Are ‘immunity passports’ key to help reopen society or idea ripe for abuse?
Some experts think they’re inevitable, but raise concerns about privacy and ethical issues
André Valleteau isn’t sure if he should count himself lucky, but he does feel a little safer than most of us.
At 27, the Toronto resident is a member of a growing but still exclusive group in Canada — the COVID recovered. Its official membership stands at 22,000 nationwide, and Valleteau was among its founding cohort.
He’s research co-ordinator for a Toronto company that conducts clinical trials, and in early March he spent an hour with a participant in a diabetes study who had just returned from the United States.
Days later, while struggling with unshakable fatigue, Valleteau was informed by a public health official doing contact tracing that the trial participant had tested positive for COVID-19. The official sent him that same day to Sunnybrook hospital, where he, too, tested positive.
Luckily, Valleteau’s symptoms were relatively mild — an irritated throat, cough, headache and fatigue. He never got a fever. And in 10 days he was back to normal. Then he thought, am I now immune?
“That’s the question with the whole immunity thing: can I just waltz around without thinking twice about things?” Valleteau asks in a phone interview.
“I don’t worry as much about the coronavirus as I would have if I hadn’t had it,” he adds. “I feel like I have maybe a safety net against getting it again. But I don’t take that as a free pass, either.”
As a graduate of a life sciences program at Queen’s University, Valleteau is up to speed on the developing science on COVID-19 immunity.
“In theory, I should be OK,” he says. “But for how long?”
That essentially sums up the World Health Organization’s warnings about “immunity passports” — proposed official documents conferring freedom to play, work and travel on the COVID recovered.
“We expect that people who are infected with #COVID19 will develop an antibody response that will provide some level of protection,” the WHO said in a tweet last weekend. “What we don’t yet know is the level of protection or how long it will last.”
It’s the reason Prime Minister Justin Trudeau has described talk of immunity passports as premature. He has set up a COVID-19 immunity task force that will “co-ordinate a series of countrywide blood test surveys” to determine the spread of the virus and potential immunity among Canadians.
The science around serological tests for COVID-19 antibodies is uncertain, but that hasn’t stopped countries around the world from rushing to get them done. Their allure is obvious.
The 54,000 Canadians who tested positive as of Friday afternoon for SARS-Cov-2, the virus that causes COVID-19, don’t tell the whole story. Some infected people show no symptoms, others have symptoms too mild to be tested.
Testing for antibodies produced by the virus gives a truer picture of its spread, a more accurate mortality rate and a better idea of how close we might be to the Holy Grail of herd immunity, often estimated as 60 to 70 per cent of the population. In other words, antibody tests could help determine how quickly to loosen physical contact restrictions and get back to normal.
They could also determine how long immunity might last and the effectiveness of proposed immunity documents. Chile isn’t waiting for results — it has announced it will soon issue “release certificates” to the COVID recovered.
Dr. Anthony Fauci, a key member of the White House coronavirus task force, told CNN recently the U.S. government is considering some form of immunity certificate, describing them as having “some merit” in determining who is vulnerable and who is not.
Maxwell Smith, a professor and bioethicist at Western University, believes mounting pressure to restart the economy makes their adoption a matter of time.
“I think it’s all but certain that we’re going to see something like an immunity passport be implemented in many jurisdictions and probably in Canada as well,” he says in a phone interview.
“Given the fever pitch we’ve reached talking about antibody testing, I think the public will be very interested in having something like this so that we can reopen society,” he adds.
Variations of the theme already exist: some countries won’t allow travellers to enter without a certificate confirming they’ve been vaccinated against yellow fever. But COVID immunity passports would be far more powerful documents, essentially conferring to those who have them the right to a life of pre-COVID normality.
With livelihoods on the line, Smith warns of the potential for a variant of “chickenpox parties,” the practice of exposing children to the virus in the belief it’s easier to recover and gain immunity at a young age. (Although less common since the development of a chickenpox vaccine, it’s still known to occur among people opposed to vaccines.)
“You could see COVID-19 parties so people can get their immunity passports and get back to work, which could be a very dangerous prospect,” Smith says, noting how contagious and deadly the virus continues to be.
Officially certifying the immunity of workers with vulnerable groups — in long-term-care homes, for example — can have obvious benefits, Smith says. But before certification is widely used, “we need to think long and hard about the intended and unintended implications, and whether they’re acceptable,” he adds. Immunity documents will become so valuable, an underground market in fake ones will likely flourish, says University of Toronto public health professor Ross Upshur, invoking the classic film “The Third Man,” where a character illegally sells diluted penicillin, causing the deaths of many. “It’s a sign of such desperation that we forget all of the lessons we’ve learned around stigmatization and infectious disease,” says Upshur, co-chair of the WHO’s working group on ethical issues raised by the virus that causes COVID-19.
“Do we have to invoke the Nazis? Are we going to have lapel buttons to say you’re immune and you’re not immune?” adds Upshur, who also heads the clinical public health division of the Dalla Lana School of Public Health.
