COVID-19 Immunity Testing: A Passport to Inequity

By Françoise Baylis, Natalie Kofler

As COVID-19 case numbers start to plateau in various places, some governments are now focusing on how best to ease restrictions and reopen the economy. In the absence of herd immunity for the population—for which the threshold may be as high as 82%—next steps are not obvious.

Recently, some have touted “immunity passports” for people who have survived infection with SARS-CoV-2 (the novel coronavirus that causes COVID-19) and tested positive for SARS-CoV-2 antibodies. Under this proposal, citizens deemed immune to the virus through serological testing (a type of blood test) could be freed from current restrictions and allowed to return to work. According to media reports, Chile is poised to become the first country to issue some kind of immunity cards. Others considering this option include Australia, Germany, Italy, the United Kingdom, and the United States.

In an already heavily stratified society, the introduction of immunity passports is ethically problematic. They would not only exacerbate current inequities but also create a novel layer of biological inequity—one based on a potentially ineffective measure of immunity.

Infection with SARS-CoV-2 activates the production of antibodies that recognize the virus, some of which can function to neutralize viral function and potentially prevent future infection. Serological testing for SARS-CoV-2 antibodies could theoretically measure a person’s COVID-19 immune status. Anyone who tested positive for neutralizing antibodies and displayed no evidence of active infection could be deemed immune, assuming recovery from COVID-19 protects against reinfection.

Scientists don’t know, however, whether everyone can produce and sustain adequate levels of SARS-CoV-2 neutralizing antibodies. Recently published data (not yet peer-reviewed) demonstrated huge variability among recovered patients in their levels of neutralizing antibody. Asymptomatic individuals add an additional layer of uncertainty since researchers don’t know if these individuals mount an immune response against the virus.

But even if an immune response is mounted, the length of time a person is protected from reinfection remains to be determined. Some researchers predict COVID-19 immunity should maintain for at least a year following infection (barring any rapid mutations in the virus). However, that timeline is likely to vary from person to person, depending on their age, their immune status, and the severity of infection. This raises the question of how often serological testing would need to be repeated and immunity passports would need to be renewed.

For all these reasons, the World Health Organization currently recommends against the use of immunity passports.

In an already heavily stratified society, the introduction of immunity passports is ethically problematic. They would not only exacerbate current inequities but also create a novel layer of biological inequity.

Yet assuming some level of COVID-19 immunity exists, providing certification for immunity still presumes access to highly sensitive and specific COVID-19 serological testing. Many available tests are not accurate enough. A recent study in Europe (reported in preprint form) assessed nine commercially available serological testing kits and found that specificity between kits ranged from 65% to 100% (65% specificity means that 35 out of every 100 samples will be false positives). If someone is granted an immunity passport on the basis of a false-positive test result, that person could still be susceptible to infection and continue to spread the disease. Meanwhile, tests that have low sensitivity can cause increased rates of false negatives. False negatives would unfairly disadvantage people who may be immune but who would have to continue to follow strict self-quarantine procedures.

Dozens of tests have been approved for use in Europe and Asia, along with several in the United States. Each test uses different platforms, assesses for different antibodies, and uses different probes to measure antibody levels. This variability opens the possibility for huge variations in false positives and negatives within and across different communities and nations.

For reasons that are unclear to us, these technical hurdles have not dampened enthusiasm for immunity passports. Perhaps governments imagine that consistently effective COVID-19 immunity tests will soon be available, that these tests will be widely distributed on a cyclical basis for repeat testing, and that the data can be safely included in an enhanced coordinated health-tracking system. Maybe, but we’re doubtful. Even so, this wishful thinking does nothing to address the salient ethical issues:

Unfair access. Given existing inequities, and past experience with preferential access to coronavirus testing by the rich and famous, there is every reason to anticipate that fair access to immunity testing will be a challenge for the poor and already vulnerable—low-income hourly workers, immigrants, people of color, older people, people with disabilities, people with addictions, and those who are incarcerated.

The same will very likely be true for small businesses. Whereas large multinational companies with deep financial pockets will have the resources to facilitate early access to serological testing for their employees, small companies will likely remain shuttered much longer. And those people in the gig economy? Those who are underemployed or unemployed? It’s hard to imagine that they won’t be last in line.

More generally, there is already evidence of considerable inequity based on socioeconomic status across communities. One wealthy town in California (home to more than a few tech executives) recently sought to test every resident. Lower-income districts strapped for adequate health infrastructure will not be able to deliver universal immunity testing.

­­­There is every reason to anticipate that fair access to immunity testing will be a challenge for the poor and already vulnerable.

