Vaccine Passports: Risks and Benefits of Requiring Proof of Vaccination

As public and private entities contemplate how to move forward with the next phase of the COVID-19 pandemic, many decision makers have considered the idea of a “vaccine passport.” This memo discusses the pros and cons of such a policy option using anecdotal evidence and a behavioral science lens.

Definition and National Landscape

As COVID-19 vaccination rates increase across the US, public health and elected officials are determining next steps to reopen the economy and permit human mobility while protecting lives. One concept that has been commonly termed “vaccine passports” would require people to provide proof of vaccination before traveling, attending in-person events with high possibilities of virus transmission, or conducting daily activities that occur around other people. Throughout this memo, we use the term “vaccine passports,” which is one of a long list of potential names for these requirements including “vaccine credential” or “digital health pass.” As of May 7, 2021, there has not been any guidance on the use of these requirements from the federal government. White House Press Secretary Jen Psaki has stated that the federal government has no intention of requiring proof of vaccination and will leave vaccine credentialing up to private businesses and nonprofits (Psaki, 2021). Despite, or perhaps because of, the federal government’s hands-off approach, several states and cities have begun using some form of vaccine passports or have initiated measures to prevent the use of vaccine passports in their jurisdiction.

In late March 2021, New York City launched the country’s first vaccine passport program, which they named the Excelsior Pass (Fowler, 2021). This digital pass is a free app that individuals can voluntarily download to prove their vaccination status or current negative COVID-19 test result when entering crowded businesses or large public events. In February, Governor Cuomo began authorizing the limited reopening of stadiums and arenas with the condition that attendees be able to provide a negative COVID-19 test result or proof of vaccination (Millman, 2021). Madison Square Garden, for example, has been using the Excelsior Pass to abide by this regulation and streamline entry for recent games (ibid). Currently, the use of this passport is voluntary and developers claim that the app should not be thought of as a “standalone identification document” (Fowler, 2021).

New York is not the only state considering vaccine passports for private businesses or inter-state travel. As of May 7, 2021, Hawaii residents are able to upload their vaccine information to Safe Travels Hawaii, which allows inter-island travel without a negative COVID-19 test result or mandatory quarantine (Morales, 2021). Hawaii Governor Ige has previously said the state is working on testing the technology for wider use (i.e. for tourists), but as of early May no definite plans have been made (Drees, 2021). In addition to New York and Hawaii, states such as North Carolina, Illinois, Connecticut, and California have been contemplating varying levels of vaccine passports (ibid). However, most states appear to agree that it is too early to implement vaccine passports while people are still in the process of getting vaccinated (Amobi, 2021).

To prevent similar programs from occurring in their states, a number of governors and legislatures have signed executive orders or passed legislation in 2021 to prohibit the use of vaccine passports. The map below displays the states as of May 21, 2021 that have passed a ban on vaccine passports. Despite the relatively few states that currently have bans, legislation to implement similar bans has been introduced in the majority of state legislatures across the country (Negovan, 2021). The strictest bans in Montana, Texas, and Florida prohibit both governments and private companies from requiring proof of vaccination, while the remaining states simply ban the government from requiring proof of vaccination.

While concerns over vaccine passports exist across the political spectrum, the issue has become politicized, with Republican leaders acting to prevent their use. Citing concerns over personal liberties and discrimination based on vaccine status, several Republican governors and legislatures have enacted bans on vaccine passports (see Figure 1). The only states in which vaccine passports have been implemented are Democratically controlled. Those who advocate for vaccine passport use tend to point to the health and safety benefits of these passports as the country reopens the economy while the COVID-19 virus continues to circulate.

Figure 1: States with vaccine passport bans. Created with mapchart.net.

Washington State Landscape

On May 3, 2021, Governor Jay Inslee presented new regulations for “vaccinated sections” which apply to sporting venues, graduations, churches, and other large venues. The concept allows vaccinated individuals to sit together without social distancing regulations (Westneat, 2021). This new guidance is only for counties in Phase 2 or 3 of reopening and can be applied to both indoor and outdoor venues. The announcement enables venues and religious institutions to increase their capacity to 50% or up to 22,000 people, whichever is smaller. This new policy outline does emphasize that capacity is limited to 9,000 people for unvaccinated people and is applicable only to venues, not restaurants (Q13 News Staff, 2021). Individuals in vaccinated sections must provide proof of vaccination by showing documentation. Acceptable forms of proof of vaccination include vaccine cards, photos of a vaccine card, electronic health records, or state immunization information system records (Inslee, 2021). Recently, state and private universities have taken steps to clarify the process to return to in-person teaching and learning. UW, WSU, Seattle University, Pacific Lutheran University, Whitman College, and other institutions have issued a COVID-19 vaccine requirement for students to return to campus in the fall (KIRO 7 and Ko, 2021). This vaccine requirement is being added to the existing requirements for MMR, Meningococcal, rabies, and other vaccines that are already required to enroll in university (WA DOH, n.d.).

