Which places will require proof of a COVID-19 vaccine? And should they?

Ask us about COVID-19: What questions do you have about the coronavirus and vaccines?

This is one of a series of articles in which reporters from WHYY’s Health Desk Help Desk answer questions about vaccines and COVID-19.

People have been getting the COVID-19 vaccine for a few months now. And some states, countries, even entertainment venues are letting those among us who have been vaccinated move about more freely — as long as they can prove they have gotten their full doses.

Which places will require such proof? And should they? Here’s what we know so far.

Will I need a vaccine to travel?

The United States will not require people to be vaccinated against COVID-19 to enter the country, regardless of whether they are visitors or U.S. residents, according to the Centers for Disease Control and Prevention. The CDC adds that people who have been fully vaccinated against COVID-19 do not need to get tested before leaving the U.S. (unless they go somewhere that requires it), nor do they need to self-quarantine after returning, but should still have a negative test before boarding. They can also travel domestically without needing to get tested or self-quarantine.

The Biden administration will not issue a federal vaccine mandate, as announced in a press briefing on March 29. Instead, it will leave that up to the private sector.

For example: American Queen Steamboat Co. will require all crew and guests to be vaccinated, starting July 1. Crystal Cruises also will not accept any unvaccinated passengers, no matter their age.

Those cruise line policies are not universal, however.

“I think everybody acknowledges that [vaccines] will become more common, and the safety levels in society and … tourism and travel will become safer,” said Brian Salerno, senior vice president of maritime policy for the Cruise Lines International Association.

“But we are a global organization, and we have companies that operate all around the world, and the vaccine distribution is not evenly distributed. It’s spotty in different locations around the world — some populations have greater access than others,” Salerno said. ”From a cruise line perspective, we have not established a policy on vaccinations for individual cruise lines. For us to develop a global policy, it has to be something that will be applicable in all those locations that we operate.”

He added that his association must consider crews who live in countries that don’t have widespread availability of the COVID-19 vaccine.

“Our crews typically come from dozens of different countries, and many of them are developing countries. So … access to the vaccines in their home countries is very uneven. So, if they were to come to the U.S. or to Europe, getting them access to the vaccines in those locations is also something that has to be factored in,” Salerno said.

“It may take a little bit of time before access is normalized, but it is something we’re watching very closely. Trust me, we’re very interested in how vaccines can add to the types of health protocols that we’ve already put in place, because it just offers that much more protection. But in the meantime, those health protocols are working.”

Some cruise lines already are operating in Europe, and they’re using safety measures to prevent the spread of the coronavirus, such as mask-wearing, physical distancing, and sanitization.

China, Japan, and the European Union are working on vaccine credentials that would make it easier for people who have been fully vaccinated against COVID-19 to travel. In the coming days, vaccinated travelers, or those previously infected with the virus, will be exempt from travel restrictions in Iceland. Belize, Ecuador, Georgia, Guatemala, Slovenia, and Estonia also will open their borders to vaccinated travelers.

Several companies, like IBM, are developing vaccine credentials — or what some call “vaccine passports” — for travelers to easily prove their vaccine status.

The phrase “vaccine passport” is not a good one, though, said Dakota Gruener, executive director of ID2020, a group that works with companies, including Microsoft, Mastercard, and Accenture, on ethical forms of digital identity. She said that’s because it implies that proof of vaccination is the sole indicator of health, and does not leave room for alternatives, like a recent negative COVID-19 test. Gruener added that unlike vaccine credentials, traditional passports cost money and can only be issued by governments.

Perry Flint, a spokesperson for the International Air Transport Association, said airlines don’t mandate vaccines. But they must abide by government-ordered vaccination requirements. Airlines can be fined if they don’t ensure that their passengers are legal to travel, and comply with border entry requirements. More than 100 countries currently require a negative COVID-19 test as a condition of entry.

Flint said if there are airline-imposed vaccination requirements, they will likely only occur in countries with strict vaccination requirements. The IATA does not support mandatory COVID-19 vaccinations, however.

