Towards Immunity Passports for COVID-19?

There is lots of talk about immunity passports, especially in Israel and in the European Union. This article analyzes what we know of the immunity passports that were announced by Israel, the country which is at the forefront of vaccination efforts in the world, but which is also facing an unprecedented number of cases and deaths from COVID-19. Will such passports be required for air travel or simply go to a restaurant or to a gym? Or even go to school or university? How can immunity acquired from a prior COVID-19 disease be integrated into such passports? This is what this article discusses.

See French version.

To this day, nearly 2 million people have received a first dose of vaccination in Israel, which corresponds to around 20% of the population. 

This occurs at a time when there is an unprecedented number of new confirmed cases and deaths in the country. 

Like most countries, Israel has not implemented early treatment protocols for COVID-19 and expects vaccination to resolve the crisis.

An immunity / vaccination passport has been announced by the authorities. The second vaccination shot is needed to get a vaccination certificate, that will in turn be part of the green / immunity passport.

The green passports “could be used to enable access to cultural and sporting events, conferences, museums and other types of mass gatherings. It added they would likely be used at restaurants and cafés, malls, hotels, gyms and swimming pools, but would not be required for schools, workplaces, public transportation, houses of worship and street-front stores.” 

https://www.timesofisrael.com/health-ministry-says-vaccinated-recovered-to-get-green-passport-for-6-months/

Another important type of benefit will be that a negative test prior to air travel will not be required, and that one will not need to go into quarantine after a return from travelling.

The passport would be granted for an initial period of 6 months for those who have been inoculated against the coronavirus or recovered from COVID-19, according to media reports.

Only the country’s ministry of health will issue the required vaccination or recovery certificates.

The passport will take the form of either a mobile app or a paper document. A paper version, which may not be the final version, can be seen in this article.

Final details have not emerged yet, but this page from a governmental website, last updated on January 13, provides information about Certificates of Recovery, issued by either a certified nurse or a medical doctor.

https://www.gov.il/en/Departments/General/corona-recovered-patients

However, another governmental page, last updated on January 12, but now removed, offered a different information, as it read: “Recovered coronavirus patients cannot receive a green booklet. The Certificate of Recovery issued by their HMO serves as written proof that they have recovered.” (this page was no longer accessible as of finalizing this article on Jan 18).

https://www.gov.il/en/Departments/General/vaccine-record

The article below, quoting the director general of the health ministry, confirms however the intention to recognize the immunity gained by people having recovered from the disease. “People with severe allergic reactions will not receive the vaccine, nor will people who have recovered from Covid-19 and who should be immune.” (bold by author)

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https://en.globes.co.il/en/article-israeli-health-ministry-sets-vaccination-priorities-1001352844

Today, in terms of number of people vaccinated per capita, Israel is leading the world. But it is also facing the question as to whether to vaccinate extremely low risk individuals, including children.

The article referred above mentions the possibility that people as young as age 16 could ultimately be vaccinated, and that “vaccination to younger age groups” could even be considered later.

Vaccination is being rolled out progressively, with people between the ages of 50 and 60 now eligible, in addition to health care workers and other high risk groups.

https://www.timesofisrael.com/israel-expands-vaccination-drive-to-anyone-50-years-and-up/

By March, Israel intends to have vaccinated 5.2 million citizens, out of a population of 9.2 million, i.e. about 56% of its population. The ultimate goal would be to achieve herd immunity, with an estimated 70% of the population needed to be immune to achieve this.

Should the Young and the Recovered be Vaccinated?

Contrary to Israel, in the US, Canada and most other countries, all much behind in terms of per capita vaccination levels, the recommendation is still to vaccinate people who have already had the  COVID-19 illness, as long as the person is no longer in isolation.

“Vaccination of persons with known current SARS-CoV-2 infection should be deferred until the person has recovered from the acute illness (if the person had symptoms) and criteria have been met for them to discontinue isolation,” states the American CDC.

https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html

While Canada is even further behind in terms of vaccination, it’s also suggested that everyone above the age of 16 would have access to a vaccine. There are priorities set, but no real stratification foreseen, and extremely low risk individuals, like minors who are 16 or 17, and young adults, would receive the shot if they ask. There are no indications that the immunity acquired by those having recovered from COVID-19 will be recognized.

https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks/covid-19-vaccine-treatment/vaccine-rollout.html

One needs to keep in mind that the risk of contracting a severe form of C19 and dying from it is highly dependent on age in addition to the quality of care being received.

This table was produced by Alex Berezoz, PhD, drawing from a study Megan O’Driscoll et al. It shows that the risk grows exponentially with age but is extremely low for minor and young adults.

https://www.acsh.org/news/2020/11/18/covid-infection-fatality-rates-sex-and-age-15163
https://www.nature.com/articles/s41586-020-2918-0

Not encapsulated in this table is the that risks can be further reduced with early outpatient treatment, which is, as discussed extensively in this blog, still widely denied to the people in most countries.

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The stance to vaccinate without risk real stratification, and without discarding those who already got COVID-19, is challenged by some in the medical profession. There are several reasons for this. First is of course is the very low risk posed by COVID-19 for most age groups, as the risk is known to grow exponentially with age. Why take a vaccine when your own risk is extremely low?

