COVID-19 PRIMER

SPECIAL EDITION
SEPTEMBER 2020

OW Partners: Joel Ghosn & Jeff Youssef

TICG Team: Amneh Tarkhan, Hala Al Salem, Ghazi Al Naqeeb, Futha Al Abdulrazzaq, Saad Al Shihabi , Marwan Lasheen, Fawaz Al Enzi, Essa Khajah
INTRODUCTION

Oliver Wyman weekly COVID-19 primers Oliver Wyman team and tools

Since the very first COVID-19 cases in the region, Oliver Wyman Oliver Wyman’s dedicated team of specialists are constantly
has been issuing weekly COVID primers for the GCC, covering monitoring the latest developments to provide actionable insights
country-specific infection forecasts, economic analyses, key for our clients.
research digests, and news round-ups from local media sources. In addition, Oliver Wyman has developed, hosts and continues to
This special edition is the round-up of the 20+ weekly primers refine a suite of proprietary tools to address the pandemic,
issued to date, consolidating our latest research and insights on including the Pandemic Navigator, COVID-19 Almanac, Scenario
the topic. Sandbox and Generator, and the COVID-19 Risk Reporting
dashboard.

Oliver Wyman MMC

© Oliver Wyman
Coronavirus Hub Coronavirus Hub 2
 CONTENTS

01 Latest pandemic developments

02 Viral mutations and comorbidities

03 Second wave prevention

04 National testing policies

05 Governments policy response

06 Re-opening schools

07 Vaccine trials

© Oliver Wyman 3
 01. LATEST PANDEMIC DEVELOPMENTS

01 Latest pandemic developments

02 Viral mutations and comorbidities

03 Second wave prevention

04 National testing policies

05 Governments policy response

06 Re-opening schools

07 Vaccine trials

© Oliver Wyman 4
 Information as of 01/09/20

COVID-19 HAS HAD A MAJOR IMPACT GLOBALLY

<1,000
1,000-9,999
10,000-99,999
100,000-499,999
>500,000

25,572,216+
confirmed cases

Number of active cases Number of deaths Case fatality rate

The USA accounts for 23.7% of
all confirmed cases, followed by GCC 47,275 5,884 0.81%
Brazil (15.3%) and India (14.4%)
World 6,913,637 852,710 3.33%
Sources: Johns Hopkins University Center for Systems Science and Engineering (link) and Worldometer (link).

© Oliver Wyman 5
 Information as of 01/09/20

ALL REGIONS HAVE BEEN IMPACTED

Total confirmed COVID-19 cases by region

% share, 1-Jan to 1-Sep

Jan Feb Mar Apr May Jun Jul Aug

Daily COVID-19 deaths by region

% share, 1-Jan to 1-Sep

Jan Feb Mar Apr May Jun Jul Aug

Africa Asia (excl. China) China Europe North America Oceania South America

Source: Our World in Data (link).

© Oliver Wyman 6
 Information as of 01/09/20

THE GCC HAS ALSO BEEN IMPACTED

COVID-19 trajectories in the GCC

Daily new cases, as of 1-Sep
XXXX Highest in one day
Bahrain
786

Kuwait

1,073
Oman

2,164
Qatar

2,355
Saudi Arabia

4,919

UAE

994

Sources: Johns Hopkins University Center for Systems Science and Engineering (link), Our World in Data (link), and health ministry press releases.

© Oliver Wyman 7
 Information as of 01/09/20

TO DATE THE GCC COUNTS 727,634 CONFIRMED CASES

Confirmed cases of COVID-19 in the GCC*

Days since 100th case, cumulative
315,772
320,000
300,000
280,000
260,000
240,000
220,000
200,000
180,000
160,000
140,000
118,778
120,000
100,000
85,772 85,109
80,000
70,231
60,000
51,972
40,000
20,000
0
1 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190

Bahrain Kuwait Oman Qatar Saudi Arabia UAE

Note (*): Comparisons between countries should only serve as a guide, as reporting standards and testing measures vary across the GCC .
Source: Johns Hopkins University (link).

© Oliver Wyman 8
 Information as of 01/09/20

STILL, GCC CASE FATALITY RATES (CFR) HAVE BEEN MUCH LOWER THAN
INTERNATIONAL PEERS

Case fatality rates by country What is driving the variation?