“How is this ever going to play out in any meaningful way that’s respectful of an individual’s right to privacy, the security of the person and to non-discrimination?
“And what happens if you’re not immune and you just can’t stand it anymore and you sneak out of the house and you find yourself in a group of immunes, and they all go, ‘Oh my God, it’s a non-immune!’ and they beat you up? I mean, it’s so dystopian, I can’t even believe it.”
Arjumand Siddiqi, Canada Research Chair in population health equity, notes that studies have long shown that people with higher incomes and higher social status have the resources that ensure better health.
Infectious diseases like COVID-19 replicate this pattern even though they’re blindly random parasites. It’s reflected in data indicating low-income and marginalized people are being infected in disproportionate numbers. They’re the people who head out to essential jobs every day — grocery store clerks, bus drivers, cleaners in hospitals and long-termcare homes and many more low-wage service sector jobs — while more affluent people with more flexible jobs safely continue their work from home.
Immunity passports would officially cement this striking social divide, says Siddiqi, a professor who also heads the Dalla Lana school’s epidemiology division.
“What you’re essentially saying is that people with immunity passports are going to make our economy run and do the work we need to get done so that you and I can continue to sit at home,” she adds.
Imagine a world, Siddiqi says, where low-paid service sector jobs were assigned randomly, and wealthy people were just as likely as anyone to do those infection-risky jobs. A lot of planning on how to restart the economy — and eagerness around immunity passports — would change, she predicts.
Immunity passports could turn into the excuse employers need to balk at restructuring workplaces, from making them safer for the next pandemic to reflecting with higher wages the true value of low-paid essential work, or for politicians to overlook the shocking deficiencies COVID-19 has highlighted in many sectors, from the lack of stable staffing in long-term-care to the need for better social and economic safety nets.
For now, the biggest hurdle to immunity passports is science. A gold standard for serological tests to detect coronavirus antibodies doesn’t exist, Upshur says. People can falsely test positive and believe they’re immune when they’re not, or falsely test negative and fear they’re at risk when they might not be.
A group of 50 U.S. scientists this month verified the accuracy of 14 coronavirus antibody tests on the market and found only three produced results that were consistently reliable.
Even with reliable results, crucial uncertainties about immunity remain. Dr. Mario Ostrowski, professor of immunology at U of T and clinician scientist at St. Michael’s Hospital, knows them well.
He heads an immunity study that has so far tested the blood of up to 50 people who recovered from COVID-19. He uses a two-hour-long procedure called leukapheresis, which draws blood and extracts some immune cells before pumping the blood back into the body.
The goal is to isolate a specific antibody that neutralizes the virus, produce large amounts of it and use it on infected people. The antibodies would bind to the virus in a way that prevents it from entering cells and the infection “just gets flushed out of the system,” Ostrowski says.
“You could theoretically completely neutralize the virus in its tracks and prevent further infection,” says Ostrowski, whose past work has focused on immune responses to HIV and hepatitis C.
Ostrowski has found that the sicker people were made by COVID-19, the higher their level of antibodies. About 10 per cent of the tested people who recovered, however, didn’t produce antibodies.
“That’s a real puzzle for us,” he says. Perhaps the virus was overcome by “killer T cells,” which are known to destroy cells hit by other infections.
Ostrowski has used isolated antibodies to neutralize the virus in a test tube, but has no idea what level of antibodies would be needed to replicate that in a human body, or how long that immunity would last.
For those answers, recovered patients would need to be followed for months to see how they do when new waves of the virus hit, Ostrowski says, noting respiratory viruses tend to mutate, so antibodies that work today may not work tomorrow.
“As a general statement, if you make antibodies, you’re probably protected against the virus, but it’s not 100 per cent,” he says.
Still, Ostrowski considers immunity passports “a great idea” if issued with warnings.
“The economy is really suffering and if you have immunity, why not start going back to work and try to make the world a little bit more normal again?” he says.
“We’re almost in a situation where people are getting stir crazy. They’re losing their livelihoods. So, if we have a population of people who are immune to this and can work, then let them work.
“But if we do the immunity passports, people have to realize they could still get infected. So, if they’ve got risk factors — if they’re older, obese, have diabetes and smoke — maybe they should still wait until all the studies come out with results.”
André Valleteau, who took part in Ostrowski’s blood study, isn’t sure about immunity passports.
“It’s a delicate subject,” he says. “You might create unintentional segregation with a group of people who can go out and a group of people who cannot. I think that will create a lot of resentment.
“But, at the same time, the work does need to come back at some point. So, yeah, it’s a bit of a tricky one and I’m not 100 per cent sure of what to say,” adds Valleteau, who has been working at home since his recovery.
For now, he keeps his recovery to himself, unless specifically asked, and continues to respect physical distancing, more for the sake of others than himself.
“If you have one person not distancing, I think other people do get uncomfortable. So, you might as well just play the same part and put people at ease.”
“You could see COVID-19 parties so people can get their immunity passports and get back to work, which could be a very dangerous prospect.” MAXWELL SMITH PROFESSOR AND BIOETHICIST, WESTERN UNIVERSITY