Passport to freedom? Immunity passports for COVID-19

Role of Gut Microbiome in Cancer Treatment

The gut microbiota influences the effectiveness and side effects of cancer treatments, particularly immunotherapy and associated immune-related complications. This important involvement of the microbiome is supported by the patients receiving antibiotics responding poorly to immunotherapy. Relatively few research has examined the underlying processes, and until recently, data regarding the detection of the microbial organisms that trigger these effects were inconsistent. Since then, a deeper comprehension of the processes of action and taxonomic classification of the relevant species has been attained. It's been demonstrated that certain bacterial species can enhance the body's reaction to immune checkpoint inhibitors through the release of distinct metabolites or products. Nonetheless, in certain patients who are not responding, Gram-negative bacteria may have a dominating suppressive impact. Patients' propensity to react to immunotherapy can be somewhat accurately predicted by machine learning techniques based on their microbiome makeup. Consequently, there has been an increase in interest in modifying the microbiome makeup to enhance patient reaction to medication. Clinical proof-of-concept studies demonstrate that dietary modifications or fecal microbiota transplantation (FMT) might be used therapeutically to increase the efficacy of immunotherapy in cancer patients. Current developments and new approaches for microbiota-based cancer treatments have been emphasized. In conclusion, preclinical research on animals and human clinical trials has made tremendous progress in our understanding of the function of the gut microbiome in health and illness. These investigations have shed light on the effects of food, FMT, probiotics, prebiotics, and microbiome-disease connections. However, there are still a lot of issues and restrictions that must be resolved before this research can be used in real-world clinical settings.

Graphical Abstract

An unintended consequence of COVID-19 immunity passports-quasi-experimental evidence of moral hazard observed after implementing the domestic Green Pass policy during the second wave of the COVID-19 pandemic in Italy

Objectives

Amidst the second wave of the COVID-19 pandemic, Italian policymakers mandated to exhibit evidence of vaccination or immunity (the Green Pass) as a condition to access retail premises and public offices. This study aims to offer evidence, in a quasi-experimental setting, suggesting that an unintended consequence of this policy was the emergence of moral hazard.

Methods

Google visit duration data measured the time customers typically spend on retail premises or public offices. A pairwise comparison of median visit time per premise was performed at a six-week interval before and after the introduction of the Green Pass.

Results

This study is the first to provide evidence of "ex-post" moral hazard associated with introducing a domestic Green Pass policy. The median visiting time on premises that required digital immunity control significantly increased after introducing the domestic Green Pass policy, contrary to other public premises where access remained free of limitations. The increase in median visit time in premises with faster customer turnaround, such as coffee shops (+49%) and fast-food restaurants (+45%), was lower than the increase observed for fine-dining restaurants (+74%) and pizzerias (+163%). No significant increase in median visit time was observed in premises where the Green Pass was not required, such as food supermarkets, retail non-food shops, post offices, banks, pharmacies, and gas stations.

Conclusion

The evidence of moral hazard highlights the critical issue of unintended consequences stemming from public health policies. This discovery is pivotal for policymakers, indicating that unforeseen behavioral adjustments could offset the intended benefits despite the intent to reduce risk through measures like the Green Pass.

Scarce resources, public health and professional care: the COVID-19 pandemic exacerbating bioethical conflicts - findings from global qualitative expert interviews

BACKGROUND

Since spring 2020, the SARS-CoV-2 virus has spread worldwide, causing dramatic global consequences in terms of medical, care, economic, cultural and bioethical dimensions. Although the resulting conflicts initially appeared to be quite similar in most countries, a closer look reveals a country-specific intensification and differentiation of issues. Our study focused on understanding and highlighting bioethical conflicts that were triggered, exposed or intensified by the COVID-19 pandemic in low and middle-income countries (LMICs) and high-income countries (HICs).

METHODS

We conducted qualitative interviews with 39 ethics experts from 34 countries (Argentina, Australia, Austria, Brazil, Canada, Colombia, Denmark, Ecuador, Ethiopia, France, Germany, India, Italy, Israel, Japan, Kyrgyzstan, Mexico, Nigeria, Oman, Pakistan, Paraguay, Poland, Romania, Russia, Singapore, South Korea, Spain, Sweden, South Africa, Tunisia, Türkiye, United-Kingdom, United States of America, Zambia) from November 2020 to March 2021. We analysed the interviews using qualitative content analysis.

RESULTS

The scale of the bioethical challenges between countries differed, as did coping strategies for meeting these challenges. Data analysis focused on: a) Resource scarcity in clinical contexts: Scarcity of medical resources led to the need to prioritize the care of some COVID-19 patients in clinical settings globally. Because this entails the postponement of treatment for other patients, the possibility of serious present or future harm to deprioritized patients was identified as a relevant issue. b) Health literacy: The pandemic demonstrated the significance of health literacy and its influence on the effective implementation of health measures. c) Inequality and vulnerable groups: The pandemic highlighted the context-sensitivity and intersectionality of the vulnerabilities of women and children in LMICs and the aged in HICs. d) Conflicts surrounding healthcare professionals: The COVID-19 outbreak underscored the tough working conditions for nurses and other health professionals, raising awareness of the need for reform.

CONCLUSION

The pandemic exposed pre-existing structural problems in LMICs and HICs. Without neglecting individual contextual factors in the observed countries, we created a mosaic of different voices of experts in bioethics across the globe, drawing attention to the need for international solidarity in the context of a global crisis.

An agent-based secure privacy-preserving decentralized protocol for sharing and managing digital health passport information during crises

The aim of this article is to identify a range of changes and challenges that present-day technologies often present to contemporary societies, particularly in the context of smart city logistics, especially during crises. For example, the long-term consequences of the COVID-19 pandemic, such as life losses, economic damages, and privacy and security violations, demonstrate the extent to which the existing designs and deployments of technological means are inadequate. The article proposes a privacy-preserving, decentralized, secure protocol to safeguard individual boundaries and supply governments and public health organizations with cost-effective information, particularly regarding vaccination. The contribution of this article is threefold: (i) conducting a systematic review of most of the privacy-preserving apps and their protocols created during pandemics, and we found that most apps pose security and privacy violations. (ii) Proposing an agent-based, decentralized private set intersection (PSI) protocol for securely sharing individual digital personal and health passport information. The proposed scheme is called secure mobile digital passport agent (SMDPA). (iii) Providing a simulation measurement of the proposed protocol to assess performance. The performance result proves that SMDPA is a practical solution and better than the proposed active data bundles using secure multi-party computation (ADB-SMC), as the average CPU load for SMDPA is approximately 775 milliseconds (ms) compared to about 900 ms for ADB-SMC.

Individual factors influencing public's perceptions about the importance of COVID-19 immunity certificates: a cross-sectional online questionnaire survey in the UK

BACKGROUND

Understanding how perceptions around immunity certificates are influenced by individual characteristics is important to inform evidence-based policy making and implementation strategies for services around immunity and vaccine certification.

