On July 15, the U.S. reached over 336.1 million total doses administered with 185.1 million persons (55.8% of the total U.S. population) having received at least one dose and 160.4 million persons (48.3% of the total U.S. population) being fully vaccinated. Twenty states, the District of Columbia, Puerto Rico, and Guam have reached 70% or more of adults having received one or more doses (those states are California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New Mexico, New York, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia, and Washington).
The CDC’s guidance for fully vaccinated individuals states that they may resume most activities without wearing a mask or social distancing, regardless of whether those activities are indoors or outdoors, except where required by federal, state, local, tribal, or territorial laws, rules, and regulations. Many state and local governments have lifted COVID-19-related restrictions or announced plans to do so. Given increases in the number of cases due to the Delta variant in their areas, however, some governments in the U.S. and abroad have decided to amend their guidance and again recommend that even vaccinated individuals return to wearing masks indoors. In many settings, there is still no uniform or reliable way to verify who is and who is not vaccinated. This is particularly concerning in regions where mask requirements have been lifted or relaxed, vaccination rates remain lower than average, and the prevalence of the Delta variant is higher or increasing.
The U.S. ranks fourteenth globally in terms of percentage of the eligible population to be fully vaccinated. Forty-six percent of individuals who have received at least one dose of a COVID-19 vaccine were in high-income countries and at least 40% were from Europe or North America. Countries with greater funding and infrastructure to support manufacturing, acquisition/purchasing, or administration have generally seen the greatest advantages in vaccinating their populations. By comparison, about one percent of the population is fully immunized in the entire continent of Africa.
As the number of individuals who are fully vaccinated continues to rise globally and within the U.S., governments and other entities have proposed or implemented various types of credentials to indicate an individual’s proof of vaccination, natural immunity (i.e., protection generated from having already had the infectious disease), and/or current infection status. These include the use of “digital health passes” (DHP), a modernized approach to what previously have been paper-based records or certificates. For example, the European Union (EU) has begun implementing a “EU Digital COVID Certificate” for residents traveling between countries that indicates if they are fully vaccinated with a vaccine authorized by the European Medicines Agency (EMA) (the EU equivalent of the U.S. Food & Drug Administration (FDA)), have tested negative for COVID-19, and/or have previously been diagnosed with COVID-19. DHPs have been proposed as a complement to or substitute for older paper-based systems like yellow fever vaccine cards that have been used in the past for global travel, school records, and some employer records (e.g., hospital and other healthcare staff). Historically, these paper-based certificates have had limitations including that they may be easily lost or destroyed, and that they can be forged or faked.
Governments, schools, employers, and private businesses (including airlines, retail stores, and entertainment/sporting venues) have considered or implemented strategies to allow secure, consistent, and accurate verification of COVID vaccine status for students, staff members, and/or patrons, including but not limited to the use of DHPs. Yet the use of DHPs presents significant scientific, ethical, legal, and technical considerations for COVID and other infectious diseases.
For example, from the scientific perspective, the effectiveness of COVID vaccines authorized in the U.S. and in other countries varies in terms of how and how much they reduce risk of infection or severity of disease. Yet if governments or other entities limit access to spaces and services based on which vaccine a person received, further inequities may arise for individuals from regions where only certain vaccines are accessible. It may also reinforce the notion that there are “inferior vaccines” which in turn may increase hesitancy or lack of confidence in those vaccines. It also remains unclear how long individuals with previous COVID infections are protected against reinfection or how long each of the vaccines remain effective. These metrics may differ for certain populations (e.g., those who are immunocompromised).
Ethically, policies requiring proof of vaccination, including DHPs, are untenable in situations in which individuals have not had access to or are otherwise medically contraindicated from receiving a vaccine. From a technical perspective, DHPs require substantial infrastructure to ensure data is reliable as well as securely and appropriately stored and shared. For example, a DHP is likely more effective when it exchanges data from a validated immunization database rather than based on self-report. In the U.S., there is no such federal registry and state-based immunization information systems (IISs) vary in completeness and quality and are not typically interoperable between states.
In the coming months and until COVID-19 is well-controlled locally, nationally, and globally, calls for vaccine-related credentials will likely continue. The form and settings in which they are developed and implemented will likely evolve over time.
Throughout 2021, NAAG will continue to provide informational updates and training opportunities to the attorney general community as COVID-19 vaccine distribution and related legal issues evolve. For more information on NAAG’s response to the COVID-19 pandemic, visit NAAG’s public health-related updates.