%

Italy 13.14 • Breadth of testing: broader

UK 12.26
testing leads to a larger
confirmed base of patients,
France 9.47 leading to a decreased CFR
Sweden 6.88
• Government response: the type
China 5.25 of policy also affects CFR. For
Global 3.33 example, the decision to pursue
a herd immunity scenario in the
USA 3.04
UK and Sweden dramatically
Norway 2.44 increased their CFRs
South Africa 2.26 • Distribution of key risk factors:
Saudi Arabia 1.24 age, gender and pre-existing
Oman 0.80 conditions all affect CFR. For
example, Italy has the second
Kuwait 0.62
oldest population on Earth
UAE 0.54
• Health system threshold: every
Bahrain 0.37 country has a health system
Qatar 0.17 capacity that, when exceeded,
will result in a higher CFR due to
Sources: Johns Hopkins University Center for Systems Science and Engineering (link) and Vox (link). inability to support all patients
© Oliver Wyman 9
 Information as of 01/09/20

GCC GOVERNMENTS HAVE RESPONDED WITH STRICT LOCKDOWNS AS THE COVID-19

CRISIS SPREAD

Historical development of lockdown measures based on the Government Response Stringency Index*
Since 1-March

March April May June July August Cases Latest measures

Bahrain launches online portal for

Bahrain 51,972 payment of customs fees and taxes

Kuwait lifts nation-wide partial

Kuwait 85,811 curfew

Oman resumes several commercial

Oman 85,928 and industrial activities

Qatar reopens schools with a 30%

Qatar 118,994 daily capacity of students

Saudi Saudi Arabia begins school year

316,670 remotely via distance learning
Arabia

The UAE reopens nurseries and

UAE 70,805 childcare centres

No data 0 10 20 30 40 50 60 70 80 90 100
First 100 cases First 10 deaths Peak active cases

Note (*): The Stringency Index, developed by the University of Oxford, is a number from 1 to 100 that reflects the stringency of government response to COVID-19.
Sources: OW Pandemic Navigator Model, Our World in Data (link), and the University of Oxford (link).

© Oliver Wyman 10
 Information as of 25/08/20

THESE POLICIES HAD A MAJOR IMPACT ON MOBILITY

Bahrain Kuwait Oman

% change % change % change
50 50 50

0 0 0
Mar Apr May Jun Jul Aug Mar Apr May Jun Jul Aug Mar Apr May Jun Jul Aug

-50 -50 -50

-100 -100 -100

Grocery & Pharmacy Stores Parks Residential Retail & Recreation Transit Stations Workplaces

Qatar Saudi Arabia United Arab Emirates

% change % change % change
50 50 50

0 0 0
Mar Apr May Jun Jul Aug Mar Apr May Jun Jul Aug Mar Apr May Jun Jul Aug

-50 -50 -50

-100 -100 -100

Sources: Google Community Mobility Reports (link) and Our World in Data (link).

© Oliver Wyman 11
 02. VIRAL MUTATIONS AND COMORBIDITIES

01 Latest pandemic developments

02 Viral mutations and comorbidities

03 Second wave prevention

04 National testing policies

05 Governments policy response

06 Re-opening schools

07 Vaccine trials

© Oliver Wyman 12
SARS-COV-2 MUTATIONS CAN WEAKEN OR STRENGTHEN VIRAL SPREAD

Mutations that weaken viral spread Mutations that strengthen viral spread

• A mutation that allows the virus to multiply • The G variant strain of COVID-19 circulating in
primarily in the nasal areas rather than the the USA and Europe contains a spike mutation
lungs would lead to the epidemic becoming that made it 10 times more contagious than
more harmless over time1 the original D variant strain in China2

• Since March, the G variant, has rapidly spread

• Such a mutation would lead to people feeling
to become the dominant COVID-19 variant
much sicker with cold symptoms and staying
around the world2,3
at home, making the mutated virus less likely
to spread1
VS • It could potentially explain why the COVID-19
outbreaks in Italy and New York quickly
overwhelmed health systems3

Virus multiplies in lungs Virus multiplies in nasal area D variant G variant

(no mutation) (mutation) (no mutation) (spike mutation)
Sources: 1. Deutsche Welle (link); 2. Scripps Research (link); 3. The Washington Post (link).

