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During the American Medical Association (AMA) House of Delegates annual meeting, members debated whether natural immunity or previous infection with SARS-CoV-2 was sufficient for the merit of immunity credentials.

Gregory Pinto, MD, a delegate from New York, called for policy recommending "that vaccination credentials be provided on the basis of natural immunity or previous SARS-CoV-2 infection" during proceedings on the virtual "floor."

He argued that there "is no indication that immunity derived from prior COVID infection is in any way inferior to that derived from vaccination." Therefore, any immunity credentialing service ought to include natural immunity stemming from a prior infection, he said.

Notably, Pinto introduced this policy resolution by amending a draft recommendation in the in such a way as to directly reverse the intent of the original authors of that resolution, who sought to prevent vaccination credentials from being given to people solely based on having had a prior COVID-19 infection.

Ryan Englander, a delegate from Connecticut who spoke on behalf of the AMA's Medical Student Section, disagreed with Pinto on whether natural immunity and immunity from a vaccine were equivalent.

He noted that natural immunity is difficult to gauge and the only technologies capable of determining such immunity are antibody titers and certain assays that aren't commercially available. He also said that prior exposure to COVID is not as "robust" in protecting individuals against variants compared with vaccination.

Englander cited a clinical trial by Novavax, in which individuals with prior SARS-CoV-2 exposure were found to be as those who lacked such exposure.

Lastly, he pointed out that endorsing natural immunity as a substitute for vaccination sets a "bad precedent" for this and any future pandemics.

"Immunity passports that are based on natural immunity may incentivize exposure," particularly among those who are vaccine-hesitant, "and that's the opposite of what we want to do," he said.

Rose Berkun, MD, an alternate delegate from New York speaking on her own behalf, said she disagreed with the medical students. She argued that several studies have found that natural immunity provides protection that is "similar to and possibly even stronger" than that of vaccination. Berkun also noted that some patients on immunosuppressive drugs did not get a good response to the vaccine.

"So, showing proof of vaccination for those people does not mean proof of immunity," she said.

She urged the AMA to consider ways to demonstrate "alternative proof of immunity" for those who have previously had COVID-19.

Paul Friedrichs, MD, chair of the Section Council on Military Medicine, essentially argued that for the AMA, "in the house of medicine," to support issuing vaccination credentials to people who haven't been vaccinated, but have only "self-reported infections" was a bad look and "terribly confusing."

"So, let's keep this simple ... vaccine credentials should only be credentials for those who are vaccinated," he said.

If, in the future, the AMA felt the need to establish "infection credentials that say you've been infected," that could be addressed later, he added.

Multiple delegates pointed out that using natural immunity in lieu of vaccination would pit the AMA's recommendations against those of the CDC.

But Arthur Fougner, MD, who spoke on behalf of the New York delegation, scoffed at the idea of trying to align the AMA's policy with CDC recommendations.

"Their guidelines have changed faster than dietary salt guidelines have changed," Fougner said. "The pendulum in medicine swings back and forth faster than I can change channels with my remote."

He also pointed to a that shared the results of a study from the Cleveland Clinic, which suggested that people who've been previously infected with COVID-19 are "unlikely to benefit" from COVID-19 vaccination.

To that end, Fougner called for the policy to be referred back "because we really do need to get this right."

Kevin Reilly Sr., MD, a delegate from the Radiological Society of North America, said that he had been infected with SARS-CoV-2. He chose to get vaccinated, but said he should not have felt "coerced" to do so just to be seen as "in the same class with all the rest of my fellow citizens."

As for the science on natural immunity, he quoted a professor at Albert Einstein College of Medicine in the Bronx, who often said, "'in our current state of ignorance, we believe' ... and that's what I think both people for and against [natural immunity] have said on the antibodies."

Ultimately, the House of Delegates voted down a policy resolution, 404-67, that would have placed natural immunity and vaccination on the same tier. They endorsed the opposite policy stance, in a vote of 414-56, "that vaccination credentials not be provided on the basis of natural immunity or previous SARS-CoV-2 infection."

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