OBJECTIVE

To assess what were the main individual factors (including health beliefs about COVID-19, vaccination views, socio-demographic and lifestyle factors) influencing people's perception of the importance of using COVID-19 immunity certificates.

METHODS

Cross-sectional online survey with a nationally representative sample in the UK, conducted on the 3rd of August 2021. Responses were collected and analysed from 534 participants, aged 18 and older, residents of the UK. The primary outcome measure (dependent variable) was the participants' perceived importance of using immunity certificates, computed as an index of six items. The following individual drivers were used as the independent variables: a) personal beliefs about COVID-19 (using constructs adapted from the Health Belief Model), b) personal views on vaccination, c) willingness to share immunity status with service providers, and d) variables related to respondents' lifestyle and socio-demographic characteristics.

RESULTS

Perceived importance of immunity certificates was higher among respondents who felt that contracting COVID-19 would have a severe negative impact on their health (β=0.2564, P<.001=0.0000) and felt safer if vaccinated (β =0.1552, P<.001=0.0000). The prospect of future economic recovery positively influenced perceived importance of immunity certificates. Respondents who were employed or self-employed (β=-0.2412, P=.0010), or experienced an increase in income after the COVID-19 pandemic (β=-0.1287, P=.0020) perceived less important the use of immunity certificates compared to those who were unemployed or had retired or those who had experienced reduction in their income during the pandemic.

CONCLUSIONS

The findings of our survey suggest that more vulnerable members in our society (unemployed or retired and those believing that COVID-19 would have a severe impact on their health) and people who experienced a reduction in income during the pandemic perceived the severity of not using immunity certificates in their daily life as higher.

CLINICALTRIAL

Vaccine Passports and Political Legitimacy: A Public Reason Framework for Policymakers

As the COVID-19 pandemic continues to evolve, taking its toll on people's lives around the world, vaccine passports remain a contentious topic of debate in most liberal democracies. While a small literature on vaccine passports has sprung up over the past few years that considers their ethical pros and cons, in this paper we focus on the question of when vaccine passports are politically legitimate. Specifically, we put forward a 'public reason ethics framework' for resolving ethical disputes and use the case of vaccine passports to demonstrate how it works. The framework walks users through a structured analysis of a vaccine passport proposal to determine whether the proposal can be publicly justified and is therefore legitimate. Use of this framework may also help policymakers to design more effective vaccine passports, by incorporating structured input from the public, and thereby better taking the public's interests and values into account. In short, a public reason ethics framework is meant to encourage better, more legitimate decision-making, resulting in policies that are ethically justifiable, legitimate and effective.

Digital Covid Certificates as Immunity Passports: An Analysis of Their Main Ethical, Legal, and Social Issues

Digital COVID certificates are a novel public health policy to tackle the COVID-19 pandemic. These immunity certificates aim to incentivize vaccination and to deny international travel or access to essential spaces to those who are unable to prove that they are not infectious. In this article, we start by describing immunity certificates and highlighting their differences from vaccination certificates. Then, we focus on the ethical, legal, and social issues involved in their use, namely autonomy and consent, data protection, equity, and international mobility from a global fairness perspective. The main conclusion of our analysis is that digital COVID certificates are only acceptable if they meet certain conditions: that they should not process personal data beyond what is strictly necessary for the aimed goals, that equal access to them should be guaranteed, and that they should not restrict people's autonomy to access places where contagion is unlikely. We conclude that, if such conditions are guaranteed, digital COVID certificates could contribute to mitigating some of the most severe socioeconomic consequences of the pandemic.

Vaccines and more: The response of Dark Web marketplaces to the ongoing COVID-19 pandemic

Early analyses revealed that dark web marketplaces (DWMs) started offering COVID-19 related products (e.g., masks and COVID-19 tests) as soon as the COVID-19 pandemic started, when these goods were in shortage in the traditional economy. Here, we broaden the scope and depth of previous investigations by considering how DWMs responded to an ongoing pandemic after the initial shock. Our dataset contains listings from 194 DWMs collected until July 2021. We start by focusing on vaccines. We find 248 listings offering approved vaccines, like Pfizer/BioNTech and AstraZeneca, as well as vendors offering fabricated proofs of vaccination and COVID-19 passports. Then, we consider COVID-19 related products. We show that, as the regular economy has become able to satisfy the demand of these goods, DWMs have decreased their offer. Next, we analyse the profile of vendors of COVID-19 related products and vaccines. We find that most of them are specialized in a single type of listings and are willing to ship worldwide. Finally, we consider a broader set of listings mentioning COVID-19, in order to assess the general impact of the pandemic on the broader activity of DWMs. Among 10,330 such listings, we show that recreational drugs are the most affected among traditional DWMs product, with COVID-19 mentions steadily increasing since March 2020. We anticipate that our results will be of interest to researchers, practitioners, and law enforcement agencies focused on the study and safeguard of public health.

Perceived threat of COVID-19, attitudes towards vaccination, and vaccine hesitancy: A prospective longitudinal study in the UK

OBJECTIVES

Using the Health Belief Model as a conceptual framework, we investigated the association between attitudes towards COVID-19, COVID-19 vaccinations, and vaccine hesitancy and change in these variables over a 9-month period in a UK cohort.

METHODS

The COPE study cohort (n = 11,113) was recruited via an online survey at enrolment in March/April 2020. The study was advertised via the HealthWise Wales research registry and social media. Follow-up data were available for 6942 people at 3 months (June/July 2020) and 5037 at 12 months (March/April 2021) post-enrolment. Measures included demographics, perceived threat of COVID-19, perceived control, intention to accept or decline a COVID-19 vaccination, and attitudes towards vaccination. Logistic regression models were fitted cross-sectionally at 3 and 12 months to assess the association between motivational factors and vaccine hesitancy. Longitudinal changes in motivational variables for vaccine-hesitant and non-hesitant groups were examined using mixed-effect analysis of variance models.

RESULTS

Fear of COVID-19, perceived susceptibility to COVID-19, and perceived personal control over COVID-19 infection transmission decreased between the 3- and 12-month surveys. Vaccine hesitancy at 12 months was independently associated with low fear of the disease and more negative attitudes towards COVID-19 vaccination. Specific barriers to COVID-19 vaccine uptake included concerns about safety and efficacy in light of its rapid development, mistrust of government and pharmaceutical companies, dislike of coercive policies, and perceived lack of relaxation in COVID-19-related restrictions as the vaccination programme progressed.

CONCLUSIONS

Decreasing fear of COVID-19, perceived susceptibility to the disease, and perceptions of personal control over reducing infection-transmission may impact future COVID-19 vaccination uptake.

Managing the risk of COVID-19 via vaccine passports: Modeling economic and policy implications

The increasing use of vaccine passports (VPs) to certify immunity from the prevailing coronavirus has created positive and negative aspects that have shaken the workings of markets. The VPs are, however, not universally used and not required by all businesses and governments at this point. Given the newness associated with VPs and the ongoing uncertainty of the pandemic, full implications of VPs have not been considered. This paper provides some formal insights into the implications of the use of VPs, borrowing from the established economic theory. Recommendations for public policy are provided.

