COVID-19 certificates helped to increase vaccination uptake

Staff of coffee bar checks the QR code confirming that people received the Covid-19 vaccine, in Milan, Italy, [EPA-EFE/Jessica Pasqualon ]

COVID-19 certification led to increased vaccination uptake 20 days before and 40 days after it was introduced in countries with lower-than-average vaccination coverage, according to a modeling study published in The Lancet Public Health journal.

The study published on Monday (13 December) examined the impact of COVID-19 certification on vaccine uptake in six countries where certification was legally mandated: Denmark, Israel, Italy, France, Germany and Switzerland, from April to September 2021. 

Modeling was used to estimate what vaccine uptake would have been without COVID-19 certification in each of the six countries, based on vaccination uptake trends from 19 otherwise similar control countries that did not have COVID-19 certificates. 

COVID-19 certification, or ‘vaccine passports’, require people to have proof of complete vaccination, negative test, or COVID-19 recovery certificate, to access public venues and events. 

It has been suggested that COVID-19 certification might encourage more unvaccinated people to get vaccinated, particularly those who perceive their own risk of hospitalisation or death from COVID-19 as low, known as vaccine complacent groups.

The lead author of the study, Melinda Mills, director at Leverhulme centre for demographic science at the University of Oxford, said the study “is an important first empirical assessment of whether COVID-19 certification can” increase vaccination uptake. 

“Overall, we observed a significant uptick in anticipation of restrictions coming into place around 20 days before introduction, which lasted up to 40 days after, but the context of existing vaccination uptake, vaccine hesitancy, levels of trust in authorities, and pandemic trajectory was crucial to the impact,” she said. 

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Differences across countries

The study showed that in countries where vaccine coverage was previously low, the introduction of COVID-19 certification was associated with a significant increase in the number of additional vaccine doses per million people – ranging from almost 128,000 in France, over 243,000 in Israel, almost 65,000 in Switzerland and over 66,000 in Italy. 

In contrast, in Denmark and Germany, where there were higher average vaccination rates before certification was introduced, there was no significant increase in vaccination. Moreover, Denmark introduced certification in April 2021, when overall vaccine supply was still limited despite demand being high.

In Denmark, the policy’s main aim was to increase testing before attending public venues, rather than encourage vaccination uptake, highlighting the multiple potential aims or consequences of COVID-19 certification policies beyond vaccine uptake.

Compared to the control countries, daily COVID-19 case numbers decreased after implementation in France, Germany, Italy, Switzerland, but increased in Israel and Denmark.

Many countries implemented certification as a response to rising cases, making it difficult to assess the effect of certification on reported infections. The authors say this highlights the importance of taking account of the phase of infection trajectory when the intervention is introduced.

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Differences across age groups

After the introduction of COVID-19 certification, increases in vaccination were highest in people under 30 years old compared to older groups.

The authors explored whether prioritisation of vaccine rollout among older age groups and eligibility in younger age groups around the time of certification may have influenced the results, but found that the effect could not be fully explained by age-based eligibility criteria.

In Switzerland, when COVID-19 certification was used to restrict access to nightclubs and large events only, increases in vaccination uptake were only observed in people under 20 years of age. When restrictions were expanded to include all hospitality and leisure settings, uptake also increased among the 20-49-year-olds. 

Co-author of the study, Tobias Rüttenauer from the University of Oxford, said that  “we know that certain groups have lower vaccine uptake than others and it may be that COVID-19 certification is a useful way to encourage vaccine complacent groups, like young people and men, to get vaccinated”.

He added that “COVID-19 certification alone is not a silver bullet for improving vaccine uptake and must be used alongside other policies”.

“Vaccine hesitancy due to lack of trust in authorities, which is common among some minority ethnic and lower socioeconomic groups, may be addressed more successfully through other interventions, such as targeted vaccine drives and community dialogue to generate more understanding about COVID-19 vaccines,” Rüttenauer said.

The authors say this suggests that the policy may be useful in encouraging uptake in particular groups, but more research investigating other factors, including socioeconomic status and ethnicity, is needed to fully understand who certificates could effectively target.

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[Edited by Zoran Radosavljevic]

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