Recent debates around “vaccine passports,” or formal/mandatory certification of vaccination, point towards a potential widening societal divide between those who are vaccinated and those who are not. Those with certification of covid-19 immunisation might be permitted to travel, work, go to the gym, play sports, attend entertainment events, dine in restaurants, and ultimately, return to “normal” life. According to Clare Wenham of the London School of Economics, such a distinction would contribute to the creation of a “two-tier system” and given “history shows that when you create division within society it leads to civil unrest,” she believes this may result in a “vaccine apartheid.”

There are many international and country level experiences in which proof of immunity or prior vaccination are either encouraged or required, highlighting the potential use of covid-19 passports both on a local, national, and international scale. Historically, this includes travel vaccine certification (for diseases such as yellow fever, or previously, smallpox), or vaccination for various occupational purposes to protect at-risk healthcare workers and/or their patients. Mandatory vaccination of children before kindergarten or school-entry is also used in some countries. 

The UK prime minister has ordered a review of vaccine passports. Ursula von der Leyen, president of the European Commission, plans to implement the Digital Green Certificate, which would have three primary objectives: providing proof of vaccination, recovery, and/or results of a recent covid-19 test. It should ultimately represent a “path to gradual, safe, and lasting reopening,” she says, by enabling citizens to “move safely and freely in the European Union. Such certificates shall be available for all EU citizens and respect non-discriminatory and data protection standards.” This is an ambitious project, particularly given the current vaccination rates in the EU. Nonetheless, this document would include an “escape clause” and potentially allow for the provision of covid-19 test certificates, which could be a partial solution to the issue of vaccine unavailability. 

The World Health Organization (WHO) has taken a distinct position regarding vaccine passports based on ethical, technological, legal, and scientific questions, and urges measures that least impede freedom of movement. Ethical considerations relate to the global shortage of vaccines and the further worsening of existing inequalities (both in terms of accessibility and availability of covid-19 vaccines and tests). WHO currently discourages national authorities from mandating covid-19 immunisations passports. They say “there are still critical unknowns regarding the efficacy of vaccination in reducing transmission.” Furthermore, to implement such passports, vaccines shall first be approved by the WHO securing quality and global availability. This is of utmost importance when considering the multitude of current covid-19 and candidate vaccines and the country-wise differences in the adopted vaccines.

The development of “fake” passports is also a concern. The need for interoperability standards, as stressed by the WHO, is crucial, along with securing confidentiality and traceability. Such solutions must work locally and internationally. 

Despite these recommendations, Sweden, Denmark, Italy, Portugal, Spain, Austria, and Greece are considering introducing covid-19 vaccine passports. Similarly, Asian and American governments are considering such a move. In contrast, the French government has expressed its concerns regarding passports. 

Use of vaccine passports may extend beyond travelling purposes and determine access to “normal life.” Israel has issued a green-pass, allowing individuals to attend gym classes, theatres, concerts, and hotels; use of such certificates has extended to those wishing to sit inside restaurants and bars. Yet, while this approach has already allowed about 5 million citizens to return to some “normality,” the process of implementing and enforcing the use of these passports remains problematic, mainly from logistic, legal, and ethical aspects. The green passport may be complemented with rapid testing. The Polish government has issued a QR code allowing a downloadable version of a vaccine confirmation document, which shall grant “rights to which vaccinated people are entitled.” In addition to national measures, large private actors (e.g. British tour operator Sage and British Airways) are considering introducing vaccine passports. Travel insurers may operate a two-tier system charging higher premiums for unvaccinated individuals. 

Vaccine passports can contribute to vaccine hesitancy in two ways, either by increasing citizens’ concerns or by encouraging vaccine uptake. Vaccine hesitancy is strongly dependent on contextual factors and the vaccines available. There are extensive areas of covid-19 vaccine hesitancy in Eastern Europe, Russia, and France. There is a higher desire for covid vaccination in Italy, Spain, Portugal, Scandinavia, and the UK. In the UK, not only are there problems with uptake and reluctance amongst certain ethnic minority groups, but there may be a shift from using the term “vaccine hesitancy” as it could perpetuate stigma and discrimination. “Vaccine confidence” conveys a more positive outlook.