How is "solidarity" understood in discussions about contact tracing apps? An overview

Background

In the context of the COVID-19 pandemic, there is much discussion about contact tracing apps, their use to contain the spread of the virus as well as the ethical, legal, and social aspects of their development, implementation, acceptance, and use. In these discussions, authors frequently mention "solidarity" when making key points in arguments. At the same time, authors rarely specify how they understand "solidarity". This lack of specification about how they understand "solidarity" can lead to misunderstandings in discussions.

Objective

To prevent such misunderstandings, it is important to specify how one understands "solidarity" when mentioning it in the discussions on contact tracing apps. Therefore, the aim of this paper is to elaborate how "solidarity" is understood in the context of contact tracing apps, i.e., how different authors understand "solidarity" when using it in discussions about these apps.

Methods

In order to find out how different authors understand "solidarity" when discussing contact tracing apps, I conduct a literature review. I collect papers from several databases, inductively work out central differences and similarities between the different uses of "solidarity", and use them to code and analyze relevant passages.

Results

In the final sample, five different understandings of "solidarity" in the context of contact tracing apps can be identified. These understandings differ in how different authors (1) imagine the basic concept of solidarity, i.e., what "solidarity" refers to, (2) how they temporally relate solidarity to contact tracing apps, and (3) how they perceive the causal interactions between solidarity and contact tracing apps, i.e., the different ways in which solidarity and contact tracing apps influence each other.

Conclusions

The five understandings of "solidarity" in the context of contact tracing apps presented here can serve as guidance for how "solidarity" can be understood in discussions-thus contributing to a better mutual understanding and preventing communicative misunderstandings.

Effect of vaccination on household transmission of SARS-CoV-2 Delta variant of concern

Effective vaccines protect individuals by not only reducing the susceptibility to infection, but also reducing the infectiousness of breakthrough infections in vaccinated cases. To disentangle the vaccine effectiveness against susceptibility to infection (VES) and vaccine effectiveness against infectiousness (VEI), we took advantage of Danish national data comprising 24,693 households with a primary case of SARS-CoV-2 infection (Delta Variant of Concern, 2021) including 53,584 household contacts. In this setting, we estimated VES as 61% (95%-CI: 59-63), when the primary case was unvaccinated, and VEI as 31% (95%-CI: 26-36), when the household contact was unvaccinated. Furthermore, unvaccinated secondary cases with an infection exhibited a three-fold higher viral load compared to fully vaccinated secondary cases with a breakthrough infection. Our results demonstrate that vaccinations reduce susceptibility to infection as well as infectiousness, which should be considered by policy makers when seeking to understand the public health impact of vaccination against transmission of SARS-CoV-2.

Social Engagement in the Fight Against COVID-19 in the Urban and Peri-Urban Areas of Cotonou (Benin, Sub-saharan Africa): Acceptability of the Vaccination and Tracking Program

Introduction

This article aims at investigating social engagement in the fight against the COVID-19 pandemic in low-resource settings (LRSs). In particular, it focuses on Benin (Sub-Saharan Africa), and reports the results of a field study that investigated the local people's acceptance of the vaccine and the tracking program.

Methods

This project is the product of a collaboration between the ABSPIE (Applied Biomedical and Signal Processing E-Health) Lab of the University of Warwick (UK) and the LAMA (Laboratoire d'Antropologie Medical Appliqué) of the University of Abomey Calavi (Benin). This international multidisciplinary collaboration brought together engineers, sociologists, anthropologists, and bioethicists. In light of the aims of the project, a qualitative methodology was deemed appropriate. The research team prepared two questionnaires that provided the basis for semi-structured interviews that took place between June and August 2021.

Results

The research team interviewed 34 Beninese respondents, comprising people aged 60+ (with multiple comorbidities), who were primarily healthcare workers and/or traditional therapists. The results of this work highlight the fact that there is widespread reticence about the vaccination program in Benin, both due to local beliefs and uncertainty about governmental management. In this study, we uncovered several local reasons interfering with the involvement of the population in the vaccination campaign against COVID-19, e.g., the existence of traditional medical practices considered as valid alternatives to vaccines, and many beliefs showing a fear of neo-colonialism hidden in the pandemic threat. Yet, another hindrance can be traced to shortcomings in the management of the vaccination campaign which resulted in obstacles to the implementation of the program.

Conclusions

This work does not intend to denounce any governmental effort or foster a regressive mindset, but shows how the overall confusion (defined by the World Health Organization as infodemic) linked to the pandemic and its management has caused even more dramatic consequences in LRSs. In addition, the paper proposes a specific framework for the interpretation and management of bioethical and biomedical issues in LRSs that the authors are validating in their current research.

Ethical reflections on Covid-19 vaccines

OBJECTIVES

More than 1 year after the start of the Covid-19 pandemic it is becoming increasingly clear that vaccines will prove to be essential in combating this global pandemic. The demand for such vaccines is great (since nearly everyone is a candidate for vaccination) yet supplies are currently limited. This raises clear ethical questions regarding the current and future Covid-19 vaccines.

METHODS

In this paper we highlight the several ethical questions that are raised using a three-fold categorization. We will discuss questions concerning: (1) the design and testing of vaccines; (2) who gets the vaccines; and (3) the tensions between public health and individual interest/autonomy. Each of these three more broad categories encompasses many different and concrete ethical questions.

RESULTS

We argue that different ethical frameworks apply both across these three categories, but also within these categories.

CONCLUSION

Despite the fact that ethical conflict might not completely disappear, we argue that distinguishing and discussing separate questions from an ethical perspective can help create the necessary clarity and provide an ethical justification in favour of particular vaccination issues.

The unnaturalistic fallacy: COVID-19 vaccine mandates should not discriminate against natural immunity

COVID-19 vaccine requirements have generated significant debate. Here, we argue that, on the evidence available, such policies should have recognised proof of natural immunity as a sufficient basis for exemption to vaccination requirements. We begin by distinguishing our argument from two implausible claims about natural immunity: (1) natural immunity is superior to 'artificial' vaccine-induced immunity simply because it is 'natural' and (2) it is better to acquire immunity through natural infection than via vaccination. We then briefly survey the evidence base for the comparison between naturally acquired immunity and vaccine-induced immunity. While we clearly cannot settle the scientific debates on this point, we suggest that we lack clear and convincing scientific evidence that vaccine-induced immunity has a significantly higher protective effect than natural immunity. Since vaccine requirements represent a substantial infringement of individual liberty, as well as imposing other significant costs, they can only be justified if they are necessary for achieving a proportionate public health benefit. Without compelling evidence for the superiority of vaccine-induced immunity, it cannot be deemed necessary to require vaccination for those with natural immunity. Subjecting them to vaccine mandates is therefore not justified. We conclude by defending the standard of proof that this argument from necessity invokes, and address other pragmatic and practical considerations that may speak against natural immunity exemptions.

