'Immunity passport, please': Should antibody testing be the ticket out of lockdown? – National Post

Some see them as get out of jail free cards to help economies stagger back to life. To others, the idea of “immunity passports” is COVID-19 madness.

As countries around the globe begin nervously emerging from pandemic lockdown, several are mulling the idea of immunity certificates — passes that would permit those who have tested positive for antibodies to COVID-19 to return to work, shop, board airplanes and otherwise circulate freely in public while the non-immune would remain mostly sheltered in place until vaccines become available.

This week, Chile said it was proceeding with plans to issue “immunity passports” that would liberate holders from quarantines and other restrictions. Germany, Italy and the U.K. have also floated the idea, while Anthony Fauci, a key member of the White House COVID-19 taskforce, told CNN last week the idea “might actually have some merit, under certain circumstances.” U.K. Health Secretary Matt Hancock has said that, should the science support it, the U.K. could introduce an immunity wristband “that says I’ve had it and I’m immune and I can’t pass it on and I’m highly unlikely to catch it.”

The idea of a hall pass out of lockdown hinges on the mass availability of antibody tests — also known as serological tests — that can identify who has been infected and developed antibodies thought to give them some protection from future infection. About half of those infected never develop symptoms, meaning there could be tens of thousands of Canadians who never knew they had the illness.

A dozen companies are seeking Health Canada approval for serological tests, including Halifax-based MedMira Inc., whose rapid antibody test takes three minutes start to finish, using a drop of blood specimen. In the U.S., more than 70 developers have notified the Food and Drug Administration they have tests ready to launch. The agency has issued four emergency use applications for antibody tests and expects that number to grow in coming weeks. “Within a period of a week or so we’re going to have a rather large number of tests that are available,” Fauci said. New York Gov. Andrew Cuomo, meanwhile, has said people who can get antibody tests — people who can “show they have had the virus and resolved” — can go back to work when the state starts to reopen. U.K.-based software company Bizagi has already developed a “CoronaPass” app to “automate, track and validate” a person’s immunity status, based on his or her antibody test. A QR code could be scanned like a boarding pass and presented to “authorities” as needed. “Those with evidence of immunity can help care for the most vulnerable in the community, staff a restricted re-opening of a retail location, or be safely prioritized for front-line healthcare work to help those still in need,” the company says.

The science, however, is still seriously murky: There are concerns about sensitivity — how good are the tests at identifying people who have had the disease — and specificity, meaning, are they cross-reacting with other coronaviruses that cause the common cold? A positive test may only indicate the person has been exposed, no more, no less. There’s no known understanding of how long immunity lasts — three months? three years? — or the level of antibodies necessary to presume a person is now “noncontagious.” Do the immune wear lanyards and badges? Would it trigger a black market of fake immunity passes? How would it be implemented and patrolled? Is a world of the immunes and the non-immunes a future we really want?

“For years, decades, we’ve been writing about stigma in infectious disease and how it’s problematic and now people are thinking of actually employing something that is by definition stigmatizing as a way out,” said University of Toronto bioethicist Dr. Ross Upshur, of the Dalla Lana School of Public Health.

“Play this out in your mind in several different scenarios,” said Upshur, an internationally recognized public health and bioethics expert. “You have to have an immunity pass. Do you get a jacket? Do you get a hat? How is it that people identify the fact they have an immunity pass or not? What happens if somebody who doesn’t have an immunity pass is found in a group of people who do? Do they get beaten up? We know humans can behave very savagely to each other under these types of circumstances.”

The proposal is tone deaf to how similar practices have worked in the past, Upshur added — “apartheid, colonial Africa, Nazi Germany” — and has a high likelihood of being used against already disadvantaged groups. Nobody wants to stay in lockdown longer than they absolutely have to. “But we do not have a valid serological test for determining immunity to SARS-Cov2,” Upshur said, and to base major decisions on who gets out and who doesn’t on antibody testing is not only premature, “it’s madness.”