Requiring proof of vaccination under current guidelines is logistically complex for venues, places of worship, airlines, and campuses. Implementing a system with digital vaccine passports would require appropriate technology for tracking and scanning passports as well as increased personnel time for managing requirements and troubleshooting technological difficulties. As of early May, at least 17 private companies are launching mobile, digital vaccine passport applications. Washington State is unlikely to choose one single mobile system, which might lead to different companies using different systems.

Types of Vaccine Passports in Washington State

As of May 3 2021, the Governor’s Office has provided guidance to safely increase capacity for spectator events and faith-based organizations. The following table summarizes the accepted methods of proving vaccination status for attendees of these events (Inslee, 2021). No additional forms of identification are required.

Risks and Benefits of Vaccine Passports

The current political climate has rendered vaccine passports challenging to implement within the public sector. As a result, passports would likely only be required by businesses or nonprofits within the private sector. Requirements like these carry unique risks and benefits as outlined below.

Risks

  1. Widening Inequities

Vaccine distribution has been inequitable, as distribution prioritized those in living situations or occupations which are disproportionately composed of people who are white, rather than essential workers who are more likely to identify as a person of color (DOH, 2021; Rogers et al., 2020). In Washington State, vaccine prioritizations that were intended to protect highly vulnerable groups ultimately favored white and wealthy populations, exacerbating inequities that have persisted throughout the pandemic. Communities of color have faced disproportionately high infection rates and low vaccination rates, while white communities with greater access and mobility have been disproportionately overserved in the vaccine rollout (DOH, 2021; anonymous interview, 2021).

At least until Covid-19 vaccines have been widely available and accessible for several months to allow people to become fully vaccinated, a vaccine passport mandate will continue to widen societal socioeconomic and racial gaps between those with the resources and knowledge to access the vaccine and those without. Widening this gap will cause greatest harm to those most affected by the pandemic (Li, 2021; Herlitz et al., 2021). Even as vaccines become widely available, communities of color may still be more reluctant to accept the vaccine due to historical and current medical and institutional abuse. Requiring proof of a vaccine to participate in essential activities may infringe upon the autonomy of marginalized groups and become a de facto mandate. In addition, vaccine passports may impose on personal privacy in a way that is especially dangerous to people who are undocumented. One user of New York’s Excelsior Pass noted that fraudulent activity was prevented by presenting identification with the passport, posing a barrier to those who do not have identification and possibly presenting an invasion of privacy (Fowler, 2021).

2. Vaccine Passports May Inadvertently Encourage Overconfidence and Stigmatization

Implementing vaccine passports in heavily trafficked areas may give individuals a false sense of security, potentially resulting in an increase in risky behavior. Those who are allowed access to locations that are controlled through vaccine passports may neglect to take additional precautions such as wearing masks and washing hands. As of May 2021, research has found that vaccination reduces the risk of transmission by approximately 50% (Harris et al., 2021). Although current research finds that the risk of transmission is reduced when compared to non-vaccinated individuals, passports may instill a false sense of safety and facilitate public gathering when it may not be safe to do so. Additionally, research shows that if a vaccinated individual contracts COVID-19, the chances that the recipient will experience severe symptoms is significantly reduced (ibid). This means that the virus could continue to circulate undetected. There is also uncertainty surrounding the vaccine’s immunity durability, with current research suggesting the vaccine is effective for six months. Vaccine passports may circumvent these issues by including expirations and updating policy restrictions as further studies are conducted to understand the vaccine’s efficacy. Finally, variants of the virus are constantly evolving across the globe, and research has only recently begun to emerge on the vaccine’s effectiveness at reducing transmission or symptoms of these variants (CDC, 2021).

Another potential effect of implementing vaccine passports is stigmatization of those who are unable or unwilling to receive the vaccine. Passports would require individuals to admit their vaccine status whenever they go to a public space with these requirements. This could result in the formation of in-groups and out-groups based on vaccination status and access to certain events. Facilitating group formation could lead to additional intergroup conflict between those who have and have not been vaccinated. Behavioral scientists suggest that being publicly stigmatized in this way may lead to negative emotional and behavioral outcomes for individuals (Bos, 2013).