© Oliver Wyman 13
 attaaaggtt tataccttcc caggtaacaa accaaccaac

SARS-COV-2 IS MUTATING AT A SLOWER PACE DUE TO THE

tttcgatctc ttgtagatct gttctctaaa cgaactttaa
aatctgtgtg gctgtcactc ggctgcatgc ttagtgcact

STABILITY OF A NEW MUTATION cacgcagtat aattaataac taattactgt cgttgacagg

acacgagtaa ctcgtctatc ttctgcaggc tgcttacggt
ttcgtccgtg ttgcagccga tcatcagcac atctaggttt
cgtccgggtg tgaccgaaag gtaagatgga gagccttgtc
cctggtttca acgagaaaac acacgtccaa ctcagtttgc
• The genetic material of SARS-CoV-2 contains 29,903
ctgttttaca ggttcgcgac gtgctcgtac gtggctttgg
nucleotides, which are the building blocks that encode agactccgtg gaggaggtct tatcagaggc acgtcaacat
all of the virus’ genes1 cttaaagatg gcacttgtgg cttagtagaa gttgaaaaag
• A change in in any one of these building blocks results gcgttttgcc tcaacttgaa cagccctatg tgttcatcaa
acgttcggat gctcgaactg cacctcatgg tcatgttatg
in a mutation, which could result in one of three gttgagctgg tagcagaact cgaaggcatt cagtacggtc
outcomes: gtagtggtga gacacttggt gtccttgtcc ctcatgtggg
D variant
1. The virus becomes more harmful (no mutation) cgaaatacca gtggcttacc gcaaggttct tcttcgtaag
aacggtaata aaggagctgg tggccatagt tacggcgccg
2. The virus becomes less harmful atctaaagtc atttgactta ggcgacgagc ttggcactga
tccttatgaa gattttcaag aaaactggaa cactaaacat
3. The mutation has no effect on the virus
agcagtggtg ttacccgtga actcatgcgt gagcttaacg
gaggggcata cactcgctat gtcgataaca acttctgtgg
ccctgatggc taccctcttg agtgcattaa agaccttcta
• After an initial period of rapid change, the mutation gcacgtgctg gtaaagcttc atgcactttg tccgaacaac
rate of SARS-CoV-2 began to slow down in April2 tggactttat tgacactaag aggggtgtat actgctgccg
• One reason for this slowdown is the stability of a new tgaacatgag catgaaattg cttggtacac ggaacgttct
G variant gaaaagagct atgaattgca gacacctttt gaaattaaat
mutated variant, the G variant, which now accounts for (spike mutation) tggcaaagaa atttgacacc ttcaatgggg aatgtccaaa
the majority of cases in many regions, especially ttttgtattt cccttaaatt ccataatcaa gactattcaa
Europe and North America2,3 ccaagggttg aaaagaaaaa gcttgatggc tttatgggta
• Increasing evidence supports the idea that the mutated gaattcgatc tgtctatcca gttgcgtcac caaatgaatg
caaccaaatg tgcctttcaa ctctcatgaa gtgtgatcat
G variant is more infectious, but it is still too early to
tgtggtgaaa cttcatggca gacgggcgat tttgttaaag
say whether it has other negative effects4 ccacttgcga attttgtggc actgagaatt tgactaaaga
Sources: 1. Frontiers in Microbiology (link); 2. bioRxiv (link); 3. The Washington Post (link); 4. Nextstrain (link). aggtgccact acttgtggtt acttacccca aaatgctgtt
gttaaaattt attgtccagc atgtcacaat tcagaagtag
© Oliver Wyman 14
gacctgagca tagtcttgcc gaataccata atgaatctgg
AMONG 4,000+ STUDIED SAMPLES, THE G VARIANT WAS MORE COMMON IN EVERY
CONTINENT EXCEPT ASIA

D variant
G variant

The G variant has rapidly spread It is increasingly being detected in

across the world and has become the Asia, with Malaysia2 and South
predominant strain in many Korea3 recently reporting new
countries1 outbreaks caused by the G variant
Sources: 1. Nextstrain (link 1, link 2); 2. The Straits Times (link); 3. Yonhap News Agency (link).

© Oliver Wyman 15
SOME STUDIES REPORT THAT THE G VARIANT IS MORE COMMON IN REGIONS
WITH HIGHER CFRS

Total number of deaths per million people1 Association of G variant with CFR
Until 2-May
• A study by the Dasman Diabetes
Belgium 670
Institute in Kuwait found that
the mutated G variant was
Spain 537 commonly found in countries
with a higher case fatality rate
475
(Belgium, Spain, and Italy), while
Italy
the non-mutated D variant was
found more commonly in
France 379 countries with lower death tolls
(Germany and Kuwait)1
Netherlands 291 • Another study from NYU
Langone Health reported that
Switzerland 203 the G variant could possibly be a
G variant more common more pathogenic (disease-
D variant more common causing) SARS-CoV-2 strain2
Germany 81
• In fact, an increased case fatality
rate was strongly correlated
Kuwait 8
with the proportion of viruses
containing the G variant
mutation2
Sources: 1. International Journal of Infectious Diseases (link); 2. International Journal of Clinical Practice (link).

