Public Health Insight

The Ticket to Freedom or A License for Segregation? Two sides of the Immunity Passports Discussion

June 23, 2020
Public Health Insight
The Ticket to Freedom or A License for Segregation? Two sides of the Immunity Passports Discussion
Show Notes Transcript

Prior to the ongoing multi-phased strategies to ease restrictions in jurisdictions across the world, countries were actively exploring innovative ways to return to normal during the COVID-19 pandemic without jeopardizing the health and safety of its citizens. At the centre of those discussions was the topic of Immunity Passports, a legal document issued by an official testing authority following a positive serological antibody test and a negative COVID-19 viral test. PHI’s Public Health Professionals engaged in an informative conversation to explore the potential benefits and limitations associated with Immunity Passports if they would have been adopted as a main strategy to facilitate the safe reopening of the economy and the loosening of public health restrictions as society yearned to return to some level of normalcy. Though very few countries proceeded to integrate immunity passports into their national reopening strategy, this concept was once seriously considered for broader application in the international context. 

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[00:00:00] Sully: Public health is a population-based field of science focused on preventing disease and promoting health. Every week, we will be engaging in interactive discussions and analyses of the latest public health issues affecting you and your communities all around the world. This is the Public Health Insight podcast.

[00:00:24] Wil: My name is Wil, and I'm here with Ben, Gordon, Leshawn, and Sully. 

[00:00:29] Ben: Before we move on, its important to note that the views expressed in this podcast are our own and do not represent any of the organizations we work for or affiliated with. 

[00:00:37] Wil: As regions around the world are slowly seeing the number of COVID 19 cases decrease, governments and heads of states begin to turn their attention towards resuming and restarting their national economies. At the center of the discussion around restarting economies is the topic of immunity passports. This concept has gained a lot of international traction with numerous countries stating their interest in further exploring the [00:01:00] plausibility of applying this to their national context.

[00:01:02] However, at the same time, the scientific community cautions against rushing to a decision, despite the need to resuscitate global economies. To begin, let's explain what an immunity passport is and talk about how they really work. 

[00:01:15] Ben: Right. So an immunity passport is basically a legal document or certificate issued by an official testing authority, following a serological test and a virus test.

[00:01:24] So the test identifies whether an individual has previously had COVID-19 and whether their immune system produced detectable antibodies, the virus test will check if the virus is still present in the body. 

[00:01:35] Gordon: Yeah. The key distinguishing thing here is the COVID-19 test is a genetic test that looks for the presence of the viral genome in the form of RNA. And the main technology that is used is a Polymerase Chain Reaction. So PCR, and basically a person is swabbed and the specimen is collected. And, um, whatever viral particles in the form of the viral [00:02:00] genome that is present, um, gets amplified by this lab technique. And this will help in the identification or the detection of active COVID-19 virus.

[00:02:12] Uh, the COVID-19 antibody test would be looking for the presence of antibodies specific to COVID-19. And these antibodies are developed after an infection has already occurred or later on in the infection cycle. 

[00:02:28] Wil: So let's so just to start, is it really necessary to have both of these tests when you're is confirming or checking whether an individual is, does in fact have immunity, like do, do we need the serological testing as well as the virus testing?

[00:02:43] Or like, can you just only do this serological testing and be content with that? 

[00:02:48] Gordon: So, both types of tests have a different role. The COVID-19 test is looking for whether the person is infected. And when we say infected, we mean the [00:03:00] COVID-19 virus is actively replicating in the human and the person is theoretically infectious. So that's what the COVID-19, the normal COVID-19 test tells us.

[00:03:11] So, the COVID-19 antibody tests will tell you if a person was exposed to COVID-19 because the only way you can develop immunity against a virus or another pathogen is if you were previously exposed to it. So at the very core, fundamental level, the COVID-19 antibody test will tell, whoever the clinician is, that this person has previously been exposed to COVID-19.

[00:03:38] And that is one of the problems that we'll be discussing is when we draw other inferences from oh, this person has been exposed, does that mean they're immune? What level of immunity do they have? And how long are they immune for? Those are some of the unanswered questions with the tests. 

[00:03:53] Wil: Okay. So there's been a lot of reporting on this issue of immunity passports over the last [00:04:00] couple of weeks.

[00:04:00] And when it kind of comparison, that's been drawn to the idea of immunity passports, is, um, what's called the yellow card. All right. So in 1959, Uh, the World Health Organization or WHO, they created, what was called the International Certificate of Vaccination or re -vaccination against yellow fever. So this certificate was initially used to track an individual's vaccination status for yellow fever.