Mandatory vaccination and the ‘seat belt analogy’ argument: a critical analysis in the context of the Covid-19 pandemic

The seat belt analogy argument is aimed at furthering the success of coercive vaccination efforts on the basis that the latter is similar to compulsory use of seat belts. However, this article demonstrated that this argument does not work so well in practice due to several reasons. The possibility of saving resources in health care does not usually apply in our societies, and the paternalist mentality that contributed to the implementation of seat belt–wearing obligation was predominant 30 years ago, but it does not apply at this moment. Furthermore, the risk/benefit analysis is totally different in both scenarios. In the case of seat belts, there is no way to discriminate between the users. In the case of vaccines, individuals present with unique circumstances that may differ substantially from those of another and might be foreseen a priori. This means that an analysis must be performed individually before vaccination is imposed. Finally, one must keep in mind that seat belts are often the only way in which we can protect third parties against a tragic hit by the occupant of another vehicle and are very efficient tools for this purpose. Vaccines, in contrast, do not always create sterilising immunity and are definitely not the only way by which we can avoid spreading a virus; immunity certificates, isolation, or even confinement may also serve as viable methods to achieve this purpose.

Payments and freedoms: Effects of monetary and legal incentives on COVID-19 vaccination intentions in Germany

Monetary and legal incentives have been proposed to promote COVID-19 vaccination uptake. To evaluate the suitability of incentives, an experiment with German participants examined the effects of payments (varied within subjects: 0 to 10,000 EUR) and freedoms (varied between subjects: vaccination leading vs. not leading to the same benefits as a negative test result) on the vaccination intentions of previously unvaccinated individuals (n = 782) in April 2021. While no effect could be found for freedoms, the share of participants willing to be vaccinated increased with the payment amount. However, a significant change required large rewards of 3,250 EUR or more. While monetary incentives could increase vaccination uptake by a few percentage points, the high costs of implementation challenge the efficiency of the measure and call for alternatives. As the data suggest that considering vaccination as safe, necessary, and prosocial increases an individual's likelihood of wanting to get vaccinated without payment, interventions should focus on these features when promoting vaccination against COVID-19.

Sense and sensitivity: can an inaccurate test be better than no test at all?

The UK government has put lateral flow antigen tests (LFATs) at the forefront of its strategy to scale-up testing in the coronavirus pandemic. However, evidence from a pilot trial using an LFAT to identify asymptomatic infections in the community suggested that the test missed over half of the positive cases in the tested population. This raises the question of whether it can be ethical to use an inaccurate test to guide public health measures. We begin by explicating different dimensions of test accuracy (sensitivity, specificity and predictive value), and why they matter morally, before highlighting key data from the Liverpool pilot. We argue that the poor sensitivity of the LFAT in this pilot trial suggests that there are important limitations to what we can expect these tests to achieve. A test with low sensitivity will provide false-negative results, and in doing so generate the risk of false assurance and its attendant moral costs. However, we also suggest that the deployment of an insensitive but specific test could identify many asymptomatic carriers of the virus who are currently being missed under existing arrangements. Having outlined ways in which the costs of false reassurance could potentially be mitigated, we conclude that the use of an insensitive LFAT in mass testing may be ethical if (1) it is used predominantly to identify positive cases, (2) it is a cost-effective method of achieving that goal and (3) if other public health tools can effectively prevent widespread false reassurance.

Why 'one size fits all' is not enough when designing COVID-19 immunity certificates for domestic use: a UK-wide cross-sectional online survey

OBJECTIVES

The present study explored public's willingness to use COVID-19 immunity certificates across six different domestic scenarios.

DESIGN

Cross-sectional online survey.

SETTING

UK representative survey conducted on 3 August 2021.

PARTICIPANTS

534 UK residents over 18 years old.

INTERVENTIONS

Participants replied to the same set of questions.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was willingness to use immunity certificates across three different domestic settings: (1) visiting the general practitioner (GP) for a non-urgent health issue; (2) dining in a restaurant and (3) attending a performance in a theatre. For each setting two options, one prioritising convenience (option A) and the other privacy (option B), were offered. Our secondary outcome measures were computed indices from items adapted from the Health Belief Model; attitudes towards sharing immunity status with service providers; prior to COVID-19 lifestyle. In addition, we recorded data about respondents' sociodemographic characteristics.

RESULTS

Respondents were more willing to use immunity certificates that prioritised convenience (92%), rather than privacy (76%), when visiting their GP . However, privacy was more favourable in the other two settings (dining in a restaurant (84%) and going to a theatre (83%)) compared with convenience (38% and 39% respectively). Personal beliefs about COVID-19 and immunity certificates were associated with variations in willingness to use these across all scenarios. No variations were observed across sociodemographics and lifestyle.

CONCLUSIONS

The findings of this survey suggest that there is not one-size-fits-all solution for designing immunity certificates. Immunity certificates are complex sociotechnical systems, any attempt to implement these for domestic use should be tailored to different settings and user needs. The design of certification services requires a more evidence-based approach and further research is needed to understand how different settings, design elements (like convenience or privacy) and personal beliefs about the pandemic should inform their design.

Papers please: Factors affecting national and international COVID-19 immunity and vaccination passport uptake as determined by representative national surveys

BACKGROUND

In response to the COVID-19 pandemic, countries are introducing digital passports that allow citizens to return to normal activities if they were previously infected with (immunity passport) or vaccinated against (vaccination passport) SARS-CoV-2. To be effective, policy decision makers must know whether these passports will be widely accepted by the public, and under what conditions? This study focuses attention on immunity passports, as these may prove useful in countries both with and without an existing COVID-19 vaccination program, however, our general findings also extend to vaccination passports.

OBJECTIVE

We aimed to assess attitudes towards the introduction of immunity passports in six countries, and determine what social, personal and contextual factors predicted their support.

METHODS

We collected 13,678 participants through online representative sampling across six countries - Australia, Japan, Taiwan, Germany, Spain, and the United Kingdom - during April to May of the 2020 COVID-19 pandemic, and assessed attitudes and support for the introduction of immunity passports.

RESULTS

Immunity passport support was moderate-to-low, being highest in Germany (51%; 775 of 1507 participants) and the United Kingdom (51%; 759 of 1484), followed by Taiwan (47%; 2841 of 5989), Australia (46%; 963 of 2086) and Spain (46%; 693 of 1491), and lowest in Japan (22%; 241 of 1081). Bayesian generalized linear mixed-effects modelling assessed predictive factors for immunity passport support across countries. International results showed neoliberal world views (odds ratio, OR = 1.17, CI[1.13:1.22]), personal concern (OR = 1.07, CI[1:1.16]) and perceived virus severity (OR = 1.07, CI[1.01:1.14]), the fairness of immunity passports (OR = 2.51, CI[2.36:2.66]), liking immunity passports (OR = 2.77, CI[2.61:2.94]), and a willingness to become infected to gain an immunity passport (OR = 1.6, CI[1.51:1.68]), were all predictive factors of immunity passport support. By contrast, gender (woman; OR = 0.9, CI[0.82:0.98]), immunity passport concern (OR = 0.61, CI[0.57:0.65]), and risk of harm to society (OR = 0.71, CI[0.67:0.76]) predicted a decrease in support for immunity passports. Minor differences in predictive factors were found between countries and results were modelled separately to provide national accounts of these data.

