Key Questions about COVID-19 Vaccine Passports and the U.S.

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As COVID-19 vaccination rolls out in parts of the world, many countries have started to implement or are considering the use of COVID-19 “vaccine passports” – paper or digital forms certifying that a person has been vaccinated against COVID-19 – for purposes of international travel. In addition, some countries are using them for domestic travel and/or access to certain establishments, activities, and events. Such certifications are separate from but related to the issue of vaccine mandates. Where COVID-19 vaccines are mandated, there will be a need to certify vaccine status, and a vaccine passport is a potential tool for that purpose.

The U.S. government is exploring COVID-19 vaccine certifications for use internationally and domestically. The administration has said that a vaccine passport may be required in the future for international travelers entering the U.S., but it will not impose a federal requirement for domestic purposes. However, it is working with the private sector to develop standards around such certifications. Within the U.S., states are landing on different sides of what has quickly become a partisan issue with several states moving to implement passports while others have come out strongly against the idea.

This brief provides an overview of what vaccine passports are, how they are being used, and identifies a number of outstanding policy issues facing the U.S. in both the international and domestic contexts.

What are COVID-19 Vaccine Passports?

A vaccine passport is a paper or digital form certifying that a person has been vaccinated against a particular disease. There is a long history of the use of vaccine certifications for international travel, with many countries currently requiring travelers to present proof of yellow fever vaccination to enter, for example. A COVID-19 vaccine certification for international travel could be used by governments in a number of ways, such as allowing an individual to move across borders more freely by potentially bypassing travel restrictions like testing or quarantine requirements upon arrival. In addition, vaccine passports may be used for domestic purposes, such as to permit individuals access to certain businesses, locations or activities within countries.

Where are COVID-19 Vaccine Passports Being Used Now?

Several countries have already begun to use COVID-19 vaccine passports, with wide variation in policies and implementation. Israel began issuing ‘green passes’ in February 2021 to their vaccinated citizens to allow for less restricted internal movement and access to businesses such as to gyms or theaters. Other countries, such as China and Bahrain, have begun issuing digital vaccine passports to their vaccinated citizens to equip them to travel internationally. Lastly, in several countries, including Georgia, Estonia, Poland, and Seychelles, proof of COVID-19 vaccination allows incoming travelers to avoid certain travel restrictions, such as testing or quarantining. Numerous other countries are considering the use of COVID-19 vaccine passports, either for internal or international movement, including the United Kingdom, Malaysia, Singapore, Greece, Denmark, the EU, and the U.S.

Multiple international organizations have already launched efforts to set standards and coordinate the design and implementation of vaccine passports for international travel, including the World Health Organization, World Economic Forum, International Chamber of Commerce, and the International Air Travel Association. The WHO is undertaking this effort as part of its mandate under the International Health Regulations (IHR) to coordinate among member states to provide a public health response to the international spread of diseases; it is possible that COVID-19 vaccination could be included in an updated version of the IHR (at this time, yellow fever is the only disease listed in the IHR for which countries can require proof of vaccination as a condition of entry).

Will the U.S. Use COVID-19 Vaccine Passports?

There is likely to be growing demand for vaccine certifications for use in the U.S., for international travel as well as domestic purposes. Airlines and tourism groups have already called for vaccine certifications as a way to ease the process of pandemic-era travel; the CDC recently released guidance saying fully vaccinated individuals can resume non-essential travel safely within the U.S. and stating that fully vaccinated persons can consider international travel if they maintain recommended precautions. Federal officials have also indicated that vaccination may in the future be required for entry into the U.S. for incoming travelers; the U.S. currently requires all air passengers coming to the U.S. to have a negative COVID-19 test.  Domestically, proof of vaccination may be required for entry into certain federal facilities in the U.S., including military bases and other federal buildings, and a number of U.S. companies and universities have already announced vaccinations will be required for their employees, students, and staff, which will require some kind of certification (see this recent KFF analysis for more discussion of vaccine mandates in the U.S.). Indeed, as stated at a recent meeting of the federal Office of the National Coordinator for Health Information Technology (ONC), “Proof of individual COVID-related health status is likely to be an important component of pandemic response” and “As more of the population becomes vaccinated, proof of immunization will likely become a major, if not the primary, form of health status validation”.