© Oliver Wyman 16
COMORBIDITIES WERE ASSOCIATED WITH INCREASED RATES OF HOSPITALIZATION
AMONG COVID-19 PATIENTS

Impact of COVID-19 on the lungs and other organs1,2 Developments

Brain and eyes • The list of known symptoms of

Altered mental state, headaches, COVID-19 has continued to
dizziness, fatigue, & conjunctivitis expand as more is discovered
about the disease
Heart • This suggests that COVID-19
Irregular heartbeat, inflammation of should be thought of as a multi-
heart muscle, blockage of blood flow to system disease rather than a
heart muscle, & inability to pump purely respiratory one, which
blood to organs carries certain implications for
those with comorbidities1
Pancreas • Comorbidity is the presence of
Worsened blood glucose levels & pH
one or more additional health
conditions that co-occur with a
Kidneys primary condition
Acute kidney injury
• Certain comorbidities, namely
hypertension, diabetes and
Stomach and intestines obesity, were over-represented
Abdominal pain, anorexia, diarrhoea, in hospitalized COVID-19
nausea, & vomiting patients3
Sources: 1. Nature Medicine (link); 2. Public domain image from the Wikijournal of Medicine (link); 3. JAMA (link).

© Oliver Wyman 17
 RATE OF HOSPITALIZED COVID-19 PATIENTS CAN REACH AS HIGH AS 94%

Prevalence of comorbidities among hospitalized COVID-19 cases Developments

%

5,700 16,749 63 1,409 1,096 1,590 • The prevalence of comorbidities

100%
6% differed among hospitalized
COVID-19 cases from different
countries
47% 49% • However, in all studies
63% mentioned, having a greater
69%
75% number of comorbidities was
associated with a worsened
clinical outcome
94%
• The most common underlying
chronic diseases included
53% 51%
diabetes, hypertension and
obesity
37%
31%
25% • In fact, the CDC reports that
hospitalization was 6 times
more likely among COVID-19
New York1 UK2 Oman3 Qatar4 Kuwait5 China6
patients with a comorbidity7
At least one comorbidity No comorbidities

Sources: 1. JAMA (link); 2. BMJ (link); 3. Journal of Infection and Public Health (link); 4. medRxiv (link); 5. The Lancet (link); 6. European Respiratory Journal (link); 7. Morbidity and Mortality Weekly Report (link).

© Oliver Wyman 18
 COMORBIDITIES HAVE ALSO BEEN ASSOCIATED WITH A HIGHER CASE FATALITY RATE

Prevalence of comorbidities among confirmed COVID-19 cases and deaths1 Developments

%
100
• Hypertension was more
90 significantly associated with
both severe COVID-19 cases as
80 well as associated deaths1
74%
70 • Similarly, both diabetes and
respiratory diseases were more
60 prevalent among deaths
50 48% compared to total cases1
41% • In an analysis of 287,320 COVID-
40 19 cases in the US, the CDC
30 found that death was 12 times
25%
more likely for COVID-19
20
14%
patients if they suffered from a
10% 11% comorbidity2
10
4%
0
At least one Hypertension Diabetes Respiratory disease
comorbidity
Total cases Deaths

Sources: 1. Postgraduate Medicine (link); 2. Morbidity and Mortality Weekly Report (link).

© Oliver Wyman 19
EXAMPLE: VITAMIN D DEFICIENCY MAY BE ASSOCIATED WITH COVID-19 INFECTION

abc subject of next slides

Vitamin D is associated with COVID-19 infection Vitamin D is not associated with COVID-19 infection

• Vitamin D levels have been observed to be lower • In a study of 449 patients, vitamin D was not
in COVID-19 patients1 associated with COVID-19 infection nor could it
explain the ethnic differences in COVID-19
• Vitamin D supplements were found to have a infection8
protective effect against acute respiratory
infections2,3,4
VS • England’s Department of Health found no
evidence to support taking vitamin D
• Vitamin D increases the conversion from ACE2 supplements to prevent or treat COVID-199
(the receptor through which SARS-CoV-2 enters
the cell) to ACE, potentially inhibiting COVID-19- • A lead researcher at the University Hospital of
induced multi-organ damage5,6 Würzburg disputes findings that link COVID-19 to
vitamin D deficiency, stating that it is a mere
• The higher COVID-19 mortality rates observed in observation and not a correlation10
northern latitudes could be attributed to the
higher levels of vitamin D deficiency6 • In a study of 144 geopolitical areas, latitude was
not associated with epidemic growth of COVID-
• A highly significant, positive correlation was 1911
found between lower COVID-19 mortality rates
and a country’s distance from the equator7

Sources: 1. Nutrients (link); 2. PLoS ONE (link); 3. BMJ (link); 4.Nutrients (link); 5. Naunyn-Schmiedeberg's Archives of Pharmacology (link); 6. Journal of Internal Medicine (link); 7. American Journal of Infection
Control (link); 8. Diabetes & Metabolic Syndrome (link); 9. National Institute for Health and Care Excellence (link); 10. Canadian Medical Association Journal (link); 11. DW (link).

