What are ‘vaccine passports’ and should we have them?

Recently, I was involved in a very heated television debate about vaccine passports.

I will put my cards on the table now, I do not have an issue with the idea of a coronavirus vaccine passport. If vaccines help protect people from getting sick and ease lockdown measures, I will happily flash a piece of paper confirming I have had my vaccine. I do not feel violated in any way, I don’t feel coerced and I do not feel it is a breach of my confidential medical records.

I feel exactly the same as when I visited Saudi Arabia and had to prove I had had my meningitis ACWY vaccine before I could enter the country – to protect others from an outbreak of a deadly disease. To me, it is no big deal.

However, to the other person in the TV debate I participated in, it was a big deal. She felt people should have a choice in whether or not they take the vaccine, and that that choice should not have any further consequences. People should not feel discriminated against, she argued, and should not be stopped from living a normal life once lockdown measures are eased.

She also argued that COVID-19 is a minor illness for most, so even if they were to catch it they would most likely survive with no long-term complications. It is important to say this woman was in her mid-20s with no underlying health conditions. In her opinion, whether or not you have had the vaccine should not affect you being allowed to attend large public gatherings, go into crowded shopping malls, have a drink in a bar or even travel on aeroplanes. She was, after all, exercising her right to choose whether or not she has something injected into her body.

On the surface of it, the argument of free will stands up. But scratch beneath the surface and, I believe, it falls apart.

Nobody is arguing for making vaccines mandatory; the decision to have a vaccine should always come down to an individual’s informed choice. It is also important to note that some people cannot have it for medical reasons, and these people should not be discriminated against.

Governments want as many people as possible to take up the vaccine and have set up campaigns encouraging us all to do so, but doing so is not compulsory. People who have taken the vaccine are given a card stating they have received one or both doses and the information is also documented on their medical records.

However, if you choose not to have the vaccine (for reasons unrelated to any medical condition which precludes you from it) you must understand that it affects not only yourself but those around you.

Having to prove you have been vaccinated against a disease before travel is not a novel idea. Anyone travelling to parts of South America will need to prove they have been vaccinated against yellow fever before admission. Muslims who embark on the holy pilgrimage of Hajj need a certificate stating they have been inoculated against strains of meningitis before they are allowed to mingle with the vast crowds of other pilgrims in Saudi Arabia.

Travel is not the only reason people might need to prove they have been vaccinated. Slovenia has one of the world’s most aggressive and comprehensive vaccination programmes, requiring children to be vaccinated against measles, mumps, rubella, polio, pertussis, Haemophilus influenza type B and hepatitis B before starting school. Unsurprisingly, it has one of the world’s highest vaccine uptake rates.

The US requires children to have received their childhood immunisations before attending school, although this has been difficult to enforce and some states make it relatively easy to get an exemption certificate.

The reason these countries insist on childhood immunisations is so they not only protect the person being vaccinated but also other children and adults they come into contact with.

Control of infectious diseases through vaccination relies on herd immunity. This means a certain threshold of the population being vaccinated so their bodies combat the illness effectively before it has a chance to make them sick and, crucially, pass it on to others. For example, in the case of measles, we aim for 95 percent uptake of the vaccine in the United Kingdom. Eventually, after enough people have been vaccinated, the illness will no longer be able to find fertile breeding ground and will fade out, leaving only pockets of outbreaks every now and again that are much easier to contain.

People who cannot have vaccines for medical reasons rely on the rest of us taking up the vaccine to protect them. When the disease has been contained through vaccination, they are far less likely to come into contact with it and get sick.

With evidence mounting that the COVID-19 vaccines also reduce transmission of the virus, we owe it to some of the most vulnerable in our society to get vaccinated if we can. Your choice to have the vaccine will affect them.

For those who say, “well, if only 80 to 90 percent of the population need to be vaccinated for herd immunity, I can refuse the vaccine and I will be part of the 10 to 20 percent who are not vaccinated; we still get herd immunity and nobody is harmed”, this is not a valid line of reasoning.

The last 10 to 20 percent should be made up of those who cannot have the vaccine for medical reasons only – they are relying on those of us who can. By refusing the vaccine, you are effectively expecting those who do choose to take up the vaccine to do so in order for your life to return to normal. It may sound harsh, but that is the reality of it.