Threats to freedom and privacy. Immunity passports, championed as an effective way to loosen restrictions on personal movement, come with huge risks to personal freedom. Law enforcement will be required to police citizens to confirm that they have a legal immunity passport. This practice could further entrench already racialized stop-and-frisk procedures and disproportionately expose people of color to police detainment, questioning, and invasive searches. Individuals with undocumented immigration status will be at particular risk.

From here, it is not far-fetched to envision a police state where all citizens have biological passports, and their mobility and employment opportunities can be limited on the basis of a passport that will come to include information beyond COVID-19 immunity. Efficient monitoring will require electronic methods of documentation. These will feed into case-tracking interfaces, putting personal autonomy and privacy at risk indefinitely.

Risks to public health. If an immunity passport is the only way for people to reenter the job market (which for some will be the only way to keep a roof over their head and put food on the table), they will have an incentive to get a falsified immunity passport through illegal means, or to intentionally risk infection so as to qualify for a legal immunity passport. Either strategy would further threaten public health initiatives designed to minimize hospital burden and protect those most vulnerable to infection. From another perspective, the introduction of immunity passports for the purpose of jumpstarting the economy could create a perverse incentive for governments to instill less stringent immunity criteria. This, too, would put communities and the health infrastructure at risk.

Risks to global health. For some people, a return to work will include a return to international travel. If some governments were to use immunity passports to support relaxed restrictions on travel, new infection hot spots might persistently emerge around the world. Variability in each individual’s immune response to SARS-CoV-2 infection means that recovery from COVID-19 does not allow for a binary yes or no immune certification, as would be the case with vaccination.

Countries with poor oversight of their immunity testing programs and those with robust illegal markets could become major exporters of the virus—a scenario that could lead to international stigmas and geopolitical instability. Alternatively, travelers from countries with fewer resources for immunity testing would be unfairly disadvantaged, as would be travelers from countries that have elected not to introduce a national program of immunity passports.

Opportunity costs. The cost to introduce and implement an immunity passport program will be considerable, and the benefits in terms of reopening the economy negligible. Consider, for example, Chile. In this country of nearly 19 million people, there are more than 14,000 confirmed cases of COVID-19 as of April 28. Most of the afflicted individuals will survive, and presumably they will have some form of immunity. Assuming they were previously employed and remain employable, granting them an immunity pass of some kind and having them return to work isn’t going to make any meaningful difference to Chile’s economy, even with increased testing capacity over time and improved case tracking to enlarge the pool of immune workers. Within and beyond Chile, there is so much more that governments can and should be doing to shore up their economies.

Given the considerable scientific uncertainty and ethical concerns surrounding immunity passports, it is imperative that their false allure of simplicity not distract from the development of fair and effective measures to safely reopen the economy.

From the perspective that everyone is in this pandemic together, it makes sense to develop a plan for relaxing current constraints on work and social activities that allows universal sharing in the potential benefits and risks of the strategy. With immunity passports, the focus is ultimately on individuals, not the community. Yet acknowledgement of our mutual vulnerability to disease and our shared interest in survival enjoins us to think long and hard about how to best promote the common good while seeking to reopen the economy.

We agree with recommendations that governments need coherent and comprehensive serological testing to monitor spread and infection followed by contact tracing strategies. But first, proactive measures must be in place to protect individual privacy and health. Gathering information on race and socioeconomic status will also be critical for monitoring access to care and identifying where there is a need to correct structural inequities.

Given the considerable scientific uncertainty and ethical concerns surrounding immunity passports, it is imperative that their false allure of simplicity not distract from the development of fair and effective measures to safely reopen the economy.

To safely reopen sectors of the economy, efforts should be equally focused on training and supporting workers to follow COVID-19 preparedness protocols. Adequate training is necessary to protect workers’ health and the health of the larger public. Special incentives that support corporate responsibility for workers’ safety could add an additional layer of protection. Educational measures taken today could help protect health during future pandemics.

Equitable care and attention must be given to everyone. COVID-19 is prevalent and spreading among the most vulnerable and disadvantaged members of society. Overcrowded living conditions, lack of access to clean water for hand washing, malnutrition, and limited access to health care all contribute to increased virulence. Society needs to address these public health risks now. At the very least, everyone has to have a safe home and access to food, clean water, and health care. Poverty reduction will be critical to safeguard these basic needs; we would like to see more programs such as Canada’s Emergency Wage Subsidies.

COVID-19 is no equalizer; it is a flood lamp illuminating the glaring fissures of society. This crisis provides a unique opportunity to reflect, reassess, and revise—to change course, to do things differently for the benefit of all. To think that the poor and vulnerable can be sacrificed, while some people return to work with only an immunity passport for protection, is the height of folly. With a healthier and more just future in sight, immunity passports would simply be for travel to the past.