© Oliver Wyman 20
 Information as of 01/09/20

THIS MAY EXPLAIN THE HIGHER CFR IN NORTHERN LATITUDES

COVID-19 mortality by country and latitude Developments

As of 1-Sep
• Latitude has been found to have a
14%
significant effect on vitamin D
13% Italy
deficiency, with populations in
UK northern latitudes at higher risk1,2
12%
Belgium
11% Mexico • Findings suggest that countries in
France northern latitudes, e.g. UK, Sweden,
10%
Spain, and France, had higher COVID-
9%
Case fatality rate

19 mortality due to vitamin D

8% deficiency3,4,5
Sweden
7% • However, this hypothesis is not
6% Spain supported by the fact that Arab
Ecuador
countries have low COVID-19
5%
Germany Finland mortality rates despite high rates of
4% Portugal vitamin D deficiency
Uruguay Norway
3% Brazil Iraq • In contrast, vitamin D levels are
Australia Japan
2% South Africa Lebanon severely low among the aging
Chile South Korea
KSA populations of Europe, who were also
1% New Zealand Oman Kuwait
Singapore UAEQatar Bahrain the most vulnerable age group to
0% COVID-196
-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70

Degrees latitude*
Note (*): degrees latitude is for capital cities.
Sources: 1. International Journal of Circumpolar Health (link); 2. The Journal of the American Osteopathic Association (link); 3. Social Science Research Network (link); 4. Centre for Evidence-Based Medicine (link); 5.
Alimentary Pharmacology and Therapeutics (link); 6. Aging Clinical and Experimental Research (link).

© Oliver Wyman 21
THIS COULD BECOME AN ISSUE FOR THE GCC AS VITAMIN D DEFICIENCY IS COMMON

Vitamin D deficiency in adults in the Middle East1-8 Developments

Measured in serum 25(OH)D levels (nmol/L)
• The major source of vitamin D for
children and adults is exposure to
natural sunlight9
• Despite the plentiful sunshine, vitamin
D deficiency is prevalent in the
Middle East, reaching epidemic
proportions in certain populations
• The extended curfews, quarantines,
and stay-at-home measures may have
exacerbated this issue, as individuals
are less exposed to the sunlight, less
physically active, and more likely to
have an unhealthy diet10
• Of concern to public health is the
association of vitamin D deficiency
with increased risk and severity of
chronic diseases and viral infections,
including HIV11,12
Sufficient (50-74 nmol/L)
Deficient (<50 nmol/L)

Sources: 1. Dermato-Endocrinology (link); 2. Journal of Public Health Research (link); 3. Sultan Qaboos University Medical Journal (link); 4. Endocrine Abstracts (link); 5. Journal of Obesity & Weight Loss Therapy
(link); 6. European Journal of Clinical Investigation (link); 7. Bahrain Medical Bulletin (link); 8. International Journal of Medical Biochemistry (link); 9. Journal of Pharmacology & Pharmacotherapeutics (link); 10.
Nutrition, Metabolism and Cardiovascular Diseases (link); 11. Journal of Clinical Virology (link); 12. Topics in Antiviral Medicine (link).