The Biden administration has made it clear it will not be the role of the federal government to issue vaccine passports or to collect and store individuals’ vaccination data at the federal level, but the government is taking on a coordination role and working with many of the international and domestic vaccine passport initiatives being developed by other parties. For example, President Biden issued an Executive Order directing the State Department to work with the World Health Organization, the International Civil Aviation Organization, the International Air Transport Association, foreign governments and others to establish international travel standards. Further, the order directs the Secretaries of the State Department, Department of Health and Human Services, and Department of Homeland Security, in coordination with relevant international organizations, to assess the feasibility of linking vaccination status with digital certificates for international travel. On the domestic side, the Administration is working with a number of privately-led vaccine passport initiatives already underway, to develop guidelines and address issues such as accessibility, privacy, and other access barriers. There are at least 17 such U.S.-based initiatives involving companies and institutions including Microsoft, IBM, MasterCard, the Mayo Clinic, and MIT. So far, these efforts remain in the development stage and none of these organizations has yet launched a vaccine passport for widespread use in the U.S. In the absence of a widely used vaccine passport system, the Centers for Disease Control and Prevention (CDC) “vaccination report card”, which is issued to each vaccinated individual, is being used as proof of vaccination in many cases for access to some activities and facilities. However, these cards can be falsified and lack a digital counterpart, upping the stakes on the need to develop standards and implement security measures.

Individual states are landing on different sides of the issue. Several have launched or are actively exploring the use vaccine certificates with New York being the first state to introduce a COVID-19 vaccine certification pass that would allow individuals to certify their vaccination status in order to access certain social activities. Other states, including Hawaii, are considering similar efforts. At the same time, several governors have come out strongly against vaccine passports, with some issuing executive orders banning their use, as has been done in Florida and Texas, or supporting legislation to prevent them, as in Tennessee. In the absence of a federally issued or sanctioned vaccine passport, and no nationwide private sector initiative yet being adopted, the U.S. may see more state or local level certification initiatives, which may or may not be coordinated across jurisdictions.

What are Key Implementation Issues to Consider?

There are a host of challenges and questions surrounding the design and use of vaccine passports, including issues of equity and access, a lack of uniform standards, and privacy and security.

Equity and access: There have already been significant equity challenges in vaccine roll out and access. Globally, most people in low and middle income countries (LMICs) do not have access to COVID-19 vaccines and may not until 2023 or later, and within the U.S. our analyses show that Black and Hispanic people have been vaccinated at lower rates than White people, and that high poverty and uninsured rates are associated with lower vaccination rates in many U.S. counties. In addition, non-citizen immigrants in the U.S. who, while eligible for free COVID-19 vaccination, may be reluctant to access the vaccine and/or to sign up for a vaccine passport that would require sharing of personal or other information with authorities. Further, it is still an ongoing question as to how populations that are either ineligible or unable to receive the COVID-19 vaccine, such as children under the age of 16, people with medical exceptions and those with religious objections, will be included in a COVID-19 vaccine passport system. Lastly, the process to sign up for a vaccine passport itself may present additional access issues, particularly for some groups. Given these inequities, some have cited concerns that proof of vaccination as a condition to access certain activities, such as travel or specific venues, has the potential to be discriminatory. For this reason, the World Health Organization’s Emergency Committee on the COVID-19 Pandemic officially cautioned countries against the use of requiring COVID-19 vaccine passports for international travel at this time, stating that COVID-19 vaccination should not exempt individuals from other risk-reduction measures while traveling and noting that vaccination as a requirement to travel would inequitably impact individuals in LMICs. Likewise, a coalition of travel organizations recently expressed concerns about imposing a travel-related vaccine requirement, recommending that vaccinated individuals be exempt from international testing requirements but that vaccination not be a “prerequisite to travel.” The EU, in its proposal for a Digital Green Certificate, has said that to ensure freedom of movement with the EU, it would include COVID-19 test certificates and certificates for those who have recovered from COVID-19 as part of its plan, in addition to certification of vaccination. New York state’s Excelsior Pass also allows for the use of a negative COVID-19 test (instead of vaccine certification).