There is another argument being made by those opposed to vaccine passports: That sharing confidential medical data is a worry for many people. As a doctor, I know how important it is to keep medical records absolutely confidential, but vaccine passports do not contain your entire medical record.

They will contain a simple tick to say you have had the vaccine, nothing else will need to be declared. To put this in perspective, all doctors and nurses in the UK have to show they have antibodies against hepatitis B to work in the National Health Service (NHS). This is to protect them and their patients should, for example, a needle injury occur when taking blood, or a scalpel injury happen during a surgical procedure. If the clinician is vaccinated against hepatitis B and is immune, then both parties are protected. Like most other doctors, I have no qualms about sharing this data with my employer.

Then there is the argument around restrictions to freedom for those who have chosen not to take the vaccine. I get it, we are all desperate for lockdown restrictions to ease but one of the main routes to this is through mass vaccination.

To be clear, in normal circumstances I would not want any restrictions on the daily lives of people – they should be free to go about their business as they see fit. But the truth is that we are not living in normal circumstances, we are in the middle of a global pandemic and we have to find ways to make the best of a bad situation.

I have not been an advocate of vaccine passports before, but if they mean we can attend sporting fixtures, music festivals and other large social gatherings without the risk of infecting others then it needs to be considered. There should, of course, be exemption certificates for those who cannot have the vaccine for legitimate medical reasons.

This is about understanding that by choosing not to take up the vaccine you are also choosing the possibility of contracting a dangerous virus, of passing that on to others and of prolonging lockdown measures as a result. We do not live in individual silos, we live in a society where our individual choices affect others. If unvaccinated people attend large gatherings, they risk passing on the virus to those who have not yet had their vaccine or are unable to have their vaccine. They may also pose a risk to children who cannot yet receive the vaccine. While serious problems with coronavirus are rare in children, there may be some who have underlying health conditions that put them at risk.

It is true that young, healthy people who contract COVID-19 are most likely to have only mild symptoms and make a full recovery, but that is not a given. The lady who I debated with argued there was no reason for her to get the vaccine as chances are she would get mild or even no symptoms, so why risk it? This statement shows very little regard for those in our society who stand to fare worse if they were to get COVID-19, the most vulnerable in society. The point is, she could still pass the disease on to someone who will suffer worse symptoms or potentially die. Furthermore, anyone could be asymptomatic and still pass it on.

By all means, ask questions of a qualified medical professional about the vaccine you are receiving. Discuss your concerns. Everyone should be valued equally, but by getting the vaccine you are protecting others.

Progress Report

Yes, the COVID vaccine does reduce transmission of the virus

Each time a COVID-19 vaccine has been approved, there has been a collective sigh of relief from the medical world. After months of seeing more death and disease than we ever expected to, there is now hope. The vaccines, we were told, protected those vaccinated against severe symptoms of the coronavirus which, in turn, would lead to reduced hospital admissions.

The vaccine roll-out programme across the world has varied. Countries such as Israel, the UK and the UAE are progressing at excellent rates, while other countries are struggling to catch up. As data emerges from those countries which are racing ahead, however, there is good news in the form of increasing evidence that the vaccines not only protect against illness from COVID-19, they also reduce transmission rates in those vaccinated.

Reducing transmission rates is crucial to containing this disease. If the vaccines only protect those vaccinated from getting sick with COVID-19 then entire populations will need to be vaccinated. But if there is evidence that those who are vaccinated are also protecting those who have not yet had their vaccines, then we can have a far greater effect on the pandemic well before everyone receives the vaccine. These findings may even influence the rates at which lockdown measures are eased.

A study from Israel, of those vaccinated, showed a four-fold decrease in “viral load” two to four weeks after the first dose of the Pfizer vaccine.

The “viral load” refers to the amount of virus a person is carrying. When a person is infected with coronavirus, it enters their cells and starts to replicate. As the virus replicates, the number of virus particles inside the infected person increases. The more virus the person carries, the higher their viral load. Higher viral loads are associated with worse symptoms of COVID-19, but potentially also increase the risk of passing on the virus. It stands to reason, then, if vaccines reduce viral load, they may also reduce transmission risk. Although more research is needed, it is promising.

Meanwhile, a study in the UK, which has not yet been formally published, suggests the vaccine may have a “substantial” effect on the transmission of the virus.