CONCLUSIONS

Our research suggests that support for immunity passports is predicted by the personal benefits and societal risks they confer. These findings generalized across six countries and may also prove informative for the introduction of vaccination passports, helping policy-makers to introduce effective COVID-19 passport policies in these six countries and around the world.

CLINICALTRIAL

COVID-19 Vaccination Passports: Are They a Threat to Equality?

In several countries, governments have implemented so-called 'COVID passport' schemes, which restrict access to venues such as bars or sports events to those who are vaccinated against COVID-19 and/or exempt vaccinated individuals from public health measures such as curfews or quarantine requirements. These schemes have been the subject of a heated debate. Concerns about inequality have played an important role in the opposition to such schemes. This article highlights that determining how COVID passports affect equality requires a much more nuanced analysis than is typically assumed. I identify a range of broadly egalitarian considerations that could be affected by the introduction of COVID passport schemes. While these schemes could undermine certain aspects of equality, I argue that they could also be used to promote equality. The magnitude and severity of these different effects, both promoting and undermining equality, depend on how precisely these schemes are framed and the local context in which they are implemented.

COVID-19 and Science Communication: The Recording and Reporting of Disease Mortality

The ongoing COVID-19 pandemic has brought science to the fore of public discourse and, considering the complexity of the issues involved, with it also the challenge of effective and informative science communication. This is a particularly contentious topic, in that it is both highly emotional in and of itself; sits at the nexus of the decision-making process regarding the handling of the pandemic, which has effected lockdowns, social behaviour measures, business closures, and others; and concerns the recording and reporting of disease mortality. To clarify a point that has caused much controversy and anger in the public debate, the first part of the present article discusses the very fundamentals underlying the issue of causative attribution with regards to mortality, lays out the foundations of the statistical means of mortality estimation, and concretizes these by analysing the recording and reporting practices adopted in England and their widespread misrepresentations. The second part of the article is empirical in nature. I present data and an analysis of how COVID-19 mortality has been reported in the mainstream media in the UK and the USA, including a comparative analysis both across the two countries as well as across different media outlets. The findings clearly demonstrate a uniform and worrying lack of understanding of the relevant technical subject matter by the media in both countries. Of particular interest is the finding that with a remarkable regularity (ρ>0.998), the greater the number of articles a media outlet has published on COVID-19 mortality, the greater the proportion of its articles misrepresented the disease mortality figures.

Conflicting attitudes: Analyzing social media data to understand the early discourse on COVID-19 passports

In several countries, vaccine passports are being encouraged to hasten the return to some form of normalcy amidst the COVID-19 pandemic. Vaccine passport is a digital or paper document that may serve as proof of the COVID-19 vaccine, thereby allowing entry to public venues, sporting events, air travel, and unrestricted access to other facilities. This study explores how the COVID-19 passport is being discussed and perceived on Twitter and the prominent entities involved in the early discourse on the issue. Twitter messages were theoretically analyzed for Health Belief Model (HBM) and Theory of Planned Behavior (TPB) variables, as well as message source, engagement, and attitudes towards vaccination certificates. Using quantitative content analysis, tweets were coded on nine dimensions: account type, tweeter profile, tweet content, tweet modality, attitude, self-efficacy, perceived barriers, benefits, and action cues. Most of the tweets originated from personal accounts, followed by media organizations, media-related personalities, politicians, and the travel industry. A significant number of tweets were from male Twitter users. Our analysis revealed that most tweeters had a favorable attitude towards the COVID-19 passports. Unfavorable attitudes toward the COVID-19 passport were based on reasons such as a lack of common standard or consensus, and personal freedoms & human rights. Tweets highlighting the benefits of COVID-19 passports cited travel as the primary reason. Based on a combination of technical, legal, and ethical practices, our study offers a set of vital recommendations for governments, health organizations, and businesses that may help stimulate the acceptance of vaccine passports.

Spectral image contrast-based flow digital nanoplasmon-metry for ultrasensitive antibody detection

Background

Gold nanoparticles (AuNPs) have been widely used in local surface plasmon resonance (LSPR) immunoassays for biomolecule sensing, which is primarily based on two conventional methods: absorption spectra analysis and colorimetry. The low figure of merit (FoM) of the LSPR and high-concentration AuNP requirement restrict their limit of detection (LOD), which is approximately ng to μg mL⁻¹ in antibody detection if there is no other signal or analyte amplification. Improvements in sensitivity have been slow in recent for a long time, and pushing the boundary of the current LOD is a great challenge of current LSPR immunoassays in biosensing.

Results

In this work, we developed spectral image contrast-based flow digital nanoplasmon-metry (Flow DiNM) to push the LOD boundary. Comparing the scattering image brightness of AuNPs in two neighboring wavelength bands near the LSPR peak, the peak shift signal is strongly amplified and quickly detected. Introducing digital analysis, the Flow DiNM provides an ultrahigh signal-to-noise ratio and has a lower sample volume requirement. Compared to the conventional analog LSPR immunoassay, Flow DiNM for anti-BSA detection in pure samples has an LOD as low as 1 pg mL⁻¹ within only a 15-min detection time and 500 μL sample volume. Antibody assays against spike proteins of SARS-CoV-2 in artificial saliva that contained various proteins were also conducted to validate the detection of Flow DiNM in complicated samples. Flow DiNM shows significant discrimination in detection with an LOD of 10 pg mL⁻¹ and a broad dynamic detection range of five orders of magnitude.

Conclusion

Together with the quick readout time and simple operation, this work clearly demonstrated the high sensitivity and selectivity of the developed Flow DiNM in rapid antibody detection. Spectral image contrast and digital analysis further provide a new generation of LSPR immunoassay with AuNPs.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s12951-021-01188-6.