“The policy would risk discriminating against markets where the vaccine may take longer to become widely available. Also, as a principle, if a country doesn’t have its own vaccine requirement for its own population, travelers shouldn’t be subject to stricter conditions than the measures being applied to the residents,” Flint said.

“And then also, obviously, there’s going to be some individuals who are not able to get vaccinated, whether for medical reasons or because they’re unwilling to, whether it’s ethical or other concerns. And this would lock them out of international travel If you had a mandatory requirement for the country.”

But because some countries do have vaccination policies, the IATA is designing an app to make the process easier.

Mandates for other vaccines — such as the yellow fever vaccine — are already in place in certain countries. Passengers use a paper process to show proof of vaccination, and it works, Flint said. But he argued that it’s not scalable.

“We really don’t think, and we’re already seeing that, that you can go to a system in which travelers are expected to carry with them paper documents with no alternative … And these are going to be inspected before you board the airplane,  when you get off the airplane, and into the country. We already are seeing, and this is with the traffic down about 85%, very long lines at some international airports because of all the inspections of paper documents,” Flint said.

He added that most people already are comfortable using digital boarding passes and airport kiosks.

IATA’s app would provide information about entry requirements and a registry of testing and vaccination centers. COVID test results or a vaccine certificate would be sent to the user’s mobile device. For privacy reasons, there would be no central database of vaccine and test information. The app would also enable the traveler to create a digital passport.

Some things still need to be resolved, however. There is no clear international standard for what might be required on a digital vaccination certificate, Flint said. The World Health Organization is working on it, but it isn’t ready yet.

Will college students have to be vaccinated before returning to class?

That depends on the school.

Rutgers, New Jersey’s state university, announced on March 25 that students returning to campus in the fall must be vaccinated. Students may request exemptions for medical or religious reasons, however. Those primarily studying online will not be required to be vaccinated, either.

The university made the decision partly because COVID-19 rates are 60% to 70% higher among its students than its faculty and staff.

Attorney Mike Jones, of the law firm Eckert Seamans, said he doesn’t think Rutgers will be the only university to impose a vaccine mandate.

“Rutgers laid out a pretty compelling case for why they think it’s important to do it,” he said. “They’re treating it like any of the other vaccines that they require for their full-time students to have before coming on the campus. So particularly given the fact that the students are going to be interacting on a social level far more frequently and living together, many of them in congregate settings like the dorms, they felt that they should treat the COVID vaccine like they would any other vaccine requirement for students.”

Jones said colleges and universities have legal authority to impose vaccine mandates, as long as they allow for medical and religious exemptions. Those with exemptions will still be able to attend class and live in the dorms.

“But it’s a narrow exemption. It’s not just someone that doesn’t want to receive the vaccine or doesn’t feel comfortable with the vaccine. They actually have to have the sincerely held religious objection to receiving the vaccine, or they have to have a medically based inability to receive the vaccine, such as, they have an allergy,” Jones said.

“Rutgers announced that they were making this notification five months ahead of time, so that if students didn’t want to take the vaccine, they can make alternate arrangements in terms of not enrolling and paying tuition if they were not comfortable just based on a personal desire not to receive the vaccine.”

So far, Rutgers is the only university in this region that has announced a vaccine mandate.

A University of Pennsylvania spokesperson said the school is not requiring its students to get the shot.

The University of Delaware is not mandating the vaccine either, but it is strongly encouraging it. An email sent to students on March 30 informed them of their eligibility to receive the vaccine, which includes those who aren’t Delaware residents. The email also ensured the vaccine’s safety and detailed how to get it. The school is also working with the state to get a vaccine site near or on campus.

“The university urges all students to get the vaccine when it is available to them,” UD officials wrote in the email.

Similarly, Drexel University is encouraging but not requiring the vaccine.

That’s the way to go, said Erin Paquette, assistant professor of pediatrics at the Feinberg School of Medicine at Northwestern University. She argued that any vaccine not fully approved by the Food and Drug Administration should be voluntary. (The three COVID-19 vaccines being administered nationwide have only FDA emergency use authorization thus far).

