Relief from the scourge of COVID-19 in the United States may be in sight. Government and private sector initiatives should be able within months to provide enough safe, effective vaccines to begin to make a dent in COVID-19 cases, hospitalizations, and deaths. But for society to approach normalcy, people will need to be able to document that they are immune to COVID-19.
Although vaccination is intended primarily to protect individuals against COVID-19 infection or reduce its severity, it can also protect the wider community when a sufficiently large fraction of the population, thought to be approximately 70% in the case of COVID-19, gains immunity to infection because of either natural infection or vaccination. At that point, the virus has difficulty finding new, susceptible hosts, and the outbreak subsides. That state is called "herd immunity."
It is important to note that in spite of the pandemic rampaging across the country, only a small minority currently has immunity from prior COVID-19 infection.
Surveys have found that Americans are the least willing globally to get the COVID-19 vaccines. Unless we address this "vaccine hesitancy" in some way, we will suffer more, economic revival will be delayed, and the U.S. will be disadvantaged relative to other countries that have more aggressively controlled the pandemic.
The government, health providers, the Ad Council, and others have begun efforts toward encouraging voluntary vaccination. For at least the time being, governments are probably unlikely to require mandatory vaccination unless voluntary acceptance proves to be insufficient. Whether or not that will occur is difficult to predict, insofar as many have shown resistance and hostility even to less intrusive measures, such as masking and physical distancing, and the anti-vaccine movement is very active on social media.
If we fail to reach sufficient levels of vaccination voluntarily, there are ample precedents for more coercive measures. In 1905, the Supreme Court (in Jacobson v. Massachusetts) upheld a Massachusetts law that, during a smallpox epidemic, required the entire population to undergo smallpox vaccination or else pay a fine. State laws typically do not permit schools to accept children without vaccination against many pediatric viral infections.
Healthcare providers and many schools will require their staffs to be vaccinated. Other employers may require vaccination of employees who will be in close physical contact with each other or with clients, and entertainment forums such as theme parks, hotels, and cruise ships may restrict entry only to people who have been vaccinated.
Vaccination could also be required in order to engage in specific activities, similar to the way that some airlines and countries now force travelers to present a negative COVID-19 test. The airline industry intends to require passengers to present documentation of COVID-19 vaccination. The International Air Transport Association has just announced that it is in the final stages of developing the IATA Travel Pass, a digital document to confirm vaccination or a negative test result, which will encourage air travel. It is similar to the "yellow card" or "carte jaune," an internationally accepted certificate of vaccination completed by health providers in the U.S., which lists current vaccinations and is required before entering certain countries that require specific vaccinations. The only vaccination required in some countries is for yellow fever, from which the common name of the certificate is derived.
The travel pass is only one possible way to identify people who are likely to have vaccine-induced immunity from COVID-19 (even the excellent COVID-19 vaccines in the pipeline are not 100% effective) or who have antibodies following natural COVID-19 infection. Such documentation will become increasingly more important as we seek to return to pre-pandemic normalcy.
Governments, businesses, testing laboratories, and the public all have a role in developing suitable proof of immunity. Governments will need to assist in formulating ways to authenticate vaccination and antibody test results. Businesses will need to advise their staffs and customers about requirements and verify that they are met. Testing laboratories will need to provide test results that are acceptable in terms of sensitivity, specificity, and timeliness of reporting results. Finally, the public will need to learn which activities require confirmation of vaccination or immunity or negative COVID-19 test results.
As vaccination offers greater opportunities and freedom for those immunized, reliable, sanctioned methods of documenting immunization, such as the travel pass, will be needed. The U.S. has neither a single national identity card nor the likelihood of introducing one. Therefore, a good start would be discussions with state governments, where driver's licenses are the most common government-verified IDs.
Incentives work, and a potent incentive for the public to participate in a vaccination documentation scheme of some sort would be knowing that other people in their communities, on public transportation, in restaurants and entertainment venues, and other places of business, worship, and education were also participating and thus unlikely to spread COVID-19. Therefore, a certificate of vaccination such as the airline travel pass would provide this assurance and go a long way toward helping us reach our national vaccination goal while avoiding the complications of a government mandate for universal vaccination.
John J. Cohrssen is an attorney and statistician who served in senior positions for White House agencies, including the office of Vice President Dan Quayle. Henry I. Miller, a physician and molecular biologist, is a senior fellow at the Pacific Research Institute. He was the founding director of the FDA's Office of Biotechnology.