Highly Sensitive and Specific SARS-CoV-2 Serological Assay Using a Magnetic Modulation Biosensing System

Sensitive serological assays are needed to provide valuable information about acute and past viral infections. For example, detection of anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) IgG antibodies could serve as the basis for an "immunity passport" that would enable individuals to travel internationally. Here, utilizing a novel Magnetic Modulation Biosensing (MMB) system and the receptor-binding domain of the SARS-CoV-2 spike protein, we demonstrate a highly sensitive and specific anti-SARS-CoV-2 IgG serological assay. Using anti-SARS-CoV-2 IgG antibodies, RT-qPCR SARS-CoV-2-positive and healthy patients' samples, and vaccinees' samples, we compare the MMB-based SARS-CoV-2 IgG assay's analytical and clinical sensitivities to those of the enzyme-linked immunosorbent assay (ELISA). Compared with ELISA, the MMB-based assay has an ~6-fold lower limit of detection (129 ng/L vs. 817 ng/L), and it detects an increase in the IgG concentration much earlier after vaccination. Using 85 RT-qPCR SARS-CoV-2-positive samples and 79 -negative samples, the MMB-based assay demonstrated similar clinical specificity (98% vs. 99%) and sensitivity (93% vs. 92%) to the ELISA test, but with a much faster turnaround time (45 min vs. 245 min). The high analytical and clinical sensitivity, short turnaround time, and simplicity of the MMB-based assay makes it a preferred method for antibody detection.

Easing Restrictions During Vaccine Scarcity. How Mitigation Measures Help Tackling Associated Moral and Behavioral Challenges

Background: When vaccines became first available during the Covid-19 pandemic, their demand significantly exceeded their supply. In consequence, the access to vaccines, initially, was distributed unequally. At the same time, governments started easing pandemic restrictions for vaccinated and recovered persons and restoring their freedoms since their risk of transmitting the virus is significantly reduced. Evidence: We show that restoring freedoms for vaccinated and recovered persons - while upholding restrictions for the rest of the population - is morally unfair during vaccine scarcity. Further, it may yield unintended side-effects, including perverse incentives, growing rifts in society, and the expansion of marginalization. Policy Options & Recommendations: We recommend accompanying easing for vaccinated and recovered individuals by mitigation measures for those who are neither vaccinated nor recovered. We propose, first, to temporarily lift the same restrictions for negative-tested individuals, as for vaccinated or recovered people. Second, the state must ensure broad and easy access to testing for everyone - free of charge. Conclusion: If done right, these mitigation measures create (at least temporarily) equal access to freedom for everybody - solving the moral problem of unfair access to freedoms and counteracting possible negative consequences.

Does the EU COVID Digital Certificate Strike a Reasonable Balance between Mobility Needs and Public Health?

The need to fight a highly aggressive virus such as SARS-CoV-2 has compelled governments to put in place measures, which, in the name of health protection, have constrained many freedoms we all enjoy, including freedom of movement, both nationally and within the European Union. In order to encourage and facilitate the return to free movement, the European Parliament has launched a "COVID-19 digital certificate". A spirited debate centered around the use of this certificate is still ongoing among scholars, many of whom have pointed out the uncertainties relative to COVID-19 immunity, privacy issues and the risk of discriminatory effects. The authors, while highlighting some critical aspects, argue that the COVID digital certificate in its current approved version can effectively help prevent the spread of the infection and promote free movement, while upholding the right to health as much as possible. However, they also stress the need for a thorough information campaign to illustrate the advantages and limitations of this document in order to avoid creating a false sense of security in the public opinion, who may wrongly assume that the emergency has been overcome for good.

The potential impact of vaccine passports on inclination to accept COVID-19 vaccinations in the United Kingdom: Evidence from a large cross-sectional survey and modeling study

BACKGROUND

The UK Government is considering the introduction of vaccine passports for domestic use and to facilitate international travel for UK residents. Although vaccine incentivisation has been cited as a motivating factor for vaccine passports, it is unclear whether vaccine passports are likely to increase inclination to accept a COVID-19 vaccine.

METHODS

We conducted a large-scale national survey in the UK of 17,611 adults between 9 and 27 April 2021. Bayesian multilevel regression and poststratification is used to provide unbiased national-level estimates of the impact of the introduction of vaccine passports on inclination to accept COVID-19 vaccines and identify the differential impact of passports on uptake inclination across socio-demographic groups.

FINDINGS

We find that a large minority of respondents report that vaccination passports for domestic use (46·5%) or international travel (42·0%) would make them no more or less inclined to accept a COVID-19 vaccine and a sizeable minority of respondents also state that they would 'definitely' accept a COVID-19 vaccine and that vaccine passports would make them more inclined to vaccinate (48·8% for domestic use and 42·9% for international travel). However, we find that the introduction of vaccine passports will likely lower inclination to accept a COVID-19 vaccine once baseline vaccination intent has been adjusted for. This decrease is larger if passports were required for domestic use rather than for facilitating international travel. Being male (OR 0·87, 0·76 to 0·99) and having degree qualifications (OR 0·84, 0·72 to 0·94) is associated with a decreased inclination to vaccinate if passports were required for domestic use (while accounting for baseline vaccination intent), while Christians (OR 1·23, 1·08 to 1·41) have an increased inclination over atheists or agnostics. Change in inclination is strongly connected to stated vaccination intent and will therefore unlikely shift attitudes among Black or Black British respondents, younger age groups, and non-English speakers.

INTERPRETATION

Our findings should be interpreted in light of sub-national trends in uptake rates across the UK, as our results suggest that passports may be viewed less positively among socio-demographic groups that cluster in large urban areas. We call for further evidence on the impact of vaccine certification and the potential fallout for routine immunization programmes in both the UK and in wider global settings, especially those with low overall trust in vaccinations.

FUNDING

This survey was funded by the Merck Investigator Studies Program (MISP).

Local characterization of the COVID-19 response: the case of a lockdown in Lusaka, Zambia

BACKGROUND

The onset of the COVID-19 pandemic has sparked heated debate among scholars on the relevance of lockdowns. There are those in favor of the lockdown and others who are critical of it. However, despite the increased interest in understanding the relevance of lockdowns, there still has not been much focus on its relevance in countries like Zambia. Thus, with the help of the Social Representation Theory (SRT), we set out to explore and document the local characterization of the lockdown by residents of Lusaka, Zambia.

METHODS

We recruited our participants through convenient and purposive sampling techniques. This was done through the use of the ZAMTEL public phone records. Initial contact was made to potential participants, and they were asked of their availability and willingness to participate in the interview. Upon agreeing to participate, they were included in the sample. A total of 68 people were selected to take part in this study. Their age ranged from 20 to 76 years old. 33 of them were male and 35 females. After this, we conducted interviews with the 68 participants. Due to COVID-19 restrictions, our interviews were conducted via telephone in conformity with the recommendations from the IRB in Lusaka and the advice of the ministry of health. We anonymized the demographic characteristics and responses from our participants. Later, thematic analysis was used to analyze the data.

RESULTS

The lockdown was on one hand lauded for slowing down the incidence rates, preventing fatalities, and protecting the healthcare system from collapse. On the other hand, it was criticized for exacerbating poverty levels, unemployment rates, increasing the rate of mental health problems, aiding gender-based violence, and intensifying political repression and corruption. The results speak to the complexity in the characterization of the lockdown as a response to COVID-19 in Lusaka, Zambia. This observation demonstrates the folly of viewing, applying and characterizing the COVID-19 lockdown as a 'one-size-fits-all' approach in Lusaka, Zambia.