[00:04:27] And, um, as it has since been expanded to capture additional vaccination statuses for a range of, um, infectious diseases. And, so, do you guys think that if the immunity passport was implemented in many countries, that it would operate the same way as this yellow card? Or do you see any differences there that could, you should be considerate of?

[00:04:48] Leshawn: Yeah. Will, I think that's an important question, but I think to start, we should really talk about the practicality of these immunity passports. So according to the literature, [00:05:00] these immunity passports are only practical when the following conditions are satisfied. So the first condition is recovered patients have protective immunity that prevents them from being reinfected.

[00:05:12] So if that immunity, they do receive from getting infected and producing antibodies is short-lived, people will just get reinfected and spread the disease. So in that case, these certificates will pretty much be rendered useless. Right? So the second condition is that the protective immunity is long lasting.

[00:05:31] The third condition that has to be satisfied is that the pathogen mutates sufficiently slowly for immunity to work against most strains. So this basically means that if we have this virus, the SARS-CoV-2 virus mutating very quickly, people can get infected because the virus is now, it has different components that can essentially infect the same individual who got infected. 

[00:05:58] And the fourth condition is [00:06:00] that immunity test have low false positive rates. 

[00:06:02] Gordon: Yeah. The piece with the, um, the virus not mutating sufficiently over a long period of time is important. For example, um, flu shots have to be readministered every year because something called antigenic drift occurs where, um, what does, this is just a fancy word for saying the specific parts of the virus that your body makes an antibody to changes from season to seasons rendering those antibodies ineffective against whatever subsequent strains occur.

[00:06:32] So we don't even know. Um, it's only been now December, 2019 since this virus was formally identified. So we don't even know the level of mutations that are going to occur and whether these antibody tests, as we know right now, will even give us the information that we're trying to get. 

[00:06:52] Wil: And so now that we've had a high level explanation and introduction to what an immunity passport is [00:07:00] and how they kind of function, I'd like to talk about their use during the current COVID-19 pandemic.

[00:07:07] So as of May, 2020, Chile's the only country in the world to have officially launched a national wide immunity passport program. And I think that's, that's pretty interesting because, um, you have countries like Italy, Germany, the UK, and other countries in Europe and higher economic powers that are considering it, but Chile, is the, the only one that has officially launched it and in the Chilean context, how this works is that, um, individuals who have recovered from COVID-19 will be given an antibody test and if their results come back positive, meaning that if they, their bodies have produced the antibodies, um, they will be issued the physical or a digital version of these cards.

[00:07:58] And what would [00:08:00] these, um, cards or like passports let's call them, what they allow these individuals to do is that they're essentially exempt from all quarantine orders and other kinds of restrictions. And they're essentially get to go out and do their regular thing and not have to follow these lockdown orders, which I think has very significant implications for themselves, as well as for the greater country.

[00:08:25] Leshawn: Right. The case in Chile is actually an interesting one. It kinda makes me think of how one can determine how much herd immunity is actually sufficient to mitigate further outbreaks of COVID-19. So one of the things that we talked about early on in one of our episodes was something called the reproduction number or the R-naught (R0) value, which is basically if someone's infected with the virus, how many people can that person spread the virus to?

[00:08:51] So, for SARS-CoV-2, that number is estimated to be around 2.2 people. So based on this R-naught [00:09:00] value of 2.2 and some fancy herd immunity calculations, it seems that at least 60% of your population will actually need to be protected and have protective immunity either from natural infection or by vaccination.

[00:09:15] So one of the things I'm actually concerned about is that there's limited testing being done. And I'm also worried about the practical aspects of rolling out the process of immunity passports, who will be the one selected to be tested and granted access to these immunity cards?

[00:09:31] Gordon: So you're, you're concerned about the practical implications of this. For example, if like were the latest estimates say, you know, around 1%, 2%, 3% of countries populations have been affected by COVID-19. So if we're going to do an immunity passport, that only allows 3% of the population to do anything, is that really practical to send 20 people back to work out of a community of [00:10:00] 5,000 or whatever?