© Oliver Wyman 22
 Information as of 01/09/20

DESPITE A HIGHER SHARE OF COMORBIDITIES, THE GCC HAS A RELATIVELY LOW CFR

CFR (%) Lowest Highest

0.17 0.37 0.54 0.62 0.80 1.24 1.61 2.26 2.44 3.04 5.25 6.88 9.47 12.26 13.14

1
Government

Lowest Highest
Tests (per thousand people)
response

n/a 37 62 67 94 102 123 142 143 145 198 217 253 647 709

2
Stringency of response 7 days Lowest Highest

after 100th confirmed case 14 23 24 36 63 72 72 75 80 84 89 90 90 90 92

1 Smoking (%) Lowest

12 16 18 20 20 21 21 22 22 23 24 27 27 28 29
Highest
COVID-19 risk factors

2
Lowest Highest
Hypertension (%)
13 13 15 16 16 16 18 19 20 21 24 25 26 29 30

3
Lowest Highest
Diabetes (%)
7 7 8 8 8 8 9 9 9 9 10 10 13 14 15

4
Lowest Highest
Obesity (%)
5 7 22 23 23 23 25 27 29 30 30 34 35 37 37

5
Lowest Highest
Median age (years)
27.3 30.7 31.9 31.9 32.4 33.7 34 38.3 38.7 39.7 40.8 41 42 43.4 47.9

The lower CFR in the GCC region could be due to a wider breadth of testing, a more stringent government response
early on in the epidemic, and a lower median age compared to international peers.
Sources: Johns Hopkins University Center for Systems Science and Engineering (link), WHO noncommunicable diseases country profiles (link), University of Oxford (link), and health ministry press releases.

© Oliver Wyman 23
 03. SECOND WAVE PREVENTION

01 Latest pandemic developments

02 Viral mutations and comorbidities

03 Second wave prevention

04 National testing policies

05 Governments policy response

06 Re-opening schools

07 Vaccine trials

© Oliver Wyman 24
THERE ARE THREE MAJOR TRANSMISSION ROUTES FOR SARS-COV-2 TO BE SPREAD

abc focus of next slides

Respiratory viruses have three major transmission routes1,2

01 Contact transmission
• Direct contact with an infected person
• Indirect contact with a SARS-CoV-2-contaminated object or surface (fomites)

02 Droplet transmission
• Occurs when a person is in close proximity (within 1 meter) with a symptomatic person, which risks the
exposure of the mouth, nose, and eyes to infected respiratory droplets (particles >5 μm in diameter)
• Both the U.S. Centers for Disease Control and Prevention and the WHO consider this to be the most frequent
mode of COVID-19 transmission3

03 Airborne transmission
• Occurs when aerosols (particles <5 μm in diameter) are generated
• A current point of contention is how much airborne transmission contributes to COVID-19 spread
• The WHO maintains that airborne transmission of COVID-19 is only significant in medical settings, i.e. during
the performance of procedures such as resuscitation and disconnection from ventilators

Sources: 1. WHO Scientific Brief (link); 2. European Centre for Disease Prevention and Control (link); 3. NPR (link).

© Oliver Wyman 25
THE SARS-COV-2 PARTICLE SIZE MAYBE SMALLER THAN ORIGINALLY THOUGHT

Particles of different sizes can be released by individuals while Particle size (μm)
breathing, speaking, sneezing, or coughing1 Respiratory
Aerosols droplets

0.1 1 10 100

Takes Takes
12.4 hours* to 4.6 seconds*
settle to the to settle to the
ground ground

1m
Respiratory droplets fall to the ground Aerosols evaporate faster than they can The WHO currently maintains that
faster than they can evaporate, fall to the ground, allowing them to aerosols carrying viable SARS-CoV-2
contaminating surfaces and objects. float in the air and be carried by air cannot be generated by normal human
They generally do not travel further currents over distances greater than 1 cough conditions2. However, on 6-July,
than 1 meter from an individual1 meter. The distances that aerosols can an open letter signed by 239 scientists
travel are significantly increased by challenged the WHO on this
sneezing and coughing1 assumption3
Note (*): in still air and from a height of 8 feet (2.44 meters).
Sources: 1. Science (link); 2. WHO Scientific Brief (link); 3. Clinical Infectious Diseases (link).

© Oliver Wyman 26
CURRENT VIEW IS AIRBORNE TRANSMISSION INCREASES SUBSTANTIALLY INDOORS

Exhibit A: Chinese restaurant1,2 Exhibit B: Washington choir3,4

• A COVID-19 outbreak occurred among 10 persons • Despite observing physical distancing and bringing
from 3 families who had eaten in a restaurant in their own sheet music, 52 out of a total of 61 choir
Guangzhou members were infected by a single symptomatic
individual during a rehearsal
• One individual (who was asymptomatic during the
lunch) had infected all the others, despite camera
• Two of the singers later died, and the median age of
the choir members who attended that practice was 69
footage showing no contact between them
years old
• It later became apparent that all three families were VS • The outbreak was later attributed to the act of singing
seated in the path of airflow from an air conditioner, in a confined setting, which caused a large amount of
which had likely spread the aerosols from the index infectious aerosols to accumulate
case

Sources: 1. U.S. Centers for Disease Control and Prevention (link); 2. medRxiv (link); 3. The Los Angeles Times (link); 4. The New York Times (link).

