Kumanan Wilson

Resolving the COVID-19 pandemic could require digitally identifying who is immune and who isn't. IN THE 1800S, SMALLPOX RAVAGED THE WORLD. Fortunately, a vaccine had been developed that could protect individuals. This vaccine left a scar at the site of injection and identified the individuals as “immune.” As we look towards the future of the COVID-19 pandemic, unless the virus burns out or an effective therapeutic intervention becomes available, the only way out of our current situation will be immunity—either natural or induced by a vaccine. If so, we will need to create a digital proof of immunity, a digital version of the smallpox scar, to help society to return to normal. A smallpox vaccination scar identifies who is immune from infection by the variola virus Ideally, a safe and effective vaccine will be available in the New Year. If this is the case, we will need to have effective systems in place to identify those who are immunized. Our existing system of largely paper records will not be adequate. Here is how such a system should work. Most provincial/territorial governments have repositories of immunization data. For the eventual COVID-19 vaccine, they will need to ensure that this data is accurate and that the individual identified did, indeed, receive the vaccine. The government could then issue a verified credential, an immunization badge, which contains an easily scannable barcode or QR code, through government portals. This can be consumable by third party apps or be downloaded similar to a boarding pass. To enter into certain venues, such as sporting events or for international travel, the digital badge will have to be presented. The bar code will be scanned and matched to an individual’s ID card, just as we do for boarding passes. This will permit entry or travel. Exemptions will exist for medical reasons. I expect our tolerance for philosophical exemptions will be much lower given the consequences on both health and the economy if outbreaks re-emerge. Ideally an international standard for this vaccination will be set under the International Health Regulations which already provide guidance for Yellow Fever vaccine certificates (Annex 7). This guidance needs to take into account the digitization of these certificates. More controversial is the issuance of digital badges for natural immunity confirmed by antibody testing. The science and ethics of this solution are not mature at present but that should not preclude us from considering this option. As for immunization, antibody data from credentialed labs could be stored in immunity repositories and digital badges issued if a threshold of immunity is considered to be achieved. The most likely initial application of this solution will be front-line workers where, if we are confident natural immunity provides protection, we can create systems ensuring certain percentages of front-line workers are identified to be immune. This will create a form of “shield immunity” disrupting the transmission of the virus and protecting front-line workers and the people for whom they care. A digital solution will have security and privacy risks that a paper record won’t have. However, a digital solution will be agile and adaptable in a way paper records cannot be. For example, if scientific evidence emerges on waning immunity, digital badges can be revoked. Decentralized ledgers (think blockchain) can facilitate the movement of this information across borders and between institutions. As we enter into the next stage of this pandemic, we must start taking steps to ensure we have the right technology in place when science provide us with solutions. I have confidence that the combination of science and technology with ethical and legal oversight can accelerate our return to normal. Kumanan Wilson, MD, MSc, FRCPC, is a physician at The Ottawa Hospital and a member of the University of Ottawa Centre for Health Law, Policy and Ethics. He has been a consultant to the World Health Organization on the IHR (2005).

MARCH 23, 2020 IT WASN'T SUPPOSED TO PLAY OUT THIS WAY. The world had entered into a grand bargain in 2005 with the approval of the revised International Health Regulations (IHR). Countries had essentially ceded some sovereignty to the World Health Organization (WHO) in order to best protect each other from global public health emergencies, and to preserve international travel and trade when these emergencies occurred. Countries also agreed to implement measures to detect, report and respond to potential international threats that emerge within their borders. The WHO would decide when an event had met the level of a public health emergency of international concern. If it did, the WHO would decide what measures were necessary to prevent the spread of the threat, while at the same time, avoiding unnecessary interference with international travel and trade. How did this unfold with COVID-19? On Jan. 20, 2020, using its authority under the International Health Regulations, the WHO declared COVID-19 a public health emergency of international concern. Currently the WHO has stated there is no role for travel bans to prevent the spread of the disease, except at the earliest stages of the disease entering a country to give the country time to develop preparedness measures. However, from the beginning of this crisis, countries and non-state actors, such as airlines, have exceeded the WHO recommendations. The United States announced a ban of all non-essential travel to mainland Europe. Canada has asked all non-essential travel to be cancelled and has closed its borders to non-Canadian travelers. European nations are rapidly closing borders. The WHO’s statement on travel restrictions remains unchanged. What went wrong? The international agreement was always a bit of a long shot. While unanimously approved by World Health Assembly (WHA) member states, there was no enforcement mechanism for the IHR. It was largely based on trust in the WHO, and a trust in global governance. And that is what has changed. The International Health Regulations were approved in a world which believed in global approaches to combating these and other threats. We don’t live in that world anymore. We live in a world which is increasingly distrustful of global elites, one characterized by increasing populist sentiment. In this world, it’s not surprising that countries would disregard WHO guidance. Did President Trump even know (or care) what this guidance was? Is Boris Johnson going to “take orders” from Geneva? Is Modi? Putin? Bolsonaro? No. In the current world, increasingly, countries are acting solely in their own best interest. But it’s not just the populist nations that are taking this action as the pandemics toll increases. Now we are all looking to protect our own citizens first. Diseases are harder to control when countries act independently. Travel and trade are unnecessarily impacted. The loss of global wealth attributed to COVID-19 is in the trillions. And when we eventually come out of this crisis, we are all going to have to agree on rules to reopen our borders – it is apparent the WHO is not currently a trusted source to make this decision. So, what needs to happen? Countries need to trust the WHO—and the WHO needs to earn this trust. Trust was dissipating after a series of questions in recent years surrounding WHO leadership in addressing emergencies, most notably its response to the 2014 Ebola outbreak. It is incumbent upon the WHO to ensure that it acts in a way that is transparent and accountable to rebuild this trust. It is very concerning that there is such a discordance between WHO advice and nation’s actions. Either the WHO advice was incorrect and contributed to the spread of the virus, or countries are over-reacting and causing unnecessary harm to international trade and travel. The WHO also needs to be financially supported and, in turn, needs to financially support low- and middle-income countries so that they can invest in surveillance and response capacity. A comparatively small investment in local public health could lead to the early detection and containment of future COVID-19-type outbreaks. A compensation program also needs to be created to offset the economic consequences of early reporting of potential threats—particularly by low- and middle-income countries. Importantly, the views of local populations affected by outbreaks and travel advisories—which can be devastating to local industries—need to be considered, and these local populations need to be supported. It is the perception that their needs are secondary to global goals that has, perhaps more than any other factor, fueled populist sentiment. The world needs the International Health Regulations, even in spite of the fact that nations are not following all of their guidance, as we're currently seeing with COVID-19. The good news is if we can learn from this outbreak and make this system work, local populations will be better supported. Investments in local public health by the global community will have tangible results. And this will increase confidence in global efforts to prevent disease spread as well as other efforts to work as a global community. Kumanan Wilson, MD, MSc, FRCPC, is a physician at The Ottawa Hospital and a member of the University of Ottawa Centre for Health Law, Policy and Ethics. He has been a consultant to the World Health Organization on the IHR (2005).