Second are the uncertainties regarding the actual effectiveness and risks associated with the various vaccinations, a complex topic which we will not analyze in detail here. Yet, just the reported complications such as Bell’s palsy facial paralysis, the non resolved issue of possible antibody dependent enhancement, and the concerns recently announced by Norway regarding the suitability of vaccinating the elderly, suggest a careful risk benefit analysis should be carried out by the authorities, for the various age and risk groups.

https://en.wikipedia.org/wiki/Antibody-dependent_enhancement
https://www.bloomberg.com/news/articles/2021-01-16/norway-vaccine-fatalities-among-people-75-and-older-rise-to-29

A third reason is the immunity acquired from previously contracting the disease. In this regard, a recent study about immunity in the UK is important noting, as it shows that such immunity is real, and that it may last at least 6 to 7 months after infection, maybe much longer.

“Despite 290 symptomatic infections in 10,137 non-immune HCWs (health care workers), there were no symptomatic reinfections in over 1000 HCWs with past infection. We conclude that SARS-CoV-2 infection appears to result in protection against symptomatic infection in working age adults, at least in the short term,” notes the study. (bold by the author)

https://www.journalofinfection.com/action/showPdf?pii=S0163-4453%2820%2930781-7

The study indicates that the risk of re-infection may exist but is probably lower than 1%, which means a very high level of protection, of approx. 99%, may be provided by having previously contracted the disease.

https://www.nature.com/articles/d41586-021-00071-6

Such level of protection confirms the intuition most virologists got with SARS-CoV2, that a substantial immunity would result from contracting the disease, yet now there are tangible elements confirming this.

An Interesting Approach out of Iceland

While most countries seem to ignore the immunity provided by a prior COVID-19 disease in their discussions about immunity passports, there are a few exceptions, in addition to Israel.

An interesting case is Iceland, which recognizes certificates of previous COVID-19 infection at the border, so that incoming travellers with such certificates can be exempted from a quarantine.

The following certificates are considered by Iceland as a valid confirmation of a previous COVID-19 infection: 

  • a positive PCR-test result for SARS-CoV-2/COVID-19 that is older than 14 days; and 
  • the presence of antibodies against SARS-CoV-2/COVID-19 measured by ELISA serologic assay.

https://www.landlaeknir.is/um-embaettid/greinar/grein/item43709/Certificates-regarding-previous-COVID-19-infection-that-are-accepted-at-the-border-in-Iceland-from-10-December-2020

A way to further improve this Icelandic approach would be to require a medical certificate asserting that the person presenting a positive PCR-test has actually gotten the disease. 

There are indeed false positives with PCR-testing, in the range of 0.4 to 4%, which is one of the reasons why compulsory negative tests prior to flying are a pretty ineffective measure.

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https://www.icd10monitor.com/false-positives-in-pcr-tests-for-covid-19

Also, as there are shortcomings with serologic testing, a combination of such test with a medical certificate and/or a positive test confirming a previous COVID-19, may be needed to improve the reliability of the immunity certificates.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337672/

Towards Immunity Passports?

Immunity / vaccination passports are presently a hot topic, especially in the European Union, with Greece, largely dependent on tourism, pushing for vaccination as a condition for travel. Such passports pose a number of issues, in terms of reliability and privacy, among others. In the UK, digital passports are already being offered, on a pilot basis, to people having been vaccinated, even if officially, there are no plans for a large scale implementation of the measure.

https://www.politico.eu/article/coronavirus-covid-vaccine-passports-pose-risk-to-privacy-experts-warn/
https://www.dailymail.co.uk/news/article-9139923/Covid-UK-Britons-received-jab-offered-vaccine-passport-trial.html

The push for such passports is also made by the private sector, especially airlines, that have been considerably impacted by the reduced amount of air travel. The push is made towards vaccination, even if there are no proof that the vaccines developed so far reduce transmission.

Last November, Qantas CEO put it bluntly: No Vaccine No Fly – maybe not understanding the issue very thoroughly.

From this brief analysis, one needs to highlight the critical importance of the immunity acquired from previously developing the disease.

Some 68 million of people throughout the world have already contracted COVID-19, developed the disease, have overcome it, and have accordingly acquired a substantial immunity.

It would make sense that any immunity passport, in addition to remaining voluntary and respecting privacy, recognizes the immunity acquired from a previous COVID-19 infection.

Will this fully resolve the issue? No, unfortunately. 

Young people, at extremely low risk of dying from COVID-19, will want to travel too, and more generally return to a more normal life, yet their vaccination probably remains unjustified given their extremely low risk from COVID-19.

Also, most countries will not be able to afford or to rapidly implement, on a large scale, vaccination efforts like those of Israel.

This brings us back to the need to implement other tools to fight the pandemic, especially the widely neglected early outpatient treatments, which considerably reduce hospitalization and mortality, and … also deliver … immunity from COVID-19.


Related articles:

Here are recent related articles about the (in)effectiveness of the recent Canadian measures to impose negative test to enter Canada by air, and about how to best protect yourself from getting COVID-19 on a plane.

Other Links:

I24 News report on Health Ministry Announcement: 

https://www.timesofisrael.com/vaccinated-will-get-green-passports-waiving-lockdown-constraints-officials/

https://www.msn.com/en-us/money/markets/israel-is-launching-covid-immunity-passports-heres-what-they-allow-you-to-do/ar-BB1cLRUb

https://www.loc.gov/law/foreign-news/article/israel-ministry-of-health-to-issue-green-passports-to-those-who-vaccinate-against-or-have-recovered-from-coronavirus/

https://healthpolicy-watch.news/81148-2/