CONCLUSION

Rather than establishing the lockdown as an incontestable good, as it is depicted by some scholars or as useless by its critics, our findings instead demonstrate the diversity and complexity in how it is locally viewed by Lusaka residents. The study provides grounds for caution on simplistic and binary characterization of lockdowns. It indicates the need for careful dialog between the designers of lockdowns and citizens in order to tailor such interventions to local realities in context-specific ways. It also shows that though the development of such interventions, all the various and complex elements it embodies must be taken into account in order to realize optimum outcomes.

Vaccination passports: Challenges for a future of air transportation

COVID-19 has been a major setback for air transportation; many airlines had to request for bailouts and the international flights connectivity is only restarting slowly. Accordingly, many aviation stakeholders put hopes into the ongoing process of vaccination, with the expectation that a high degree of vaccination will push the envelope for a return to normalcy. One prerequisite for reviving international air connectivity is the introduction of verification documents, also called "vaccination passports". These passports, however, come with several challenges which need to be overcome in order to enable recovery. In this study, we propose a framework covering five important aspects and policy challenges concerning the introduction of vaccination passports for a return of aviation, covering the topics: Competition, Epidemiology, Technology, Ethics, and Politics. Neglecting to appropriately address these challenges will likely not only delay the recovery, but possibly miss an important opportunity before new disastrous events appear on the horizon.

Conscience and Vaccines: Lessons from Babylon 5 and COVID-19

Babylon 5, like other great sci-fi franchises, touched on important ethical questions. Two ethical conundrums relating to the series' main characters included providing life-saving treatment to a child against their parents' wishes and potential involvement with a highly beneficial but morally dubious medication. I use these cases to discuss some aspects of the COVID-19 vaccines' development and roll-out, demonstrating that people (be it patients or clinicians) might object to some vaccines due to reasonable ethics and safety-based concerns rather than due to an anti-vaxxer mind-set. I highlight that it would be disingenuous to lump these two groups of objections together for not all objections to specific vaccines are objections to vaccination in general. Rather, governments and pharmaceutical companies should seriously engage with the concerns of reasonable objectors to provide citizens with the appropriate products and ensure large vaccination uptake - in the case of COVID-19 this should include giving patients the choice of the product they will be inoculated with.

COVID-19 immunity (or vaccine) passports: a documentary overview and analysis of regimes of health verification within the coronavirus pandemic

Purpose

Introducing immunity or vaccine passports is one non-pharmaceutical intervention that governments are considering to exempt immune, vaccinated or otherwise risk-free individuals from lockdowns and other public health restrictions during the coronavirus pandemic. The primary objective of these documents would be to begin reopening societies, restarting economies and returning to a pre-pandemic normalcy. This article aims to present the start of a conceptual documentary analysis of (proposed and existing) COVID-19 immunity passports in order to more fully center their documentary status within research, considerations and conversations about their potential roles, impacts and implications.

Design/methodology/approach

Inspired by Paula A. Treichler's argument for the importance of theoretical thought for untangling the socio-cultural phenomena of epidemics, and drawing upon interdisciplinary theories of documentation, identity and public health, combined with recent news coverage of the coronavirus pandemic, this article provides a contemporary overview and conceptual analysis of emerging documentary regimes of COVID-19 immunity verification involving immunity or vaccine passports.

Findings

Three major interconnected objectives could be fulfilled by immunity passports. First, they would establish and materialize an official identity of COVID-19 immune for people possessing the formal document. Second, they would serve as material evidence establishing and verifying individuals' immunity, vaccination or risk-free status from the coronavirus that would, in term, determine and regulate their movements and other privileges. Third, they would create tangible links between individuals and governments' official or recognized identity category of COVID-19 immune. Immunity passports would, therefore, help enable and enforce governmental authority and power by situating individuals within documentary regimes of COVID-19 immunity verification.

Research limitations/implications

In the expanding interdisciplinary literature on COVID-19 immunity passports, sometimes also called certificates, licenses, or passes, there appears to be only minimal reference to their documentary instantiations, whether physical, digital, and/or hybrid documents. As yet, there is not any specific documentary approach to or analysis of immunity passports as kinds of documentation. A documentary approach helps to illuminate and emphasize the materiality of and ontological considerations concerning the coronavirus pandemic and its associated kinds of immunity or vaccination.

Social implications

By beginning an exploration of what makes immunity passports thinkable as a public health response to the coronavirus pandemic, this article illuminates these health and identity documents' material implications for, and effects on, individuals and societies. This article, therefore, helps shed light on what immunity passports reveal about the complicated and contested intersections of identity, documentation, public health and socio-political control and discipline.

Originality/value

This article contributes the start of a documentary analysis of (proposed and existing) COVID-19 immunity passports in order to more fully center their documentary status within research and conversations about them.

Scientists have favorable opinions on immunity certificates but raise concerns regarding fairness and inequality

During the first wave of the COVID-19 pandemic, we collected over 12,000 responses from a survey of scientists, who were asked to express their opinions on immunity certificates (also called "immunity passports") as a potential instrument to lessen the impact of the crisis. Overall, we find that scientists perceive immunity certificates as favorable for public health (50.2%) and the state of the economy (54.4%) while one-fifth (19.1%) and one-sixth (15.4%) disagree. Scientists stipulate some concerns about fairness (36.5%) and inequality (22.4%) arising from implementation of immunity certification. We find some smaller differences among scientific fields, particularly between health scientists and social scientists, with the latter being slightly more positive about the effect of immunity certification. Scholars in the United States, including health scientists, are more likely to view the immunity certificates favorably and mention fewer concerns about this policy's effect on fairness and inequality. Female scholars are significantly less in favor of immunity certificates, while scientists with more conservative political views hold more favorable opinions. Our results reveal that given the uncertainties during an early phase of a pandemic, scientists see scope for immunity certification to lessen the general societal impacts of the crisis.

Two-tiered SARS-CoV-2 seroconversion screening in the Netherlands and stability of nucleocapsid, spike protein domain 1 and neutralizing antibodies

BACKGROUND

Serological testing in the COVID-19 pandemic is mainly implemented to gain sero-epidemiological data, but can also retrospectively inform about suspected SARS-CoV-2 infection.

METHOD

We verified and applied a two-tiered testing strategy combining a SARS-CoV-2 receptor-binding domain (RBD)-specific lateral flow assay (LFA) with a nucleocapsid protein (NCP) IgG ELISA to assess seroconversion in n = 7241 individuals. The majority had experienced symptoms consistent with COVID-19, but had no access to RT-PCR testing. Longitudinal follow-up in n = 97 LFA + individuals was performed up to 20 weeks after initial infection using NCP and spike protein S1 domain (S1) IgG ELISAs and a surrogate virus neutralization test (sVNT).

