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Passport to Freedom? Immunity Passports for COVID-19 Rebecca C H Brown ‍ ,1 Julian Savulescu,1 Bridget Williams,2 Dominic Wilkinson ‍ 1

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Passport to Freedom? Immunity Passports for COVID-19 Rebecca C H Brown ‍ ,1 Julian Savulescu,1 Bridget Williams,2 Dominic Wilkinson ‍ 1 Extended essay J Med Ethics: first published as 10.1136/medethics-2020-106365 on 15 August 2020. Downloaded from Passport to freedom? Immunity passports for COVID-19 Rebecca C H Brown ,1 Julian Savulescu,1 Bridget Williams,2 Dominic Wilkinson 1 1Oxford Uehiro Centre for ABSTRACT One of the reasons such lockdown measures Practical Ethics, University of The COVID-19 pandemic has led a number of countries are deemed necessary is the potential for asymp- Oxford, Oxford, UK 2School of Public Health and to introduce restrictive ’lockdown’ policies on their tomatic infection and spreading of COVID-19. Preventive Medicine, Monash citizens in order to control infection spread. Immunity Estimates vary widely, but the number of people University, Clayton, Victoria, passports have been proposed as a way of easing the who do not experience symptoms when infected Australia harms of such policies, and could be used in conjunction with COVID-19 seems likely to be around 40%.6 with other strategies for infection control. These Research suggests that close to half of all transmis- Correspondence to passports would permit those who test positive for sion events occur before the onset of symptoms, Dr Rebecca C H Brown, Oxford COVID-19 antibodies to return to some of their normal and people are thought to be at their most infec- Uehiro Centre for Practical 7 8 Ethics, University of Oxford, behaviours, such as travelling more freely and returning tious on or before the time of symptom onset. Oxford OX1 1PT, UK; to work. The introduction of immunity passports raises a Viable virus has been detected from patients as rebecca. brown@ philosophy. number of practical and ethical challenges. In this paper, early as 6 days before the onset of symptoms.9 ox. ac. uk we seek to review the challenges relating to various This means, to prevent spreading of the disease, Received 29 April 2020 practical considerations, fairness issues, the risk to social even those without any symptoms need to be Revised 8 July 2020 cooperation and the impact on people’s civil liberties. contained. Accepted 10 July 2020 We make tentative recommendations for the ethical The risk of death or hospitalisation from Published Online First introduction of immunity passports. COVID-19 infection increases with age and 15 August 2020 according to the presence of other underlying health conditions including heart disease, diabetes 10 11 INTRODUCTION and immunological problems. Efforts to reduce As the COVID-19 pandemic progresses, many the spread of infection are, in part, aimed at people worldwide will contract the virus and reducing the numbers of severe cases, and avoiding recover. Many of these will be asymptomatic or a large peak of severe infections. Such a peak could experience mild symptoms only.1 Due to the novel overwhelm the healthcare system, particularly crit- nature of the virus, it is not yet clear what level ical care services, making it unable to effectively of immunity is conferred by infection. However, provide care to both COVID-19 sufferers and evidence from COVID-19 thus far, and experi- others. The diminished ability of healthcare systems ence with previous coronaviruses, suggests that to provide non- pandemic- related care may already some level of protection from reinfection is likely be affecting public health. For instance, the UK in the short term, and may persist for several Office for National Statistics (ONS) has reported a http://jme.bmj.com/ years.2 Thus, there is a good chance that people significant rise in excess mortality not labelled as who have been infected and subsequently recov- due to COVID-19 since the outbreak started. While ered are likely to be at least temporarily at lower some of these may result from undercounting of risk of reinfection, less likely to suffer the harmful COVID-19 deaths, others may be due to people effects of the virus and less likely to spread the not receiving care for other conditions (including, virus to other people. perhaps, an unwillingness to attend hospitals 12 Many countries, including the UK, have used because of perceived COVID-19 risk). on March 23, 2021 by guest. Protected copyright. strict lockdown measures in order to reduce the Those at low personal risk from COVID-19 spread of the virus. These include social distancing (ie, unlikely to suffer serious harms from infec- (working from home and only leaving for essential tion), and who pose a low social risk (ie, unlikely purposes), school and university closures, mask to spread the disease to others) might reasonably wearing and home quarantining. Some of these be permitted more freedom than current lock- measures result in enormous social and economic down measures allow. One group at low