3. Threatening Medical Privacy

Because the creation and implementation of vaccine passports are at the discretion of private entities, this sector has significant potential for collecting and protecting users’ private medical data. To ensure this is done voluntarily, consumers ought to be able to control the type and quantity of data they share when presenting their vaccine passports. In addition, private entities must be transparent with their use of consumer data, including whether they will retain or collect it (Bloomberg Law, 2021). Additionally, whether vaccine passports violate the Health Insurance Portability and Accountability Act (HIPAA) is determined by whether there is healthcare provider involvement. If consumers upload their own medical information, including their vaccination status, app developers may be exempt from HIPAA protocol (Bloomberg Law, 2021). Lack of federal guidance in the vaccine passport sphere may also create issues with medical privacy. States independently creating requirements may result in a hodgepodge of vaccine passports, leading to multiple digital applications. Since each app provides an opportunity for personal data breaches security risks increase with the number of apps (ibid). Security, privacy, and safety must be prioritized in each engineering processes, which would be more easily facilitated by federal vaccine passport standards.

4. Increasing Vaccine Skepticism

Since mid-April, when COVID-19 vaccines became available to all United States residents, the average number of vaccine doses administered per day has been decreasing despite only 60% of US adults having received at least one dose as of May 21, 2021 (The New York Times, 2021). Many are considering whether COVID-19 vaccine hesitancy is to blame. As discussed in the Communication Strategies memo, vaccine hesitancy is caused by politicization, misinformation, distrust in medical institutions and pharmaceutical companies, and concerns about the rapid development of the vaccine. All three vaccines currently administered in the US are done so through an emergency use authorization (EUA) and are not approved by the Food and Drug Administration (FDA) at this time (HHS, 2021). Although the vaccines will apply for formal Federal Drug Administration approval in the coming months and years, and all vaccines currently being administered in the US have been through clinical trials, some are concerned that they have not been tested rigorously enough. A direct corollary of this is that mandating vaccine passports may increase skepticism among those who are wary of the vaccines’ long-term effects.

Benefits

  1. Encouraging Vaccine Uptake

Businesses requiring vaccine passports may be able to incentivize some individuals to receive the vaccine. After 14 months of pandemic related closures and restrictions, people are eager to return to in person activities with their social networks. Requiring a vaccine for desirable activities may be a necessary nudge for some individuals, potentially increasing vaccine uptake as the push for encouraging as many people as possible to be vaccinated continues. Vaccine passports are one tool for businesses and nonprofits to increase vaccine uptake. Higher levels of vaccine uptake will protect more people from the virus and allow the economy to grow.

2. Expediting Reopening of Economy

The pandemic has devastated the economy, and impacts have been disproportionately felt by communities of color. In Washington State, unemployment claims peaked at 711,945 claimants in May 2020, which is over twice as many claims filed during the height of the great recession over a decade earlier (Washington State Employment Security Department, 2021). The sector that faced the most significant impact was leisure and hospitality with over a 20% decrease in employment. Other sectors hit the hardest include manufacturing and customer-facing service positions, which still face a relatively slow recovery when compared to those which are more conducive to working from home, such as tech (ibid). As of December 2020, 2,369 businesses within the food service industry have permanently closed in Washington State since the beginning of the pandemic, with small and immigrant-owned businesses being hit the hardest (King 5, 2020). Some public leaders assert that implementation of vaccine passports will allow local economies to reopen more quickly. For example, by May 19, 2021, New York State plans to reduce many of its restrictions on public gatherings with the stipulation that large events (defined as more than 250 people inside and more than 500 people outside) require vaccine passports for entry (forward.ny.gov, n.d.). Reopening the economy safely will help decrease unemployment and improve US residents’ mental health.