The role of vaccine passports for countering vaccine hesitancy remains problematic. Those who actively resist vaccine programmes (anti-vaxxers) may portray vaccine passports as coercive measures of the global vaccination plan to control the population and violate privacy. The lack of consistent evidence of effectiveness highlighted by the WHO compromises the message to be vaccinated. Furthermore, the lack of globally endorsed-measures and a WHO-accepted vaccine leads to questions such as: “Which vaccine is best? Which vaccine would I like my neighbour to have had, before a flight or before attending a gym class? Which vaccine is safest for me to travel given the various mutations?” A key issue in relying on individual consumer choice weakens the ability of governments to vaccinate large percentages of their populations. All these factors can exert negative influences on hesitant individuals and may subsequently lower immunisation rates. 

In contrast, vaccine passports may increase the uptake of immunisation as part of a collective desire to return to “normality.” Moreover, individuals may realise that vaccinated individuals do not suffer from adverse effects leading to higher perceived benefits than risks. For instance, the Israeli green-pass has been seen as beneficial in enabling freedom of movement and persuading many, including minorities and hesitant groups to be vaccinated. Employers may reasonably believe that vaccine passports offer an additional level of assurance to keep their workplace safer and their workforce protected, maintain business continuity, and ensure protection from litigation and trade disputes. Vaccine passports may be highly desirable in areas with high infection rates, often stimulated by poor quality working and living conditions. 

There is an urgent need for coordinated, global policy on vaccination passports or certification, and for complementary policies at national and local levels. The need for such policies raises many questions: How should vaccine prioritisation plans be modified in light of possible growing demands linked to immunisation passports? How would this deal with the different variants and their fit with prior vaccines? How would vaccine passports be implemented in countries/areas with high vaccine-hesitancy rates? Would this result in fraudulent documentation? Would clinicians come under pressure to provide medical exemption certificates? Will vaccine passports be a precondition for one’s working environment? 

Imposing vaccine passports is likely to provoke even more community resistance to vaccination where it exists. We need high levels of vaccination coverage across and within all countries. We will not be free from the virus until everyone is free. Since passports are an imminent reality, trust, community involvement and consent are essential in bringing societies together and ensuring effective international action. 

Giulia Sesa, European Public Health, Department of International Health, CAPHRI, FHML, Maastricht University

Brian Li Han Wong, Medical Research Council Unit for Lifelong Health and Ageing at UCL, Department of Population Science and Experimental Medicine, Institute of Cardiovascular Science, University College London.

Katarzyna Czabanowska, Past President of ASPHER and Department of International Health, CAPHRI  Maastricht University 

John Reid, Honorary Professor of Public Health, Chester University.

Nadav Davidovitch, Professor of Public Health,  Ben Gurion University of the Negev, Israel. 

Jose M Martin-Moreno, ASPHER Honours Committee & Department of Preventive Medicine and INCLIVA, University of Valencia, Spain

John Middleton, HonProfessor of Public Health University of Wolverhampton and President, Association of Schools of Public Health in the European Region (ASPHER).

Competing Interests: none declared

On behalf of the Association of Schools of Public Health in the European Region (ASPHER) COVID-19 Task Force Vaccination group: Laurent Chambaud, Katarzyna Czabanowska, Nadav Davidovitch, Ranjeet Dhonkal, Manfred Green, Jose M Martin-Moreno, John D Middleton, Jean-Philippe Naboulet, Robert Otok, John Reid, Giulia Sesa, Mohamud Sheek-Hussein, and Brian Li Han Wong. Address for correspondence john.middleton@aspher.org