Paquette recently wrote, for the Journal of Pediatrics, about whether schools should allow nonmedical exemptions to mandatory vaccinations in general. She said that when it comes to the COVID-19 vaccines, universities are “kind of a crossbreed between my thoughts about school and my thoughts about workplace vaccinations.”

Paquette noted that the COVID vaccines are not universally available yet, so mandates or incentives will not be equitable.

“Rather than thinking in terms of things like mandates or incentives or other things that only certain people can really gain access to, we need to think about: How do we in a public health framework appropriately allocate vaccines? How do we appropriately address the reasons behind which people are not getting vaccines?” she said.

“If doing that, there is still a rate of disease that is so high that it’s putting public health in harm’s way … then you move to more restrictive things like mandates and potentially removing exemptions from mandates … but you don’t start there, that’s a place that you get to if you’re pushed.”

Can and will my employer require me to get vaccinated?

Employers can legally mandate the COVID-19 vaccine, as long as they allow for medical and religious exemptions, attorney Mike Jones said.

During an earlier flu pandemic, the Equal Employment Opportunity Commission took the same stance, and has reiterated it during the coronavirus pandemic. Generally, though, not many employers have mandated vaccines.

“Having said that, frankly, many employers haven’t had to make that decision for real, because the availability of vaccines has not been widespread enough that that could even be a realistic requirement at this point,” Jones said.

“I think you may see, particularly from employers that have been operating in a partial or fully remote capacity, I think come fall — when the scientists believe we may start to see the beginnings of a potential increase or surge due to the seasonal nature of respiratory type infections — it wouldn’t surprise me to see some employers start to shift towards a model where they’re going to require vaccinations for employees that are going to be returning back to an office or congregate setting,” Jones said.

Some companies, especially those in customer-facing industries like hospitality, retail, and transportation, have tried to incentivize getting the vaccine. That includes giving employees a paid day off to recover from the side effects of the shot, or in some cases even money, said Todd Thames, senior regional medical director for the health care company Grand Rounds Health. But there have been no requirements so far, he said.

Thames consults for more than 100 companies in various industries, including retail and finance. He said most companies have asked him about the safety and efficacy of the COVID-19 vaccines, and whether it would be possible to set up vaccination clinics at work sites, which is common for flu shots. That’s not feasible, however, because federal and local governments have control over the vaccine supply.

Still, Thames said, once the FDA approves the vaccines and the supply increases, the whole country might think differently about whether to require them. “I could see some companies having to cross that bridge as time goes on,” he said.

What rights do employees have to work remotely until they’ve been vaccinated?

Jones said there are no blanket laws protecting employees from returning to work before being vaccinated. People with medical conditions that put them at risk for severe illness from COVID-19 should have a legal case to work remotely, but the law requires that assessment to be made on an individual basis.

Will entertainment and sports venues require vaccination?

In Israel, which has vaccinated a significant portion of its population, concerts have been able to resume safely by restricting attendance to those who have been vaccinated. Concertgoers are required to show a government-validated certificate proving they’ve received both doses of the vaccine more than a week prior to the event — or that they have recovered from COVID-19 and are presumed immune. Gyms, swimming pools, theaters, and hotels also are open to pass-holders only.

It’s still not known if something similar will be widespread in the U.S.

A spokesperson for the National Independent Venue Association said it wants the U.S. to safely return to normalcy, and it recognizes that vaccines are one way to accomplish that. However, it also understands some of the ethical concerns surrounding mandates.

“We’re grateful to learn that there will not be a national mandated verification program; independent venues will be making their own individual policy decisions taking into account guidelines and recommendations from the CDC,” a statement from the association reads.

“That said, while vaccine verification is the hot topic, we have questions and concerns surrounding the effectiveness of only implementing verification at live events and not other businesses where people gather. We have concerns about equitable access, ethical considerations and the issue of small businesses shouldering the brunt of cost of implementing the program, which may or may not be practicable for small businesses.”

Plans are up in the air for sports, too. Currently, the NFL has no plans.

“We are working with clubs and local, state and federal public authorities on plans for the upcoming season. NFL games do not begin until August, so we are continuing to monitor developments around the country,” a spokesperson said in an email.

