Public & Social Sector Practice

An optimistic scenario
for the US response
to COVID-19
Much would need to happen, but returning the country to something
that approaches stability by next summer may be possible.

by Michael D. Conway, Navjot Singh, Shubham Singhal, and Guang Yang

© FG Trade/Getty Images

September 2020
 The course of the COVID-19 pandemic thus far has maintain discipline, a best-case scenario to
not been kind to optimists. Those who pointed to control the pandemic might be reached—perhaps
early successes in some areas have been shaken by as soon as next summer. It will be difficult. It will
subsequent waves of infection. Those who hopefully take investment and coordination. Setbacks
reopened businesses and community organizations along the way are probably inevitable, and less
have been shaken when new cases popped up. hopeful scenarios are a distinct possibility. What
Today, it’s hard to be optimistic in the face of the follows is an overview of the current state of the
tragic human outcomes: more than 900,000 essential recovery elements that support an
people around the world have died, including more optimistic outlook: we’re getting better at reducing
than 200,000 Americans. Meanwhile, 13.6 million transmission, improving case management, and
Americans remain unemployed. And for each month developing a robust pipeline of vaccines. All these
of delay in getting the virus under control, more will also support a hopeful prognosis for the economy.
die—and the return of GDP to precrisis levels will be
delayed by about two months.
Getting better at reducing transmission
Nonetheless, we have made progress. As slow as it We continue to collect more natural history and
may seem, we’ve continued to learn more about the transmission data on the prevention of COVID-19
natural history and epidemiology of COVID-19. We’re infections. The understanding of the benefit of
developing better diagnostics, including rapid point- masks, physical distancing, and travel restrictions,
of-care tests, a few of which can be completed in as well as the risk levels of various activities,
about 15 minutes. An army of doctors and researchers continues to improve by the day. So far, more
around the country has been managing and treating than 1,500 published scientific articles describe
the disease and producing a wealth of new knowledge COVID-19’s characteristics and modes of
on treatment strategies and procedures. To date, the transmission, and more than 18,000 have discussed
US Food and Drug Administration has reviewed 310 prevention, control, responses, and management
drug trials, and nearly 600 more are in the planning strategies. For example, most research confirms
stages.1 Pharmaceutical companies have also that wearing masks, physical distancing, and
turned out a remarkably robust pipeline of vaccine limited capacity are the keys to reducing the risk
candidates: 51 are already in human trials as of this of transmission in indoor spaces. Similarly, the
writing and more than 250 in all are in development. risk of transmission is lower in outdoor spaces
where people wear masks and keep six feet away
On balance, as our colleagues suggest, normalcy from others.2 Under the best-case scenarios, this
might resume in the first half of 2021, and herd knowledge will be translated into appropriate
immunity could be reached in the second half. public-health measures and interventions that the
And as medical progress builds, there may yet public actually follows, preventing transmission
be a place for optimism. If we stay focused and without structurally impeding economic recovery.

If we stay focused and maintain discipline,

a best-case scenario to control the pandemic
might be reached—perhaps as soon as
next summer.

1
“Coronavirus treatment acceleration program,” US Food and Drug Administration, August 31, 2020, fda.gov.
2
“Deciding to go out,” Centers for Disease Control and Prevention,” September 11, 2020, cdc.gov.

