COMMENTARY

Implementing digital passports for SARS-CoV-2

immunization in Canada
Kumanan Wilson MD MSc, Colleen M. Flood SJD

n Cite as: CMAJ 2021 April 6;193:E486-8. doi: 10.1503/cmaj.210244; early-released March 3, 2021

T
he emergence and deployment of vaccines for severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
KEY POINTS
that are safe and effective offers hope for the alleviation
of the enormous social, economic and health tolls of the corona- • Public authorities and private entities may soon require people
to provide proof of immunization to severe acute respiratory
virus disease 2019 (COVID-19) pandemic. Public authorities and syndome coronavirus 2 (SARS-CoV-2) in certain contexts as an
private entities may soon require people to provide proof of adjunct to efforts to safely re-open society.
immunization to SARS-CoV-2 in certain contexts as an adjunct to • International bodies have explored potential standards and
efforts to safely re-open society. “Immunization passports” or immunization passport solutions, with an initial focus on
certificates would allow bearers to show proof of adequate vac­ international travel.
cination. We discuss how SARS-CoV-2 immunization passports • In Canada, provincial and territorial governments should ensure
could work, the infrastructure required to operationalize them their ability to issue a crytographically signed digital vaccination
and potential barriers and limitations to their use. record from a government repository to operationalize
immunization passports that meet national standards and are
Proof of immunization is far from a new idea; during cam- aligned with international initiatives.
paigns for the smallpox vaccine, the vaccine scar often served as
• If governments do not implement immunization passports,
this proof and gated access to such things as train travel.1 In Can- private corporations (e.g., airlines and large event venues) may
ada, certain provinces require proof of immunization for school develop their own requirements and systems, potentially
entry.2 Internationally, proof of vaccination against yellow fever leading to problems related to equity, privacy and coercion.
is required for entry into countries where the disease is endemic, • Limited access to vaccines, technology and other resources may
as outlined in Annex 7 of the International Health Regulations.3,4 prevent people from using immunization passports.
In the current context, a move to digitize vaccination records and
to use digital immunization passports to safely open activities
and events to those able to prove their immunity is novel. place or activity, the passport holder would present it to be
The World Health Organization (WHO), International Air Traf- scanned for verification of the holder’s immunity status. The bar
fic Association and World Economic Forum have explored poten- code would include a cryptographic digital signature so that the
tial standards and mechanisms for the implementation of verifier would know that the passport was issued by a trusted
immun­ity passport solutions, 5–7 reflecting the likelihood that entity, such as a provincial or territorial government. The system
their first implementation would be for international travel. How- used to scan the bar code would require the ability to check
ever, their use may be extended to proving immunity for certain whether the immunization record satisfied current public health
workplaces and mass gatherings. Several concerns have been guidelines on which vaccine products, dose intervals and dose
raised in the past about immunity passports that focus on nat­ counts confer adequate levels of immunity based on currently
ural immunity.8 We believe the use of passports will be restricted available evidence. The passport holder may also need to provide
to immunity conferred by vaccines, as there is more scientific evi- proof of identity with government-issued photo identification.
dence for immunity from vaccines than from natural immunity. To enable effective digital immunization passports, govern-
In Canada, a digital passport for SARS-CoV-2 immunization ments will need to establish several core requirements, such as
could take the form of a a scannable bar code or Quick Response those articulated by the Royal Society in the United Kingdom
(QR) code showing vaccination status, which would be stored on (Box 1).9 The foundation of any system must be an accurate and
a smartphone device in the same way as an airline boarding pass. comprehensive digital vaccination record in a government reposi-
The passport could be downloaded from a provincial or territorial tory, with a mechanism to give people access to their records and
immunization repository through a government portal and be those of their children and dependents. In certain provinces, emerg-
linked to an individual’s identity. On seeking entry to a restricted ing digital identity solutions may help people securely access their

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Can­adian Medical Association or its subsidiaries.

E486 CMAJ | APRIL 6, 2021 | VOLUME 193 | ISSUE 14 © 2021 Joule Inc. or its licensors
 development should occur in concert with legal and ethical