However, some venues have started offering entertainment exclusively for vaccinated fans. For example, the Miami Heat has a special section in its arena for people who have been vaccinated. And at New York’s Madison Square Garden, Knicks and Rangers fans are required to show proof of either the vaccine or a negative COVID-19 test before they can attend games.

New York Gov. Andrew Cuomo recently announced the statewide launch of an app, known as the Excelsior Pass, that confirms an individual’s recent negative COVID-19 or antigen test result, or proof of vaccination. The voluntary and free app, which was designed by IBM, aims to fast-track the reopening of businesses and event venues safely.

Attorney Mike Jones said it’s possible more venues will require the vaccine, but it could present legal challenges if there are not medical and religious exemptions. He said he would not be surprised if the entertainment industry imposed vaccine requirements to increase state-mandated capacity limits.

“Because frankly, even the guidance that the CDC put out about, ‘Once you’ve been vaccinated, what can you do?’ If you dig into that guidance that they put out, particularly the part where they were talking about vaccinated individuals can meet with other family members that haven’t been vaccinated … the CDC basically acknowledged that that was being done as a carrot, loosening that guidance to encourage people to want to get vaccinated, and that even though there was some degree of risk, particularly for the unvaccinated people, that they thought it was important to show people a light at the end of the tunnel if they chose to get vaccinated,” Jones said.

“And it wouldn’t surprise me if we see some sort of similar carrot incentive, as opposed to the sticks that we’ve seen so far, of closing venues, restricting capacity severely. It wouldn’t surprise me to see offering things like that to people that have been vaccinated as a way to make it more desirable and advantageous for people to go out and voluntarily choose to be vaccinated,” he added.

“It wouldn’t shock me to see hotels, restaurants, offering specials and discounts and incentives for people that have been vaccinated, just to encourage people to get back to a comfort level, particularly in some of these industries that have been so hard hit with the COVID shutdowns.”

Could requiring the vaccine reduce the spread of disease?

In general, places with mandatory vaccination have higher vaccination rates, and thus are less likely to see outbreaks of vaccine-preventable disease like measles, said Northwestern University’s Erin Paquette. Yet there will be some people who do not get vaccinated, despite a mandate. Paquette said the question is, “How can medical and public health officials change their minds?” She said it’s important to find out why people won’t or can’t get vaccinated, and then educate them or help them get access to the vaccine.

Paquette used Jones’ carrot-and-stick analogy, saying that “the carrot works a little better.”

She said vaccine mandates always must include exemptions, and added that authorities can always restrict exemptions during public health emergencies.

Should any organization require the COVID-19 vaccine?

Jones said vaccine mandates are legal, as long as they provide exemptions for medical or religious reasons. For religious exemptions, there is no specific requirement for faith leaders to provide certification. The law only requires the exemptee to have a sincerely held religious belief.

Those who oppose vaccinations in general, and people who don’t want to get the COVID-19 vaccine for political reasons or because they don’t trust the vaccine, are not legally protected from vaccine mandates, Jones said.

Nicole Hassoun, a bioethicist at Binghamton University, argues that vaccine mandates without exceptions are not fair while access is limited in the U.S., let alone in other countries that have not been able to buy as many doses. After writing an op-ed for Scientific American about this topic, Hassoun heard from a single mother who got so sick from the first dose of the COVID-19 vaccine that her doctor recommended against a second dose. Any organization contemplating a mandate should consider people like that, Hassoun said.

“They’re trying to make ends meet, and very, very worried about the passport system being put in place, because they couldn’t get vaccinated; testing wasn’t covered by insurance, and so they couldn’t even get tested,” Hassoun recalled of a woman who had lost her job during the pandemic.

“There should be exceptions to people who are willing to take precautions … social distance, wear a mask, get tested, and making sure that we … offer them the vaccine, offer them the testing … and not make it too difficult, and make sure that we really have reason to do this in the first place.”

She said that if the U.S. government required COVID-19 vaccinations for travel, work, and school, there should be a full consideration of the benefits and issues around equity and access. A good example of this, Hassoun said, comes from the Swiss National COVID-19 Task Force, which released a policy brief about requiring proof of vaccination.