2 An optimistic scenario for the US response to COVID-19

 To build public confidence and strengthen the Improving case management
resolve to reduce levels of transmission, we need At the beginning of the pandemic, the proportion
not only an improved understanding of it but of people dying from COVID-19—the case fatality
also the transparent communication of accurate rate—was over 10 percent in the United States and
actual case counts. Although testing capacity is as high as 20 to 30 percent elsewhere. Patient
still well below estimates of what is needed, it has demographics, overwhelmed health systems, lack
generally improved. In addition, researchers are of testing capacity, and a limited experience and
developing several novel technologies for screening understanding of managing the disease were largely
and diagnostic testing at a lower cost and more responsible. Progress since then bodes well for a
quickly, with a better experience for the patient. For more hopeful scenario even if vaccines are delayed.
example, one card-based antigen test can generate
results for just $5 in about 15 minutes with a high Over the past six months, mortality has declined.
level of specificity, though with a shorter detection The precise numbers depend on underlying
window than the gold standard (the reverse- assumptions about, for example, complicating
transcription polymerase-chain-reaction test) can conditions and excess deaths, but are generally
boast.3 Recent data suggest that saliva-based around 1 or 2 percent. This improvement results in
testing is as effective as nasal swabs.4 To improve part from the availability of therapeutic treatments,
speed and scalability, companies are also exploring such as remdesivir, which have been authorized for
a large number of gene-editing and membrane- emergency use to treat COVID-19 and appear to
protein treatments across CRISPR5 and LAMP6 have significantly reduced the death rate.7 Improved
platforms. Screening tests relying on breathalyzer clinical knowledge of the disease and experience
technologies are being evaluated to screen people managing it have also played a role. For example,
quickly before they enter public areas such as pilots of “virtual wards,” which use telemedicine
schools and airports. and remote monitoring to care for patients in their
homes, have shown promising early results. These
Taking full advantage of the progress of science would enable healthcare providers to intervene
and technology in reducing transmission requires medically at an early stage while reserving hospital
behavior change, communication, and education capacity for patients with the most urgent need.8
at all levels. A wary and skeptical public must be
persuaded to follow public-health measures and More help is on the way: a raft of new therapeutics
interventions if they are to be effective. Physicians is now in the development pipeline. More than 300
and health providers must define proper use cases unique therapeutic agents have already progressed
for both screening and diagnostic tests coming to to late-stage (Phase III) human trials. One of these
market if they are to be effective. Given COVID-19’s agents, the first COVID-specific treatment with
high level of contagiousness, defining and applying neutralizing antibodies isolated from recovered
test use cases without a proper understanding of test patients, has shown early potential.9 Neutralizing
characteristics and human behavior might provide antibodies have been effective in other diseases,
an unwarranted sense of security—for example, by such as Ebola, and could act as a stopgap until
providing false-negative test results—and thereby herd immunity can be established through broad-
unintentionally cause an infected person to break with based vaccines.
other directives, such as distancing and mask wearing.

3
“Abbott’s fast, $5, 15-minute, easy-to-use COVID-19 antigen test receives FDA emergency use authorization; mobile app displays test results
to help our return to daily life; ramping production to 50 million tests a month,” Abbott, August 26, 2020, abbott.mediaroom.com.
4
Anne L. Wyllie et al., “Saliva or nasopharyngeal swab specimens for detection of SARS-CoV-2,” New England Journal of Medicine,
August 28, 2020, nejm.org.
5
Clustered regularly interspaced short palindromic repeats.
6
Linux, Apache, MySQL, and PHP (Hypertext Preprocessor).
7
Joseph Walker, “Covid-19 deaths significantly reduced by use of steroids, analysis says,” Wall Street Journal, September 2, 2020, wsj.com.
8
Jacqui Thornton, “The ‘virtual wards’ supporting patients with covid-19 in the community,” BMJ, June 5, 2020, bmj.com.
9
“Lilly announces proof of concept data for neutralizing antibody LY-CoV555 in the COVID-19 outpatient setting,” Eli Lilly, September 16, 2020,
lilly.com; “Neutralizing antibodies isolated from COVID-19 patients may suppress virus,” Columbia University Irving Medical Center,
July 22, 2020, cuimc.columbia.edu.

An optimistic scenario for the US response to COVID-19 3

 The success rates of past therapeutics in various approved for COVID-19 (Exhibit 1). As more of them
stages of the approval process are reassuring. Even are brought into use, the mortality rate for COVID-19
assuming conservative criteria to define (admittedly could continue to fall—it is not unrealistic to expect
subjective) medically sound endpoints and trial- it may approach 0.1 percent, given that 0.2 percent
design factors, past success rates suggest that has been achieved in countries with broad testing.
more than a dozen therapeutic treatments will be

Exhibit 1
Historical therapeutic-approval ratessuggest
therapeutic-approval rates suggestthat
that several
several COVID-19
COVID-19 therapeutics
therapeutics may receive
may receive approval. approval.