3. Increasing Convenience for Certain Groups

One of the biggest arguments in favor of app-based vaccine passports is their ability to centralize individuals’ passports in a digital setting, which is easier to keep track of than the paper vaccination card provided by the CDC. A digital passport would also allow users to easily update their vaccine history as they received booster shots. However, this method favors those who are tech savvy and requires reliable access to a mobile device. Even those who traditionally have access to technology may face problems if their device fails or they experience other technical difficulties. Even so, a digital credential could reduce the administrative burden on local health clinics by limiting the number of patients frequently requiring replacement vaccine cards, and facilitating an easier and more convenient vaccine tracking system. Additionally, vaccine passports allow people who have been vaccinated to enjoy benefits not afforded to those who have not received the vaccine. For example, the Seattle Mariners have added vaccinated seating sections, which can be seated at a higher percentage capacity with no social distancing restrictions (Washington State Governor’s Office, 2021). Washington State’s spectator event guidelines specify that facilities should not prohibit separate seating areas to unvaccinated individuals (ibid). This rewards-based approach, which provides additional benefits for vaccinated individuals, is a stronger motivator for reinforcing desired behavior (such as receiving the vaccine) in comparison to a punishment-based approach which removes the benefits or the rights of those who are not vaccinated (Guitart-Masip et al., 2014).

4. Improving Vaccine Tracking Within the US

Compared to peer countries, the US currently has an inadequate tracking system to account for those who have received vaccinations (AMA, 2021). There is already a market for counterfeit or blank white paper cards, which are currently the country’s only form of individualized vaccine tracking. A well-designed digital vaccine passport could more accurately and reliably identify vaccine recipients and make forgery more difficult. As noted above, the federal government has no plans to require vaccine passports or to even provide technical assistance for jurisdictions that wish to do so (ibid). The absence of federal guidance increases the likelihood that there will be a heterogenous patchwork of policies throughout the country. Current versions of vaccine passports within the United States, such as the Excelsior pass, have been digitized. Until there are federal-level efforts to build a “digital infrastructure” that would more accurately and consistently track vaccine uptake across a variety of sectors and geographies, there will be issues with falsification resulting from having only physical cards to track vaccines, leaving the potential benefits of digital vaccine passports unrealized.

Strategies for Successfully Implementing Vaccine Credentials

Framing

How vaccine requirements are discussed and marketed can greatly influence the way they are perceived by the public. Both the specific language used to describe these requirements and the historical context of vaccine requirements could be used to accurately describe them in a positive way. First, several different names for these policies have been circulated. The word “passport” has an international connotation, yet these permits would also be used to regulate behavior within US borders. One phrase recommended by the American Medical Association is the term “digital health pass.” Another recommended phrase is “licensing,” since this practice would be akin to how drivers’ licenses are used to better assure that a driver is minimizing danger to those in the vicinity (AMA, 2021). Alternatives include “credential,” “safe pass,” or “certificate.” Names that include “safe” or “health” would help people draw the connection between the requirement and their own health and safety.

Another key framing lens includes reminding the public that vaccine requirements are commonly used tools for international travel and safety in public schools. The concept of requiring a vaccination to prevent disease before traveling and potentially exposing others has been safely and effectively used for decades. Reminding users of these historical practices will help people understand that this is a routine and normal action for participating in society.

Remove Barriers and Connect People with Vaccines

To best address some of the equity concerns outlined above, it is critical that a business or nonprofit make it as easy as possible for patrons to demonstrate their proof of vaccination. This means both that the vaccine proof should be simple and present few barriers to provision or verification, and that vaccines should be fully available and accessible to all patrons and target populations. Accepting proof of vaccination through multiple platforms before the event or service, as well as allowing proof to be shown upon arrival either digitally or with a hard copy would all improve accessibility. Transparency and access will also be improved when businesses are clear in their expectations for use of these credentials, posting such expectations on their websites for people to consult before they attempt to comply. In addition to making proof of vaccination simple, businesses benefit from reducing barriers to vaccination itself by offering resources to get vaccinated.

Offer Choices

Finally, behavioral science shows that how service providers offer choices affects how people behave. As previously discussed, the Seattle Mariners and other sporting venues have begun setting aside discounted seats specifically for people who are fully vaccinated. In theory this system incentivizes people to change their behavior and use vaccine credentials if they deem it important to be in that section of the park. Offering this option to customers when they purchase their tickets ahead of time can serve as a “nudge” to encourage people to get vaccinated.

Conclusion

The risks and benefits laid out above are meant to guide organizations as they weigh the potential for implementing vaccine passports in their places of business. We do not offer a blanket recommendation because our analysis does not find that a one size fits all approach is appropriate for all businesses in the current climate. Without federal guidance and considering the highly charged political climate on this issue, organizations will need to determine the best way to move forward. Organizations should evaluate the positionality of their business, the geographical location in which they operate, and what their industry partners are doing to determine the best way to move forward to protect customers and employee health and reopen their businesses. This will look different across regions, and different approaches to vaccination will be received differently across populations. We hope this memo provides useful considerations in making this decision.

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