[00:10:01] So my concern with this, and I would love to hear more from technical experts in the field because I'm not a technical expert. I would love to hear more about the kind of technical concerns and the underlying assumptions of this test, because the test is assuming, so the test at the basic level tells us, okay, um, Gordon was infected with COVID-19 at some point. Okay. Um, what it doesn't tell us is one, uh, how long that immunity will last? How effective that immunity will last? And what my chances are of being infected again, or reinfecting someone in the future. So if we can't use this test to answer those basic questions, I'm seriously concerned about the usefulness of the COVID-19 antibody test. 

[00:10:47] And if the COVID-19 antibody test doesn't give us clean information, then this pretty much renders an immunity passport ineffective. And I want to go back to the yellow fever example. The key thing with the [00:11:00] yellow fever is, uh, as we said, it incentivizes vaccinations. And the thing with vaccinations, vaccines are very heavily scientifically studied and tested, um, everything from the robust immune response, you know, how long immunity lasts. That's why people get booster shots. Cause this thing has been studied. Okay. The immunity dies off after 10 years, people it's recommended to get another vaccine. Right. Um, when you get infected with COVID-19 naturally, we don't know how long the immunity will last. We don't even know how long people have anybodies for.

[00:11:34] For example, there are two antibodies involved in the adaptive immune response. There's the Immunoglobulin, which I believe is antibodies that are produced in the first kind of week of infection. And those tend to taper off. And then the Immunoglobulin G, which is a longer-term immunity comes in, you know, weeks later. Uh, we don't know if these, because there's no standardization for these tests, right.

[00:11:58] So we don't know what [00:12:00] to compare a test from Chile and one from Canada. Canada recently, uh, announced that, um, on May 12th that they have approved the first antibody testing for use in Canada. We don't know if we can even compare it to the Chile ones right? Because we don't know, are they testing the different types of Immunoglobulins? What is the sensitivity level that they need? Is it, you know, what's the threshold? 

[00:12:21] So, then you have, you have difficulty comparing populations to populations, you know, in Canada, there's different provinces. What if, you know, Quebec uses a different test than Ontario? Um, are you going to be able to compare those populations?

[00:12:36] I think this is, you know, their criteria for immunity might be different from Ontario. So does that mean you can travel to Quebec? Like it's just a logistic nightmare because it's not standardized. 

[00:12:46] Leshawn: Yeah. Gordon, that's a great point you brought up about the standardization of testing and comparisons between populations.

[00:12:53] I think it's important that the test properly distinguished between past infections of SARS-CoV-2 [00:13:00] and those caused by other, um, human coronaviruses, which there are about six of, so four of those six human Corona viruses are implicated in the common cold and circulate widely. And the other two of the viruses are implicated with Middle East Respiratory Syndrome and Severe Acute Respiratory Syndrome, otherwise known as SARS.

[00:13:22] So I think the worry here is that people infected by any one of these viruses may produce antibodies that actually interfere with antibody testing. And this would basically mean that people are falsely labeled as either a positive or negative. 

[00:13:36] Ben: Yeah. Leshawn. There's a lot of technical limitations and assumptions when we're trying to see the accuracy of these tests. For example, my concerns are the false positives and the false negatives that could arise from such tests and the social implications of that. So just quickly a false negative is a non-immune individual who is being led out and then creates a risk of additional infections.

[00:13:56] And then a false positive is an immune individual kept under [00:14:00] lockdown when they should be out. So when we get to the whole, um, complications, is this test accurate? And if it's not accurate, then how can we go and make these long-lasting assumptions of how people's behavior should be modified? Right? So additionally, one of my major concerns is that the, WHO has even said that there's a lack of evidence that people have recovered from COVID-19 will be protected from a second infection.

[00:14:25] The very basis of this immunity passport is not even concrete. We've seen examples across Asia, for example, in South Korea and in China, where individuals who were initially recovering from COVID-19 and fully recovered, as stated by medical staff, were then infected again. So an individual has COVID-19, they get the immunity passport. They say, they're all good. They go out into the world, they do their thing, they get infected again. And then we have again, community transmission. So I'm having a hard time trying to figure out why immunity passports are being a discussion when the very basis of it is not concrete.[00:15:00]

[00:15:00] Sully: So looking at the bigger picture here, I think we need to look at the benefits and the cons, and then see if the benefits outweigh the cons. For example, one benefit would be concerning health care workers, where if they're recovered and they have this passport, they can treat patients knowing that they're not risking themselves or others around them.

[00:15:23] Whereas say a, a con of that is that, this test that we're talking about is lacking supporting evidence. We don't know how accurate it is and it's not answering the basic questions that we've asked previously. 