Potential approval rates for COVID-19 therapeutics by clinical-trial phase, based on historical rates
(index = 100 candidates)1
Advancing candidate Nonadvancing candidate Approval rate

Phase l: Phase Il: Phase lII: Approved:

100 candidates 62 candidates 21 candidates 13 candidates

62.1% 34.2% 61.5%

Likelihood of Phase l Phase Il Phase lII Approved

candidate 13.0%
receiving
approval 21.0% 13 candidates
by phase 61.5%

Status of current COVID-19-therapeutic candidates by type and trial phase

Mortality or clinical-marker endpoint Other endpoints

Phase l: 76 candidates Phase Il: 265 candidates Phase lII: 322 candidates
Combination 23 71 135

Immunomodulator 17 78 60
663
Antiviral 5 8 23 candidates
currently in
Antibody therapy 13 2 5 Phases I–III
Other2 18 106 99

Historical approval rates calculated for 1999–2018.

1

Includes angiotensin-converting-enzyme (ACE) inhibitors, angiotensin II–receptor blockers (ARBs), nonsteroidal anti-inflammatory drugs (NSAIDs), other
2

anti-infectives, other antihypertensives, oncolytics, and supplements.

Source: ClinicalTrials.gov, US National Library of Medicine, September 4, 2020, clinicaltrials.gov; Pharmaprojects, Informa, September 4, 2020,
pharmaintelligence.informa.com; WHO, September 4, 2020, who.int; McKinsey analysis

4 An optimistic scenario for the US response to COVID-19

 To be clear, the therapeutics are still challenging. An cutting-edge technologies, including RNA-based
uncoordinated rush to develop them led to a large research.10 As a result, they’ve made significant
number of clinical trials that lacked the resources progress. Ten vaccine candidates have announced
to produce definitive conclusions. A number of potential timelines for emergency-use authorization
ongoing trials continue to focus on products or are currently in late-stage testing (Phase III or
that have been shown not to work, competing for Phase II/III), with a significant number of human
precious clinical resources. In addition, researchers volunteers, so that their safety and efficacy can
have found it challenging to enroll patients in clinical be measured. Compare that with the historical
trials, whether because of overwhelmed health average over the past 20 years: seven years
systems, an insufficient number of local cases, or needed to develop a vaccine. Early results indicate
the unwillingness of patients to enroll if they may get that candidate vaccines elicit levels of antibodies
a placebo. However, medical experts experimenting exceeding those from recovered patients.11
with and adapting protocols have already made
significant progress, ensuring that we have supplies While no probability assessment can entirely
of tools that work and bringing new tools to bear. rule out the worst-case scenarios, in which no
successful vaccine emerges, the sheer volume of
vaccine candidates gives reason for hope. Applying
Developing a robust pipeline of vaccines the historical probability of success for anti-
With the continued reduction of transmission levels infectious disease vaccines to the number of known
and decreased mortality from COVID-19, we can vaccine candidates in late-stage trials indicates that
begin to get the disease under control. Prophylactic about six vaccine approvals are likely (Exhibit 2). The
vaccines that prevent infection and transmission situation is fluid; it is unclear if expedited approval,
would be the final part of the most hopeful say, or emergency authorization will change the
scenarios for ending the pandemic. Six months into odds. But with several “shots on goal,” and based
it, scientists, industry, and governments across the on what we know about the vaccine-development
globe are working in unprecedented collaboration to process, some vaccine candidates are likely to
develop such a vaccine. become available between the fourth quarter of
2020 and the beginning of 2021.
Researchers have not only tested a large number of
candidates but are also deploying a wide range of

Researchers have not only tested a

large number of candidates but are also
deploying a wide range of cutting-
edge technologies, including RNA-
based research.

10
Alan Bernstein, “I’m optimistic that we will have a COVID-19 vaccine soon. But will everyone be able to get it?,” Atlantic, August 29, 2020,
theatlantic.com.
11
Heidi Ledford, “What the immune response to the coronavirus says about the prospects for a vaccine,” Nature, August 17, 2020, nature.com;
Elizabeth Cohen and Dana Vigue, “Novavax Phase 1 data shows coronavirus vaccine is safe and elicits an immune response,” CNN Health,
August 5, 2020, cnn.com.