Mutual recognition of passports: Countries that have begun or are considering issuing COVID-19 vaccine passports will need to establish agreements with other countries in order to have these passports recognized for international travel. Already, some of the initial passport proposals demonstrate limitations in this regard. For example, the EU’s proposal would allow for any vaccinated EU citizen to travel freely across all EU member states, but not outside of the EU. Israel has signed an agreement with Cyprus and Greece to allow for international travel, while Malaysia and Singapore are considering an agreement for reciprocal recognition. The U.S. has not yet weighed in on an international standard or indicated what form of passport the government would accept for international arrivals, though such standards are being discussed and developed but have yet to be applied. This has created confusion, and a fragmented approach across countries so far. It is also likely to be an issue within the U.S. as different jurisdictions take varying approaches.

Lack of uniform digital standards: Related to the issue of mutual recognition is that of digital standards. Currently, there is no standardized guidance related to the design of COVID-19 vaccine passports, including any standards for issues such as data privacy or interoperability. One report has identified at least 12 issues that will require international guidance in order to create a universally recognized COVID-19 vaccine passport system. The WHO’s Smart Vaccination Certificate Working Group is currently working to provide such international guidance and standards. The group released its first round of guidance addressing several digital standards issues, including interoperability and minimum data standards, in March 2021. A complete set of recommendations in expected in June 2021, though in the meantime, countries are moving ahead with individual efforts. Within the U.S., the interoperability of individual organization or jurisdiction passport efforts also presents a domestic challenge.

Diverse vaccine authorization and approval landscape: Across countries, different combinations of vaccines have been authorized and administered. Some of the vaccines used in one country may not be recognized or accepted by another country, raising questions about whether and how to certify different vaccines across this landscape for purposes of a vaccine passport. For example, Iceland has stated that only vaccines approved for use by the European Medicines Agency or the WHO will be recognized in order to waive certain screening and quarantine requirements for incoming travelers, which would exclude persons who have been vaccinated with the Russian Sputnik V vaccine or one of the Chinese-developed COVID-19 vaccines. Similarly, the EU’s Digital Green Certificate proposal would also only include vaccines that have received EU-wide authorization. So far, the U.S. has not stated which vaccines it might accept for the purposes of a vaccine passport.

Scientific considerations: The WHO has stated there is a need for further scientific investigation into COVID-19 vaccine products to understand in more detail the extent vaccines reduce transmission, and the strength and duration of immunity provided. For example, Israel’s green passes are only valid for six months starting the week after vaccination, to take into consideration the potential for waning immunity over time. COVID-19 passports may need to consider each vaccine product’s unique immunity profile when issuing certification of vaccine-induced immunity over a certain period of time, a process which becomes even more complicated in the presence of variants with unknown effects on vaccine effectiveness.

Privacy and security: Among the concerns raised in the lack of uniform digital standards and COVID-19 vaccine passports is the issue of privacy and data security. Combining and storing individuals’ vaccination data in a centralized database could expose this information to data breaches and raises questions about oversight and control of that data. In fact, some vulnerabilities have already been detected in COVID-19 vaccine passports under development. Individuals and organizations are less likely to want to participate if these concerns about security and privacy are not adequately addressed.

Conclusion

There are a large number of as-yet uncoordinated efforts underway already to develop vaccine passports. It is not yet clear if or when the U.S. might adopt a vaccine passport standard for cross-border travel or for domestic purposes, and what form such a credential will take or what restrictions it might place on individuals. It is likely that attention to, and calls for, vaccine passports for both international and domestic use will increase over time, as more people are vaccinated and governments and employers seek to find ways to balance public health concerns while also easing a return to some level of normalcy. However, there a number of significant issues to consider related to the design, use, and ethics of vaccine passports, and many questions about how they can and should be implemented in the U.S. and elsewhere.





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