[00:15:35] Wil: Right. One of the issues that come to mind for me, it's a very, like, this issue is a very much a double-edged sword.

[00:15:42] Yeah. In that countries are incentivized and are pressured and feel the need to quickly restart their economies. Given the pressures place on governments, you know, because right now with the economies at a standstill, governments are forced, you know, to [00:16:00] start adopting more and more social welfare policies and just other programs to support their populations.

[00:16:06] So that people aren't starving or going up, going without food and water, things like that, which I think is a perfectly valid reason for wanting to implement these passports. But on the flip side of that, an issue that I see coming out of this is the potential creation of societal divides. Right, because here you're having a document that essentially gives COVID immune individuals, freedom to do whatever the heck they want.

[00:16:33] And, you know, to, for example, to go back to work, to go out and see friends and family, things like that, right. Because there's no risk of them infecting others. And the risk of them being infected is also thought to be knelt. So, the issue with the societal divide that I see is that with this passport, you're going to start seeing differences in privileges, right?

[00:16:54] You have already disproportionately affected populations who [00:17:00] will be further stigmatized. And then for example, even just with being issued this passport, how are they going to decide who gets tested first? It's just a whole whack load of societal risks that I think can come out of it. And I think that's something that maybe we could have a brief discussion about.

[00:17:17] Gordon: So let's backtrack a bit, we know that certain populations like African Americans in the United States, um, have a disproportionate negative outcome from, uh, COVID-19 infection. So, um, they're overrepresented in the number of deaths compared to the non African-American population. So if you're an insurance broker or a health insurance broker, you know that for, you know, people in certain communities who haven't yet been exposed to COVID-19 their chances of dying from it are higher.

[00:17:49] So then you might be more inclined to want to increase their premiums because, um, you're going to know that you have the data. Uh, we know that increasingly [00:18:00] more jurisdictions are starting to collect race-based data. So if you can kind of predict who is more likely to die from COVID-19, you can essentially increase insurance premiums on those groups. So that is, that goes to the privilege piece as well. 

[00:18:16] Wil: And just going back to what I was talking about earlier with that creation of the societal divide, um, for me a document like this will only increase and widen the inequality gaps that already exist in many of these countries.

[00:18:31] So for example, um, you know, you have, if you have individuals who are out there able to make a living. Able to earn a wage kind of thing because they have immunity. Um, and then you have other people who have to stay home, who have to follow these lockdown orders. Isn't that, um, a difference in economic opportunity there, between those two groups?

[00:18:53] And what I see with that, uh, potentially happening is you, you have, you have the groups who are able to kind of just [00:19:00] get ahead and get further along in life, or just in terms of their wealth. Because they, because they had this immunity and just pushing more and more people to the other side of that who don't have access to, and who are going to have to depend on these social welfare programs that authorities are starting to roll out.

[00:19:17] Gordon: Yeah. And another thing too is we might even get the chicken pox situation, you know, when you're, you know, you're a kid and maybe you're in your elementary school and there's someone in your, maybe someone in your friend circle, or even in your family who has chicken pox. I know back in the day, my mom would kind of try to get everyone together so that you could get chicken pox, um, at an early age, because, you know, the symptoms are less severe, right? So, and this would be, you know, you get it over with, so you can go back to school and not worry about it. So COVID-19, if you're going to have a roadblock to whether people can return to work, people might deliberately start exposing themselves to COVID-19 in order to get this passport to go back to work.[00:20:00]

[00:20:00] And we know that, you know, we discussed that it affects different populations differently depending on the already existing health disparities. And this might also increase the number of deaths in certain populations. So that's kind of one of the, uh, I don't think they created it to cause this, I think its more, one of the unintended consequences of having something that as we discuss kind of incentivizes people who are desperately in need to get back to work, to kind of put themselves in harm's way to get infected.

[00:20:31] Wil: Yeah. And wanting to go back to what Ben said earlier about the false negatives and false positives and the WHO's warning against immunity passports. A thought that came to me was how rolling out a system involving these certificates can really give people a false sense of hope or confidence in themselves.

[00:20:52] And this could be very problematic. And an example that came to mind was initially when people started [00:21:00] wearing gloves, wearing masks as a way to protect themselves from getting COVID, there was a lot of warnings, at least in Canada from our CPHO, Dr. Tam saying that the risk with what people wearing masks and gloves is that they will likely act more carelessly and know, think that, oh, because I'm wearing a mask and gloves, I'm safe. I don't have to worry about being infected and they'll go out and start doing regular activities. We're in a similar way, if an individual gets an immunity passport, they might also act carelessly. And as we mentioned earlier, like, like the WHO said there isn't concrete evidence surrounding secondary infections, that we don't know what can come out of this. And it's really something for government authorities to consider before implementing a program like this is what are the, um, the risks of careless behavior that comes with it? 