We cannot all march forward out our doors

During the 1878 yellow fever epidemic in the Deep South, survivors became “acclimated,” Kathryn Olivarius, an assistant professor of history at Stanford University, wrote in New York Times. Unacclimated white people couldn’t get a job. “If you were white, immunity-status impacted where you lived, how much you earned, your ability to get credit and whom you were able to marry.”

Immunity passports could also present a perverse motivation to get deliberately infected, like misguided mothers who bundled their children off to chickenpox parties. “That may be unthinkable for those fortunate enough to be able to weather this economic storm from behind a monitor in their home office, but that option just isn’t available to millions,” Noah Rothman, author of Unjust: Social Justice and the Unmasking of America, wrote in Commentary magazine. With rolling lockdown-lift-lockdown cycles that could stretch a year or longer until vaccines become available, people with families to support and crushing debt “could begin to seek out the status that allows them to live fully once again — as dangerous as that may be,” Rothman said.

Others have argued that it would be entirely ethical for grocery stores, restaurants and other businesses to require immunity passports of customers — that, the price of coming out is to surrender some civil liberties. “If you don’t want to carry that document or don’t trust it, you’re not coming out,” said NYU Langone Medical Center bioethicist Arthur Caplan.

The tests measure the amount of antibodies, or proteins present in blood when the body responds to an infection caused by the virus. The tests don’t detect the virus itself, or an active infection, like the nasal and throat swab used to diagnose COVID-19, but whether the person’s immune system produced antibodies after having encountered the infection some time in the past.

However, it’s not clear which particular antibodies are actually providing immunity after the person recovers, or for how long.

It’s nice to think of an immunity passport if you’re the one “immune,” Upshur added. “Because that means there is at least the possibility that some of us would be able to freely move in the environment.”

But how to do the testing fairly and equitably? “You would need a regimen to give everybody the fair opportunity to have the test, and look at how well we’ve been rolling out testing in Ontario in the first place,” he said.

The plan would also be premised on the idea that the non-immune would remain largely sheltered until vaccines become available. But Upshur, who has been on multiple meetings with top scientific minds on World Health Organization teleconferences, says the probability that there will be a vaccine in the near future with over 90 per cent efficacy and available in seven billion doses “is almost non-existent.”

It’s likely that people exposed to the pandemic virus in the past would have some reasonable degree of immunity. “One hundred percent immunity? Probably not. One hundred per cent of the time? Definitely not. But better than nothing,” said Amir Attaran, a professor of law and medicine at the University of Ottawa who has a PhD in immunology.

However, in our shelter-in-place isolation, we didn’t magically develop immunity, Attaran noted. “We’ve been sitting on the couch watching Netflix and drinking beer.

“We cannot all march forward out our doors. We are going to have to divide it up into batches, into cohorts of people who go back, more or less, to society and more or less the jobs they left behind, in stages,” based on disease susceptibility and occupation, he said.

Young people are just as likely as older ones to get infected, but they’re much less likely to die. “So, the first batch would favour young people over old, assuming they don’t have a pre-existing condition that makes them more vulnerable,” Attaran said. Later batches could include older people and the immune suppressed. “All the boomers get to take a little longer time out. This is the time of Gen X and Gen Y.”

Attaran said we ought to consider immune passporting, “giving those who are thought to be immune a bill of health that says they can circulate more extensively in society without risking the health of others.”

But what level of immunity makes someone passport worthy? How would it work? “The head waiter can go back to work but nobody else?” tweeted one Imperial College London scientist.

There are currently no validated serology tests in Canada “and thus there is no mechanism to implement such an initiative,” a spokeswoman for the Ontario health ministry said in an email. However, the province is working with the Public Health Agency of Canada “to understand the evolving technology and its applications,” she said.

While we wait for the testing to be sorted out, everyone wants to know the answer to, how soon can we come out? “Unfortunately, there is no clear answer,” Dr. Barbara Yaffe, Ontario’s associate chief medical officer of health said this week. It won’t be like a light switch, she said, “you know, on-off.” It will be gradual, and the impact of each change will have to be monitored carefully for signs of any fresh outbreaks. But once the genie is out of the bottle it will hard to put her back in. “Once we lift it, it will be very hard to go back,” Yaffe said.

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