence of vaccination against yellow fever in an international certificate of vaccination or prophylaxis is required under International Health Regulations. For any immunity certificate to be valid in the case of COVID-19, it would need to satisfy the criteria outlined in Table 1. A population-based study from Switzerland estimated that 10.8% had been infected with SARS-CoV-2.3 Similarly modest seroprevalence levels have been reported elsewhere. The question of whether seropositivity reflects durable immune protection against the virus remains unanswered. While most COVID-19 patients seroconvert within 2 weeks of the onset of symptoms, the IgG titer has been found to decline significantly within weeks of infection in some patients.4 A recent Cochrane review examined studies that measured the accuracy of COVID-19 antibody tests.5 The authors expressed doubt about how well commercially available serologic tests detect evidence of past infection beyond 5 weeks of symptom onset. The introduction of immunity passports is beset with challenges, not least of which is the potential erosion of civil liberties, as travelers are stratified into the ‘immune privileged’ and the ‘Immuno deprived’. Such societal inequalities could be amplified if an effective vaccine becomes available, but is not universally accessible.
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Citizens from countries that are unable to implement immunity passport programs could be denied entry to countries that mandate them. The racial disparities in rates of death from COVID-19 reported in this journal6 underscore the need to militate further healthcare inequities. Immunity passports could create perverse incentives, such that nonimmune individuals may expose themselves to infection.
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Counterfeit yellow fever vaccination certificates are a concern7, and fraud could also undermine the biosecurity of a COVID-19 immunity certificate. While the role of immunity passports may be revisited at a later date, if there is universal, timely access to a protective COVID-19 vaccine, we subscribe to the recent guidance from the World Health Organization that the use of such certificates may increase the risk of viral transmission where individuals falsely assume that they are immune to further infection and ignore public health advice.8 While seroprevalence studies will continue to improve our understanding of COVID-19, the use of antibody tests as a means of certifying fitness for international travel would appear to be limited for now.
Table 1 Immunity passport validation criteria for COVID-19
References
1 Wilson ME, Chen LH. Re-starting travel in the era of COVID- 19: preparing anew. J Travel Med 2020. doi: 10.1093/jtm/ taaa108.
2 Chen LH, Freedman DO, Visser LG. COVID-19 immunity passport to ease travel restrictions? J Travel Med 2020. doi: 10.1093/jtm/ taaa085.
3 Stringhini S, Wisniak A, Piumatti G et al. Seroprevalence of anti-SARS-CoV-2 IgG antibodies in Geneva, Switzerland (SEROCoV-POP): a population-based study. Lancet 2020. doi: 10.1016/S0140-6736(20)31304-0.
4 Cheng MP, Yansouni CP, Basta NE et al. Serodiagnostics for severe acute respiratory syndrome-related coronavirus-2: a narrative review. Ann Intern Med 2020. doi: 10.7326/M20-2854.
5 Deeks JJ, Dinnes J, Takwoingi Y, et al. Antibody tests for identification of current and past infection with SARS-CoV-2. Cochrane Database Syst Rev 2020;(6): CD013652.
6 Alobuia WM, Dalva-Baird NP, Forrester JD et al. Racial disparities in knowledge, attitudes, and practices related to COVID-19 in the USA. J Public Health (Oxf) 2020. doi: 10.1093/PubMed/fdaa069.
7 Schönenberger S, Hatz C, Bühler S. Unpredictable checks of yellow fever vaccination certificates upon arrival in Tanzania. J Travel Med 2016;23(5):1–5. doi: 10.1093/jtm/taw035.
8 World Health Organization. “Immunity passports” in the context of COVID-19. Scientific Brief 2020. https://www.who.int/news-roo m/commentaries/detail/immunity-passports-in-the-context-of-co vid-19 (5 July 2020, date last accessed).
9 Kirkcaldy RD, King BA, Brooks JT. COVID-19 and postinfection immunity: limited evidence, many remaining questions. JAMA 2020. doi: 10.1001/jama.2020.7869.
10 Lisboa Bastos M, Tavaziva G, Abidi SK et al. Diagnostic accuracy of serological tests for COVID-19: systematic review and meta-analysis. BMJ 2020;370:m2516.