[00:21:54] Gordon: Yeah. So another thing as well, and this, this is something that always bugs me.[00:22:00]

[00:22:00] We're struggling to meet the demand for regular COVID-19 genetic testing. So the test that tells you if someone has an infection or not, uh, and this is what's four or five, six months since December, 2019. And we're still, haven't kind of, I don't think people are fully a hundred percent confident in regular COVID-19 tests and we want to implement something that basically defines whether someone can have economic prosperity or not. I'm not sure if that's a good idea. We don't even know how many of these tests are going to be available. Right. How, you know, is it going to be able to be scaled up to a meaningful level where contests 50% of a population and maybe send some of that back to work?

[00:22:42] Um, if you only, you know, if you're only able to test a certain amount per year, per day, then, I mean, how meaningful is it gonna be? I I'm just not really sure. I'm not really sure. I think what the thing with testing people have to understand, if I can come up with a COVID-19 test that has [00:23:00] no false negative or false positives. Right. And that's great. But can I then scale this up at a meaningful level? That's another question that we have to ask ourselves can test be scaled up on a meaningful level without compromising the quality. And that's one of the biggest problems. 

[00:23:15] Wil: Yeah. I think. I think we need to take a step back though and realize what we've discussed today was a lot about the risks associated with implementing immunity passports, right.

[00:23:27] And as we've discussed, we have seen that this concept needs to be better understood and strategically planned out before actually implementing it. However, we also need to consider just what kind of like the level of economic strain that are placed on certain countries. And try to understand why so many regions are seriously considering something along these lines, because, um, you know, as we all know in public health, your socioeconomic status, it's incredibly linked to your overall health.

[00:23:59] [00:24:00] Right? And I think before we kind of nitpick at the specifics of immunity passports. I think we all really need to consider, um, is, is this the best option that we have at the current moment? Because as we've seen around the globe, countries readying to start getting people back to work so that the whole society and the whole economic system is able to start running again. And I think that that's, that's part of the difficulty and the pressures that are placed on policy makers, because they need to find some way to kind of support the country and support the finance and the economy, but also caring about the wellbeing of other people living there. So it's, it's definitely a very messy issue that there isn't really, uh, right or wrong solution, but I think we, I think we need to also just be mindful of how much of there is a need to kickstart work again. 

[00:24:54] Gordon: Um, and I had another closing remark, so I think science is [00:25:00] very important and we're not, obviously we're not anti-science in this discussion. Um, our concern is more, the conclusions that can be drawn from results of this test. So I think, um, once these become more accessible, I think it needs to be made clear what a positive or a negative test result means. And that's what I'm worried about. A positive test result based on the current diagnostic limitations that we have now with these tests is that a person was previously infected.

[00:25:30] It does not mean that you are immune to re-infection and it doesn't tell us how long you're going to be infected. Because we don't have this information, we know about past regular passports for travel, have an expiration date on it. Correct? So are these immune passports going to have an expiration date?

[00:25:49] We can't put an expiration date if we don't know how long someone's immune for. So I think science and politicians, um, politicians, and decision-makers need to take an honest look at this [00:26:00] and acknowledge these limitations and, we know misinformation is a very powerful tool. So that's why I'm very cautious with implementing this on a wider scale. I think it just needs to be made clear what they do and what they don't do. 

[00:26:16] Wil: So, as you've heard today, we discussed the concept of COVID 19 immunity passports and considered the positives and negatives associated with the idea, are governments around the world providing an innovative opportunity for communities to return back to work? Or are they unknowingly setting the stage for greater levels of segregation and inequalities?

[00:26:34] Thank you for listening! 

[00:26:36] Sully: Remember public health is a field of inquiry and an arena for action to improve lives, one population at a time. This has been the Public Health Insight podcast. If you've enjoyed this episode, please drop us a like, and follow us on Spotify, Apple podcast, Google podcast, or your podcast platform of choice.

[00:26:55] You can also send us your questions, comments, and suggestions for [00:27:00] discussion topics at: thepublichealthinsight@gmail.com 

[00:27:03] Thank you for listening. And we'll see you in the next episode.