Friday, April 02, 2021

mRNA Therapeutics Don't Confer Immunity - So - How Do These Lying Liars Say "Immunity Privileges"

NEJM  |  The public appears to be deeply divided on the appropriateness of immunity privileges. Last summer, we elicited views from a nationally representative panel.2 Support for certification programs based on positive tests for antibodies to Covid-19 was almost evenly split (see graph). Moreover, in contrast with views on many other pandemic-control policies, the division of opinion on immunity passports cut across ideological, racial, and socioeconomic lines. The survey was conducted during an earlier phase of the pandemic and did not address vaccination-acquired immunity explicitly, although more recent surveys that have done so have also revealed deeply divided views.3

The mixed views and range of competing arguments suggest that it would be precipitous — and extremely unlikely in the United States — to adopt an official government policy requiring widespread use of vaccine passports. On the other hand, we believe the objections raised fall short of justifying a ban on any and all uses of vaccine certification (which some commentators have proposed). Access to vaccines is increasing rapidly, with special efforts being made to reach disadvantaged groups. Although better understanding is needed of the nature and degree of immunity that vaccination confers, it seems clear enough that risk — especially for severe disease — is dramatically reduced. Mechanisms for reliable and accurate certification are important. But development of such mechanisms is largely a technical issue — one that some leading technology companies are addressing — and it should not completely block an otherwise sensible policy. Finally, requiring people who decline vaccination to bear some consequence for their refusal seems only fair, especially if, collectively, such hesitancy puts herd immunity out of reach.

Thus, rejecting policy extremes — a broad mandatory public scheme or a prohibition on all private uses of certification — is a relatively easy call. But how should policymakers navigate the large and complex space in between? What is either acceptable or optimal can vary substantially by context. Two features of this landscape are particularly important for evaluating the appropriateness of policy moves: the nature of privileged activities and the identity of the regulator.

An important starting point is distinguishing passports from mandates. When government conditions participation in essential activities such as work or education, certification essentially functions as a mandatory vaccination program. The legal and ethical perils of a government mandate for SARS-CoV-2 vaccines at this time have been well reviewed elsewhere.4 Therefore, we focus here on policy uses of vaccine certification other than having the government itself restrict physical access to essential settings such as workplaces, schools, and health care institutions.

The “passport” concept applies most obviously to travel. Federal and state authorities currently impose quarantine requirements on people who cross state or international borders. Most such policies do not make exceptions for vaccinated travelers. However, some states are considering doing so. The Centers for Disease Control and Prevention recognizes vaccination as grounds for lifting quarantine for people exposed to Covid-19 infection; and for travel from most countries, the agency has recommended lifting restrictions on entrants who have recovered from Covid-19.5 It seems only a matter of time before the same policies would apply to travelers who can show proof of completed vaccination.

In taking the lead on vaccination-related travel policy, government can start by establishing standards for reliable documentation of vaccination. Such standards are likely to emerge relatively soon from public–private partnerships in the travel sector, and then spread to other settings.

Those other settings include social and recreational gatherings. Here, the case for government control is weaker, because frontline policy setting and implementation more naturally fall to private actors. Allowing sports leagues, concert and sporting venues, clubs, restaurants, and bars some latitude to set rules that determine access on the basis of customers’ vaccination status would be reasonable; doing so may also serve wider efforts to encourage vaccine uptake. Although not in the driver’s seat, government will have to help steer. Private actors need standards and bounds, including clear directives barring uses of vaccine certification that constitute unlawful discrimination. More generally, government can help to mitigate inequities arising from private certification by boosting the supply and distribution of vaccines and redoubling efforts to reach underserved populations.