© Oliver Wyman 27
IF SO, SEVERAL FACTORS MIGHT INCREASE THE RISK OF AIRBORNE TRANSMISSION
IN THE GCC

Air conditioning Indoor building ventilation Incense burning Cigarette smoking

It has been suggested that air Poor indoor ventilation can The habitual burning of incense SARS-CoV-2 may attach to
conditioning may play a role in cause SARS-CoV-2 particles to is a major source of airborne aerosols and respiratory
COVID-19 transmission, as accumulate in the air, particles, and incense smoke droplets in secondhand smoke,
individuals rebreathe more air potentially increasing the may facilitate the transmission which can increase the reach
when in an air-conditioned indoor spread of COVID-192 of COVID-19 in an indoors and transmission of COVID-19
indoors environment1 environment3 from infected smokers5
The harsh climate of the GCC
The use of air conditioning is countries make it near Burning incense is widespread Smoking is common among
widespread among the GCC impossible to make use of among households and certain males in the GCC, with an
countries due to the harsh natural ventilation, especially in public spaces in the GCC, which average of 28.5% of the male
climate, which also forces the hot summer months3 could be a potential cause for population being smokers
people to rebreathe more air as concern for public health compared to just 3.0% of the
As a result, most household,
they spend more time in air- officials4 female population6
public, and office settings in
conditioned spaces2
the GCC suffer from poor
indoor ventilation levels due to
architectural designs that rely
on air-conditioning systems3
Sources: 1. The Harvard Gazette (link); 2. City and Environment Interactions (link); 3. Science of the Total Environment (link); 4. BMC Pulmonary Medicine (link); 5. American Chemical Society (link); 6. Tobacco
Induced Diseases (link).

© Oliver Wyman 28
THE OECD PREDICTS SEVERE AND LONG-LASTING ECONOMIC CONSEQUENCES,
ESPECIALLY IF ANOTHER WAVE OF INFECTIONS OCCURS

Double-hit scenario: a second wave of infections Single-hit scenario: a second wave of infections
occurs before the end of 2020 is prevented

• Another wave of infections would trigger new • Current lockdowns are lifted, and business
lockdown measures activity is not frozen by future lockdowns

• World economic output would fall by -7.6% in • World economic output would fall by -6% in
2020 and climb to 2.8% in 2021 2020 and climb to 5.2% in 2021

• OECD unemployment rate would nearly

double from 5.4% in 2019 to 10% in 2020, with
VS • OECD unemployment rate would increase
from 5.4% in 2019 to 9.2% in 2020
insignificant job recovery by 2021

Real GDP growth in double-hit scenario Real GDP growth in single-hit scenario
3.4% 2.7% 2.8% 5.2%
3.4% 2.7%

-7.6% -6.0%
2018 2019 2020 2021 2018 2019 2020 2021

To prevent a second wave, governments must strengthen health care systems, ensure global cooperation on
vaccine development, and utilize testing, tracing, and distancing strategies.

Source: OECD Economic Outlook, June 2020 (link).

© Oliver Wyman 29
PHYSICAL DISTANCING, FACE MASKS AND EYE PROTECTION CAN SIGNIFICANTLY
REDUCE COVID-19 TRANSMISSION AND PREVENT A SECOND WAVE

Physical distancing Face mask use Eye protection

• Current policies of at least 1 m physical • Wearing a face mask can also reduce the • Wearing eye protection, such as
distancing result in a large reduction in risk of infection from 17.4% to 3.1% goggles, face shields or even large eye
risk of infection (from 12.8% to 2.6%) • Multi-layer cloth masks offer better glasses, can reduce the risk of infection
from 16% to 5.5%
• However, distances of 2 m might be protection for the general public than
more effective in reducing risk of single-layer masks
infection (from 12.8% to 1.5%)

However, even when properly used and combined, none of these interventions offers complete protection against
COVID-19. Basic protective measures, such as hand hygiene, are still essential to reduce transmission.

Sources: ABC News (link) and The Lancet (link).

© Oliver Wyman 30
EFFECTIVE COMMUNICATION IS CRITICAL. FOR EXAMPLE, MASKS WERE NOT
IMMEDIATELY ADOPTED DUE TO MIXED GUIDELINES

Why have masks been the subject of such mixed

guidelines?
• Initially, the WHO did not recommend the usage of
masks except for those who were sick and showing
symptoms
• However, what was not known then was the
significance of asymptomatic and pre-symptomatic
transmission of COVID-19
• In its updated guidance (6-Apr), the WHO stated that,
while masks could limit the spread of the disease,
there was no evidence that they would prevent
healthy people from contracting COVID-19
• In contrast, the US Centers for Disease Control and
Prevention urged the American public to wear masks
or face cloth coverings in public places
• As of May, more than 85% of the global population
lived in countries where the use of masks in public
places was recommended or mandated

Sources: Health ministry press releases, Centers for Disease Control and Prevention (link), The Guardian
(link), and Masks4All (link).