personal costs, severely restricting people’s interactions risk and who pose low social risk are those who ► http:// dx. doi. org/ 10.1136/ outside the home and preventing many from have been infected by COVID-19 and recovered, medethics- 2020- 106814 working. The UK government has sought to miti- and are now likely to have some level of immu- gate some of the economic harms by introducing nity to the virus. It has been indicated by the UK the Coronavirus Job Retention Scheme, whereby Health and Social Care Secretary, Matt Hancock, © Author(s) (or their employees are furloughed (placed on temporary that ‘immunity certificates’ might be provided to employer(s)) 2020. Re- use leave) and the government pays them 80% of those who have recovered from the virus.13 14 This permitted under CC BY. their wages (up to £2500 a month). In June, the follows the ambition laid out in the UK govern- Published by BMJ. cost of the scheme was estimated at £60 billion for ment’s plan for scaling up testing programmes, To cite: Brown RCH, the expected 8 months of its duration (though this which includes mass antibody testing (‘pillar 3’ of Savulescu J, Williams B, et al. could be further extended).3 One estimate of the the five- pillar plan): ‘Antibody tests offer the hope J Med Ethics that people who think they have had the disease 2020;46:652–659. global economic cost associated with COVID-19 is £4.7–£7.1 trillion.4 5 will know they are immune and get back to life 652 Brown RCH, et al. J Med Ethics 2020;46:652–659. doi:10.1136/medethics-2020-106365 Extended essay J Med Ethics: first published as 10.1136/medethics-2020-106365 on 15 August 2020. Downloaded from investigation. However, experience with other coronaviruses Box 1 Overview of immunity passports (including viruses that cause mild illness as well as more serious diseases like severe acute respiratory syndrome (SARS) and What are immunity passports? Middle East respiratory syndrome (MERS)) suggests that anti- ► Immunity passports are a way of recording that an individual body responses are likely to persist for at least a year and protect is believed to have immunity to COVID-19 and is presumed against reinfection at least in the short term.27 Antibody responses unlikely to contract or spread the disease. They could take the in SARS and MERS waned after 2–3 years, which might suggest form of a certificate, wristband, mobile- based app or other immune passports should be time limited. Reports of individuals document. becoming reinfected with COVID-19 are likely to be cases where ► Possessing an immunity passport could grant people the individual falsely tested negative in the setting of prolonged freedoms otherwise suspended during partial/full lockdown, viral shedding.28 Assuming that antibodies do indicate solid immu- such as travelling to work and socialising with people outside nity, the difficulty lies in correctly identifying those antibodies in the home. a way that permits testing to be scaled up significantly, without ► At present, no vaccine is available for COVID-19, so immunity exceeding a tolerable level of false positives/negatives. is presumed, in the main, to be acquired by infection and Someone who is identified as having antibodies to a particular subsequent recovery. This would need to be established via disease—in this case, COVID-19—is described as seropositive. testing at the time of infection and/or subsequent testing for Those without are seronegative. Antibodies might not be identi- antibodies. fiable in blood tests until days or weeks after illness has resolved ► It is unknown for how long after infection people remain in the infected individual.23 29 There is therefore a delay between immune to COVID-19 so passports may need an expiry date, an individual being infected with COVID-19 and them testing or people may need to be retested to confirm continued seropositive. A key feature of diagnostic tests is their sensitivity immunity. and specificity. Sensitivity refers to the test’s capacity to correctly ► Immunity passports could be used in combination with other identify those who have antibodies as seropositive. Specificity measures, such as widespread testing, and contact tracing for refers to the test’s capacity to correctly identify those who lack infected cases. antibodies as seronegative. A test that is very sensitive will have a low false negative rate: there will be few people who have anti- bodies whom the test erroneously identifies as seronegative. A as normal.’15 Other countries, including Germany and Chile, test with very high specificity will have a low false positive rate: may also be considering similar schemes.16 there will be few people whom the test identifies as seropositive The introduction of some form of immunity passport scheme who in fact lack antibodies. (see box 1) raises a number of ethical and practical problems, It is particularly difficult to develop a serological test for many of which have provoked significant debate.17–21 In the COVID-19 that has very high sensitivity and specificity.
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