Ticket to ride: the potential of COVID-19 ‘immunity passports’


‘Immunity passports’ have been touted as a tool to get the world economy back on its feet as fast as possible, but risk driving the emergence of an underclass of immunologically vulnerable people whose liberty continues to be curtailed while their neighbours are free to get their lives back on track.

In early April, the UK’s Secretary of State for Health and Social Care, Matt Hancock announced that the government was considering an ‘immunity certificate’ to ‘get back as much as possible to normal life’.

The possibility of getting people back to work and relinquishing them from isolation as early as is safe is attractive, although accompanied by political and societal dangers, alongside practical challenges.

What is an immunity passport?

The concept rests on three key tenets: exposure to SARS-CoV-2 generates an immune response that persists beyond the duration of active infection; the persisting immune response is protective against reinfection with SARS-CoV-2; and that it is possible to test, through antibody serology, if a person has this active immunity.

There are already private providers of ‘immunity passports’. Florida-based Avers LLC offers a range of certifications enabling people to instantly substantiate an individual’s medical or health status based on verified documents submitted by a medical laboratory or physician, including STI status, drug free confirmation and ImmuniPass.  ImmuniPass is being specially marketed to help people confirm they have immunity against SARS-CoV-2. With no government or regulatory backing, the ImmuniPass is currently only useful to demonstrate to friends and family that you are safe should you wish to skirt the current lockdown rules, but in future it could provide the basis of a more formal ‘immunity passport’.

Potentially, governments could establish a register of those who are immune and issue ‘immunity passports’ enabling them to circumvent the current lockdown restrictions. While many governments are considering what if any role ‘immunity passports’ would play, there has been no confirmation that the UK government will introduce them. However, this article considers the potential implications should ‘immunity passports’ become part of an exit strategy.

How will the UK move out of lockdown?

The UK government has not detailed its plans for exit from lockdown, although it is likely that there will be a stepwise easing of restrictions, and that identified groups and specific individuals, perhaps those groups least likely to suffer from the severe form of the disease, will be able to return to aspects of pre-Covid-19 life.

However, policing who is and who isn’t permitted to live outside of the restrictions will be challenging without some form of certification.

Does prior exposure to SARS-CoV-2 result in immunity?

The hypothesis that exposure to SARS-CoV-2 and survival of any Covid-19 symptoms will confer immunity to clinically significant reinfection is yet to be proven.

Although the coronavirus that causes the common cold produces a weak immune response lasting only a matter of months, other coronavirus diseases SARS and MERS potentially produce long-lasting immunity. Data is limited because both viruses have infected far fewer people than SARS-CoV-2, but SARS-CoV-1, the virus that causes SARS, has a genome that is 76% similar to that of SARS-CoV-2 and we should therefore expect a similar pattern of post-infection immunity in both instances. A 2007 study reported in the journal Emerging Infectious Diseases, detailed evidence of high levels of SARS specific antibodies in a group of 176 survivors. This immune protection remained strong for two years, with their immune response starting to wane in the third year.

The assumption that high titrates of specific SARS-CoV-2 antibodies in the plasma protect against infection forms the basis of the ‘immune passport’ thesis. Further widespread antibody testing, and patient follow-up will be required before a definitive answer can be reached.

How would immune status be determined?

Current methods of testing for SARS-CoV-2 infection use PCR to identify the virus in the blood, but this technique is only effective in the detection of active infection and does not indicate the likelihood of post-exposure immunity. Measurement of antibodies against parts of SARS-CoV-2 specific to that viral strain is highly indicative of prior exposure, and potentially of ongoing immunity to reinfection, but the serological testing is challenging. To date, progress has been slow to develop a diagnostic measure that effectively identifies those who have been exposed to the specific SARS-CoV strain that is at the heart of the global pandemic.

Several ambitious programmes to test for SARS-CoV-2 antibodies have now been launched around the globe. The World Health Organisation’s Solidarity II study will pool antibody data from more than half a dozen countries. In the US, a collaborative multi-year project has been established to provide a picture of nationwide antibody prevalence.

Diagnostic tests are imperfect and can produce both false positives and false negatives. Cellex, which was the first company to get a rapid SARS-CoV-2 antibody test approved by the FDA, has a sensitivity of 93.8% and a specificity of 95.6%, which is pretty impressive but still means there would be people who are immune excluded from an ‘immunity passport’ and people with false positive results potentially endangering themselves and others.

How could immunity passports work in practice?

The issuance of ‘immunity passports’ would, of course, be dependent on having a reliable serology test for antibodies to SARS-CoV-2, and for this to be deployed. Given there is likely to be limited capacity for testing there will have to be prioritisation by governments of who gets tested and therefore who has the possibility of being granted an ‘immunity passport’.

In the first instance, key workers are likely to be at the front of the queue. In the UK, according to a recent RCP survey, 15% of doctors are currently unable to work because of illness or self-isolation resulting from suspected Covid-19 in a member of their household. 

Once ‘immunity passports’ are issued to key workers to support their return to work, a Pandora’s box of possible tiered rights to freedom is opened.

The government will have to consider if those with known or likely immunity should have other liberties restored. For example, could people with positive serology congregate together? Will there be pubs open only to the immune? Immune-only football matches? Immune-only marriages?

How would a person prove their immune status?

Whenever a bureaucratic system is in place to control individuals’ access to significant liberties, there will be people who seek to find its weaknesses. An ‘immunity passport’ system will require an efficient and easy means for an individual to present to policing authorities’ their status, and for their status to be reliably checked against a central register.

There would be a requirement for a national, or perhaps international, database to track immunological status. Although not lauded with acclimation, a number of existing technology companies already operate comparable systems for UK government bodies including for passport and visa processing.  

Electronic health records might be the most sensible place to store the immunity status of patients, although the UK system is a mess with fragmented provision and failures in interoperability. To burden these systems with another function is a risky strategy.

Public trust in government to manage healthcare data is fairly abysmal, and it may fall on a much newer entrant to the market to implement ‘immunity passports’. Bizagi, a UK-based technology, company has released ‘CoronaPass’, an app that will use an encrypted database to store information about users’ immune status, based on antibody test results provided by hospitals or other healthcare providers. The app would present a QR code that a government or company official could scan to certify an individual’s immunity status has been verified, allowing them to return to work, board an airplane, or otherwise relax their social distancing

Irrespective of who holds the central register of immunity status and associated rights to freedom, there remains the practical issue of an individual being able to demonstrate their status and the rights they hold.

Verification of immune status could be done via an RFID chip on a new identity card, or via a mobile app, to gain access to certain areas. For example, cinemas, music venues or even public transport. However, the opportunity for immune status to be forged or shared is a real possibility with these solutions.

Could access to healthcare be dependent on immunity status?

During the lockdown period, many primary healthcare providers abandoned face-to-face appointments and moved to remote consultation. Disadvantages of telemedicine include the inability to undertake physical examination or collect samples for analysis, a reduced ability to make incidental observations and potential breakdown of the relationships between care providers and patients. Telemedicine undoubtedly will have a far greater role in the provision of diagnoses and treatment following the pandemic, but the ‘laying on of hands’ will remain an important component of good quality medical practice. As face-to-face medical consultations return, will only those with an ‘immunity passport’ have access to them? In such a staged access programme, the care provider could fall foul of government regulations (e.g. the UK Equalities Act) by providing a service of worse quality to the non-immune.

Dr Joe Taylor is Principal at Candesic, a specialist healthcare, life sciences and MedTech consultancy.  Read the full article in Healthcare Markets.



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