COMMENTARY
Box 1: The Royal Society’s criteria for vaccine passports9 review to ensure that the solution is the least restrictive means of
• Meet benchmarks for severe acute respiratory syndrome reopening society, without adversely affecting populations that
coronavirus 2 immunity are already marginalized.
• Accommodate differences between vaccines in their efficacy, In Canada, further complexities exist for the implementation of
and changes in vaccine efficacy against emerging variants digital immunization passports, related to technological matur­ity,
• Be internationally standardized the absence of digital identities and our federated system of gov-
• Have verifiable credentials ernment. The federal government will need to consider interna-
• Have defined uses tional standards that are designed for international travel, and
• Be based on a platform of interoperable technologies potentially facilitate their adoption by provincial governments for
• Be secure for personal data other purposes. At the federal level, the National Advisory Com-
• Be portable mittee on Immunization should establish standards for what con-
• Be affordable to individuals and governments stitutes vaccination-derived immunity. As general responsibility
for immunization resides with provinces and territories, they
• Meet legal standards
should develop digital immunization records that are accessible
• Meet ethical standards
from their immunization repositories and that respect privacy and
• Have conditions of use that are understood and accepted by the other human rights concerns as much as possible. However, these
passport holders
provincial efforts should be guided by a federal or international
standard. If governments do not develop the necessary capacity to
health data through third-party applications, which may be used for implement immunization passports, it is likely that private cor­
return-to-work solutions. Governments will need the capability to porations (e.g., airlines and large event venues) will develop their
generate and issue cryptographically signed immunization records. own requirements and systems, potentially leading to problems
Software, implemented in a standardized fashion, will be required related to equity, privacy and coercion.
to verify vaccination status and to determine whether immunization We expect that immunization passports will be imminently
passports meet current requirements for entry or access. Mech­ introduced for international travel. Canada will need to ensure
anisms must also exist to revoke passports if, for example, data alignment with global standards for security, authentication, pri-
emerge that new variants of SARS-CoV-2 are resistant to vaccines. vacy and data exchange, developed by the WHO Smart Vaccina-
The questions of what vaccination series constitute immunity, and tion Certificate initiative.5 This initiative would further benefit
for how long immunity is established after completion of the vac­ from creating international standards for what constitutes
cination series, will be challenging to answer, as variations are immunity and standardizing approaches to gating access as evi-
already occurring with the recommended vaccine schedules. dence on immunity changes. A properly constructed approach to
The development and implementation of an immunization immunization passports, tested first for international travel,
passport must occur with input from legal and ethical experts.10 could help to limit the spread of SARS-CoV-2 while allowing the
Safeguards must be in place to protect the privacy of people’s global economy to be revitalized.
information, for example when third parties are logging into the
system to verify vaccine status. Although the information in an References
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of the passport against the issuer’s server, which creates the   2. Immunization of School Pupils Act, R.S.O. 1990, c. I.1. Available: www.ontario.
potential for the issuer to track the location of passport holders. ca/laws/statute/90i01 (accessed 2021 Jan. 27).
  3. Wilson K, Atkinson KM, Bell CP. Travel vaccines enter the digital age: creating a
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of such passports in Canada may need to be limited until ization; 2016. Available: www.who.int/publications/i/item/9789241580496
(accessed 2021 Feb. 27).
­population-wide access to vaccines is established. In the mean-
  5. Smart Vaccination Certificate Working Group: about us. Geneva: World Health
time, there may be situations where people are required to show Organization. Available: www.who.int/groups/smart-vaccination-certificate​
either proof of vaccination or proof of recently testing negative -working-group (accessed 2021 Jan. 27).
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for SARS-CoV-2 to obtain access to a restricted activity such as air
(IATA). Available: www.iata.org/en/programs/passenger/travel-pass/
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discriminated against or be denied access to services.   7. CommonPass. The Commons Project. Available: https://thecommonsproject.
org (accessed 2021 Jan. 27).
Access to technology may be a barrier to using immunization
  8. Kofler N, Baylis F. Ten reasons why immunity passports are a bad idea. Nature
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although those without access to digital devices will likely be dis-   9. Twelve criteria for the development and use of COVID-19 vaccine passports. The
advantaged by not having easy access to records. The need for Royal Society; 2021 Feb. 14. Available: https://royalsociety.org/news/2021​/02/12​
-challenges-for-vaccine-passports/ (accessed 2021 Feb. 20).
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CMAJ | APRIL 6, 2021 | VOLUME 193 | ISSUE 14 E487

 Competing interests: Kumanan Wilson is the CEO of CANImmunize Inc. Content licence: This is an Open Access article distributed in accordance
COMMENTARY

CANImmunize is currently not developing an immunization passport with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0)
but has been asked to provide input on proof of immunization status for licence, which permits use, distribution and reproduction in any medium,
COVID-19. CANImmunize has received funding from public and private provided that the original publication is properly cited, the use is non-
sources (https://www.canimmunize.ca/en/partners). Dr. Wilson owns commercial (i.e., research or educational use), and no modifications or
shares of CANImmunize and does not receive renumeration for his activ- adaptations are made. See: https://creativecommons.org/licenses/
ities as company CEO. He is a member of the independent data safety by-nc-nd/4.0/
board for the Medicago COVID-19 vaccine trial. No other competing
Funding: This research is funded in part by the COVID-19 Immunity Task
­interests were declared.
Force, launched by the Government of Canada in collaboration with
This article has been peer reviewed. Canadian Institutes of Health Research.
Affiliations: Department of Medicine (Wilson), School of Epidemiology Acknowledgements: The authors thank Cameron Bell for guidance on
and Public Health, University of Ottawa; Bruyère Research Institute and the technological architecture related to digital immunization passports
Ottawa Hospital Research Institute (Wilson); Faculty of Law (Flood), and Bryan Thomas for his contributions on this topic.
Common Law Section, University of Ottawa; University of Ottawa Centre
Disclaimer: Kumanan Wilson is married to an employee of CMAJ,
for Health Law Policy & Ethics (Flood), Ottawa, Ont.
who was not involved with the editorial decision-making process for
Contributors: Both authors contributed to the conception and design this article.
of the work, drafted the manuscript, revised it critically for important
Correspondence to: Kumanan Wilson, [email protected]
intellectual content, gave final approval of the version to be published
and agreed to be accountable for all aspects of the work.

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