RESULTS

Individuals reporting symptoms from January 2020 onwards showed seroconversion, as did a considerable proportion of asymptomatic individuals. Seroconversion for symptomatic and asymptomatic individuals was higher in an area with a known infection cluster compared to a low incidence area. Overall, 94% of individuals with a positive IgG result by LFA were confirmed by NCP ELISA. The proportion of ELISA-confirmed LFA results declined over time, in line with contracting NCP IgG titres during longitudinal follow-up. Neutralizing antibody activity was considerably more stable than S1 and NCP IgG titres, and both reach a plateau after approximately 100 d. The sVNT proved to be not only highly specific, but also more sensitive than the specificity-focussed two-tiered serology approach.

CONCLUSIONS

Our results demonstrate the high specificity of two-tiered serology testing and highlight the sVNT used as a valuable tool to support modelling of SARS-CoV-2 transmission dynamics, complement molecular testing and provide relevant information to individuals.

Ethics of genomic passports: should the genetically resistant be exempted from lockdowns and quarantines?

Lockdowns and quarantines have been implemented widely in response to the COVID-19 pandemic. This has been accompanied by a rise in interest in the ethics of 'passport' systems that allow low-risk individuals greater freedoms during lockdowns and exemptions to quarantines. Immunity and vaccination passports have been suggested to facilitate the greater movement of those with acquired immunity and who have been vaccinated. Another group of individuals who pose a low risk to others during pandemics are those with genetically mediated resistances to pathogens. In this paper, we introduce the concept of genomic passports, which so far have not been explored in the bioethics literature. Using COVID-19 as an illustrative example, we explore the ethical issues raised by genomic passports and highlight differences and similarities to immunity passports. We conclude that, although there remain significant practical and ethical challenges to the implementation of genomic passports, there will be ways to ethically use them in the future.

Who should be tested in a pandemic? Ethical considerations

BACKGROUND

In the initial phase of the Covid-19 pandemic, difficult decisions had to be made on the allocation of testing resources. Similar situations can arise in future pandemics. Therefore, careful consideration of who should be tested is an important part of pandemic preparedness. We focus on four ethical aspects of that problem: how to prioritize scarce testing resources, the regulation of commercial direct-to-consumer test services, testing of unauthorized immigrants, and obligatory testing.

MAIN TEXT

The distribution of scarce resources for testing: We emphasize the use of needs-based criteria, but also acknowledge the importance of choosing a testing strategy that contributes efficiently to stopping the overall spread of the disease. Commercial direct-to-consumer test services: Except in cases of acute scarcity, such services will in practice have to be allowed. We propose that they should be subject to regulation that ensures test quality and adequate information to users. Testing of unauthorized immigrants, their children and other people with unclear legal status: Like everyone else, these individuals may be in need of testing, and it is in society's interest to reach them with testing in order to stop the spread of the disease. A society that offers comprehensive medical services to unauthorized immigrants is in a much better position to reach them in a pandemic than a society that previously excluded them from healthcare. Obligatory testing: While there are often strong reasons for universal testing in residential areas or on workplaces, there are in most cases better ways to achieve testing coverage than to make testing mandatory.

CONCLUSION

In summary, we propose (1) decision-making primarily based on needs-based criteria, (2) strict regulation but not prohibition of direct-to-consumer test services, (3) test services offered to unauthorized immigrants, preferably as part of comprehensive medical services, and (4) broad outreach of testing services whenever possible, but in general not obligatory testing.

Global Ethical Considerations Regarding Mandatory Vaccination in Children

Whether children should be vaccinated against coronavirus disease-2019 (COVID-19) (or other infectious diseases such as influenza) and whether some degree of coercion should be exercised by the state to ensure high uptake depends, among other things, on the safety and efficacy of the vaccine. For COVID-19, these factors are currently unknown for children, with unanswered questions also on children's role in the transmission of the virus, the extent to which the vaccine will decrease transmission, and the expected benefit (if any) to the child. Ultimately, deciding whether to recommend that children receive a novel vaccine for a disease that is not a major threat to them, or to mandate the vaccine, requires precise information on the risks, including disease severity and vaccine safety and effectiveness, a comparative evaluation of the alternatives, and the levels of coercion associated with each. However, the decision also requires balancing self-interest with duty to others, and liberty with usefulness. Separate to ensuring vaccine supply and access, we outline 3 requirements for mandatory vaccination from an ethical perspective: (1) whether the disease is a grave threat to the health of children and to public health, (2) positive comparative expected usefulness of mandatory vaccination, and (3) proportionate coercion. We also suggest that the case for mandatory vaccine in children may be strong in the case of influenza vaccination during the COVID-19 pandemic.

COVID-19, immunoprivilege and structural inequalities

As cases of COVID-19 continue to rise, some countries, including the US, Chile, and Germany, have considered issuing "immunity passports." This possibility has raised concerns and debate regarding their potential social, political and economic ramifications, especially for marginalized communities. This paper contributes to that debate by exposing that ways in which immunoprivilege already exists and operates within our present system of structural inequalities.

Good reasons to vaccinate: mandatory or payment for risk?

Mandatory vaccination, including for COVID-19, can be ethically justified if the threat to public health is grave, the confidence in safety and effectiveness is high, the expected utility of mandatory vaccination is greater than the alternatives, and the penalties or costs for non-compliance are proportionate. I describe an algorithm for justified mandatory vaccination. Penalties or costs could include withholding of benefits, imposition of fines, provision of community service or loss of freedoms. I argue that under conditions of risk or perceived risk of a novel vaccination, a system of payment for risk in vaccination may be superior. I defend a payment model against various objections, including that it constitutes coercion and undermines solidarity. I argue that payment can be in cash or in kind, and opportunity for altruistic vaccinations can be preserved by offering people who have been vaccinated the opportunity to donate any cash payment back to the health service.

Provide Vaccines, Not Require Immunity or Vaccination Passports … For Now

In principle, mandatory vaccination in employment could be justified in certain circumstances. These include: (1) the availability of safe and effective vaccination; (2) if alternative, less coercive strategies did not work; and, (3) the costs to the individual were proportionate. However, in COVID-19, the long term safety of vaccines is yet to be established. Vaccines should be made available by employers, and voluntary vaccination encouraged.

Immunity passports, fundamental rights and public health hazards: a reply to Brown et al

In their recent article, Brown et al analyse several ethical aspects around immunity passports and put forward some recommendations for implementing them. Although they offer a comprehensive perspective, they overlook two essential aspects. First, while the authors consider the possibility that immunological passports may appear to discriminate against those who do not possess them, the opposite viewpoint of immune people is underdeveloped. We argue that if a person has been tested positive for and recovered from COVID-19, becoming immune to it, she cannot be considered a hazard to public health and, therefore, the curtailment of her fundamental rights (eg, the right to freedom of movement) is not legitimate. Second, they omit that vaccine distribution will create similar problems related to immunity-based licenses. Vaccine certificates will de facto generate a sort of immunity passport. In the next phases of the pandemic, different immunity statuses will be at stake, because the need to identify who can spread COVID-19 is unavoidable. If a person does not pose a threat to public health because she cannot spread the infection, then her right to freedom of movement should be respected, regardless of how she acquired that immunity.