An optimistic scenario for the US response to COVID-19 5

 Exhibit 2
Historical
Historical vaccine-candidate-approval
vaccine-candidate-approval ratesratessuggest
suggest that
that some
some COVID-19
COVID-19 vaccines
vaccines may receive approval; sponsors could file for emergency use
may receive approval; sponsors could file for emergency use authorization in the
authorization
fourth quarterinofthe fourth
2020 quarter
or first of 2020
quarter or first quarter of 2021.
of 2021.
Potential approval rates for COVID-19 vaccines by clinical-trial phase, based on historical rates
(index = 100 candidates)1
Advancing candidate Nonadvancing candidate Approval rate

Phase l: Phase Il: Phase lII: Approved:

100 candidates 56 candidates 24 candidates 16 candidates

56.2% 42.7% 64.9%

Likelihood Phase l Phase Il Phase lII Approved

of candidate 15.6%
receiving
approval 27.7% 16 candidates
by phase 64.9%

Global status of current COVID-19-vaccine candidates by type and trial phase

Phase l: 13 candidates Phase Il: 12 candidates Phase lII: 9 candidates
DNA 1 5 0

Protein subunit 4 2 0

RNA 3 1 2
34
candidates
Viral vector 3 2 1 currently in
Phases I–III
Inactivated 0 2 3

Other2 2 0 3

Note: As of Sept 18, 2020, there were 224 additional vaccine candidates in preclinical trial phase.
Historical approval rates calculated for 1999–2018.
1

Includes attenuated-virus and virus-like-particle types, repurposed vaccines, and candidates with undisclosed properties.
2

Source: BioCentury; Milken Institute; Nature; Pharmaprojects, Informa, September 4, 2020, pharmaintelligence.informa.com; WHO, September 4, 2020,
who.int; McKinsey analysis

In addition, the at-risk ramping up of manufacturing A number of obstacles remain. The development
capacity could make as many as a billion doses of of vaccines is inherently risky because of the high
COVID-19 vaccines available globally by the end safety bar for inoculating the healthy population.
of 2020 (an estimate based on manufacturers’ Moreover, many leading vaccine candidates use
announcements). As more vaccines are approved unproven platform technologies. No RNA vaccines
and more doses become available, viral transmission have ever been approved. Vaccines utilizing adeno-
rates may drop significantly—assuming sufficient associated viruses to activate the body’s T-cell
public submission to vaccination. defense mechanisms were previously approved

6 An optimistic scenario for the US response to COVID-19

 only for Ebola vaccines, and they were not widely much progress over the past six months. Given
deployed. In addition, even though vaccines may what we now know about preventing transmission
be available around the fourth quarter of 2020, and treating the disease, as well as the robust
they may be limited to use for specific groups of pipeline of vaccines being developed, there is
patients, and the supply and cold supply chain may reason to hope once again that we can put the
be constrained. Finally, the potential for reinfection, pandemic behind us. If global financial systems
while currently thought to be unlikely, is yet don’t suffer long-term structural damage, the
unknown—so a seasonal-vaccine approach, similar economic recovery could proceed quickly—though
to that for flu, may be required. In the end, the most a broad and sustained recovery will require ongoing
momentous challenge ahead may be psychological investment in human and physical infrastructure
rather than epidemiological: getting a wary, and the continued adaptation of business models,
reluctant, or even disbelieving population to submit including digital technologies.12
to the vaccines or inoculations available.
Strong leadership can meaningfully tilt the odds
toward this hopeful outcome. That will take
courage, a bias for action in the face of uncertainty
The tenacity of SARS-CoV-2 (the novel coronavirus) and retrospective criticism, collaboration across
has shaken global confidence even in places institutions, and the moral suasion to build a sense
where COVID-19 has at times seemed to be under of higher purpose among the people.
control. Despite those setbacks, we have made

12
Shubham Singhal and Kevin Sneader, “‘And now win the peace’: Ten lessons from history for the next normal,” July 27, 2020. McKinsey.com,

Michael D. Conway is a senior partner in McKinsey’s Philadelphia office, Navjot Singh is a senior partner in the Boston office,
Shubham Singhal is a senior partner in the Detroit office, and Guang Yang is an associate partner in the Charlotte office.

The authors wish to thank Gaurav Agrawal, Mohammad Behnam, Matt Craven, Emily Capra, Peter Ha, and Jennifer Heller for
their contributions to this article.

Designed by McKinsey Global Publishing

Copyright © 2020 McKinsey & Company. All rights reserved.

An optimistic scenario for the US response to COVID-19 7