The study followed people who had had the Oxford-AstraZeneca vaccine. It swabbed those who had been given the vaccine weekly afterwards, looking for the presence of the virus. Test results by the University of Oxford, published in a pre-print report with The Lancet, showed a 67 percent reduction in positive COVID-19 swabs among those vaccinated. This would mean that by reducing the number of infected people in the population the vaccines could have a substantial effect on transmission.

This is a good reason for cautious celebration; reduced transmission through vaccination could dramatically change the landscape of the pandemic. More research is needed, and this will come as more and more people get vaccinated. The fly in the ointment may well be new variants with mutations that allow the virus to escape the immune response set up by vaccines, but manufacturers of the vaccines are confident they can combat these with tweaks to the current vaccines and potential booster shots.

In the Doctor’s Surgery

Looking after those with non-COVID-related illnesses

Mrs B sat quietly on the chair, staring down at an invisible spot on her skirt.

“When did you first notice the lump?” I asked.

“Nearly six weeks ago,” she replied, not looking up. She tucked a loose strand of hair behind her ear, not taking her eyes off her skirt. “I didn’t want to bother you. I know you are busy with everything that has been going on.”

Mrs B had found a lump in her left breast. I had examined her and was worried that the lump could be cancerous.

“The important thing is you are here now,” I said gently. There was no point chastising her for not coming in sooner. It wasn’t her fault; it is easy to watch the news or read the papers and think healthcare professionals are too busy to see patients for non-COVID related issues. But the truth is, there is no respite from other illnesses during a pandemic; they just don’t get the media coverage the coronavirus is getting.

“Mrs B, there are some features of this lump that make me worry that this could be cancer,” I explained. I had to be honest with her. The lump was three centimetres (1.8 inches) across, felt irregular and was tethered to the skin. None of these is good signs.

“What happens now?” She asked, this time looking up at me. I could see her eyes were wet with tears.

“I will ask the breast team to see you urgently. They will scan your breast and perhaps take a sample of the lump, it will give us a better idea as to what this lump is.”

Mrs B gave a faint nod.

“Who is at home with you, Mrs B?” I asked. She suddenly looked very vulnerable sitting there. It was cold outside and she had been wearing several layers; her cardigan lay on the chair next to her. She had taken it off and neatly folded it in preparation for the examination.

“I am on my own,” she said. “But I have friends.”

It is hard; the pandemic means social restrictions. At any other time, I would have told Mrs B that it was best she was not alone, that she should be around family and friends after receiving such news.

“Are you part of a social bubble?” I asked. She shook her head.

“It is OK Dr Khan, I will phone one of my friends up when I get home and ask them to come out on a walk with me.” She started unfolding her cardigan and putting it on.

I promised I would ring her when I had the results of all of her tests and said goodbye.

It was difficult. If Mrs B did have cancer, then she would most probably need intensive treatment so she was best isolating and keeping herself safe from not just the coronavirus but any other infection. At the same time, she had just received potentially devastating news and she needed the support of her loved ones right now.

This is the cruel reality of the pandemic. People are being kept apart at times when they need others around them the most. Some of my patients have delayed seeking medical help because they are worried about catching the virus if they venture into the surgery or they feel their illness is not as important as coronavirus. As a result, I have seen many delayed presentations of serious conditions.

I finished my documentation in Mrs B’s medical records and closed my computer down. She had been my last patient of the day. The next day I had been assigned to the COVID-19 vaccine clinic; as I packed my bag I reminded myself the vaccines are bringing infection rates down, they are reducing hospital admissions and there will be a time when coronavirus is no longer the all-encompassing disease it is today.

And now, some good news
Europe’s oldest person survives COVID-19

A French nun, believed to be Europe’s oldest person, tested positive for coronavirus on January 16, 2021. Lucile Randon, also known as Sister Andre, is 117 years old. She is blind and uses a wheelchair. She told reporters she had no idea she had the virus but after testing positive had to isolate to protect those she lived with. Thankfully, she has made a full recovery and celebrated her 117th birthday soon after getting the all-clear.

Reader’s question

I have had COVID-19, do I still need the vaccine?

Yes, you should be vaccinated regardless of whether you have already had COVID-19. This is because we do not know how long you are protected after having caught coronavirus and, although it is rare, there have been documented cases of people catching the virus twice. The vaccines can act as a booster, providing you with more neutralising antibodies and better protection in the long term. Getting the vaccine is safe and there are no known long-term side effects. The coronavirus vaccines are the safest and best way to protect yourself and your loved ones from COVID-19.