© Oliver Wyman 31
EMERGING EVIDENCE ALSO SUGGESTS THAT CLIMATE COULD MODULATE THE
SPREAD IN MORE SUBSTANTIAL WAYS THAN PREVIOUSLY THOUGHT

In a study of 50 cities with and without

COVID-19, those with significant
community transmission were
distributed within a defined latitude
50o N
corridor (30° N to 50° N)1

30o N

Cities in this latitude corridor (including

Winter in northern hemisphere: 1 December – 1 March
Seattle, Madrid, Paris, Milan, Qom, Winter in southern hemisphere: 1 June- 1 September
Equator

Wuhan, Daegu, and Tokyo) displayed

consistently similar weather patterns, 30o S

mean temperatures of 5 to 11 °C and

50o S
low humidity1

This distribution is consistent with the The decrease in humidity during winter As winter begins in the southern
behaviour of a seasonal respiratory is especially worrisome, as a 1% hemisphere, a surge in respiratory
virus, which might suggest the decrease in humidity can increase cases have been observed in Brazil3,
potential for seasonal outbreaks in the COVID-19 cases by 6%2 while a leading Australian
upcoming months1 microbiologist warned that winter
could raise the risk for COVID-19
Sources: 1. JAMA Network Open (link); 2. Transboundary and Emerging Diseases (link); 3. Bloomberg (link); 4. Xinhua News Agency (link). spread in the southern hemisphere4
© Oliver Wyman 32
 04. NATIONAL TESTING POLICIES

01 Latest pandemic developments

02 Viral mutations and comorbidities

03 Second wave prevention

04 National testing policies

05 Governments policy response

06 Re-opening schools

07 Vaccine trials

© Oliver Wyman 33
THE WHO HAS ISSUED RECOMMENDATIONS ON TESTING POLICIES AND BENCHMARKS
FOR REOPENING THE ECONOMY

Recommendations for testing policy

• The WHO recommends to test all suspect cases

Testing • However, if diagnostic capacity is insufficient, countries should implement prioritized
policy testing that targets vulnerable populations, health workers, and the first symptomatic
individuals in a closed setting (e.g. prisons, schools)

Recommendations for testing rates

Testing • The WHO suggests that a general benchmark of adequate testing involves at least 10
rate daily tests per newly confirmed case

Recommendations for reopening

• The WHO advises governments that rates of positive cases should remain at 5% or lower
Positivity
for at least 14 days before they reopen, with an adequate positivity rate ranging
rate
between 3% and 12%

Sources: Johns Hopkins University Coronavirus Resource Center (link), Our World in Data (link), WHO interim guidance (link), and the WHO virtual press conference (link).

© Oliver Wyman 34
NOT ALL COUNTRIES FOLLOW THE SAME TESTING POLICY, WHICH CAN CAUSE A
DISCREPANCY BETWEEN THE REPORTED AND TRUE NUMBERS OF CASES

The University of Oxford divides current government testing policies* into four main groups:
No Symptoms Anyone Open
testing & key with public
policy groups symptoms testing
• Testing is not guided by any • Testing is limited to those • Testing includes anyone • Testing is open and
government policy who both (a) have showing COVID-19 available to the public, e.g.
symptoms and (b) meet symptoms, e.g. fever, dry “drive-thru” testing is
• Only two countries,
specific criteria, e.g. key cough, and tiredness available to asymptomatic
Tanzania and Yemen, do
workers, came into contact people
not have a testing policy
with a known case, or
currently in place
returned from overseas

Allows detection
Could lead to a low testing
Could miss out on asymptomatic cases, which can account asymptomatic cases,
capacity, uneven access to
for up to 45% of active cases in the overall population and ensuring reported active
testing, and supply
more than 60% of active cases in younger individuals cases is closer to the true
bottlenecks
number
Note (*): testing policy only includes PCR testing and not antibody testing.
Sources: Annals of Internal Medicine (link), Bloomberg (link), and the Oxford COVID-19 Government Response Tracker (link).

© Oliver Wyman 35
SIGNIFICANT VARIATION EXISTS WITH REGARD TO THE NUMBER OF DAILY TESTS,
WHICH FLUCTUATES BETWEEN COUNTRIES AND ON DIFFERENT DAYS

Number of daily tests conducted per newly confirmed case Developments

As of 1-Sep, logarithmic scale
100,000 • Following the WHO’s suggestion,
Bahrain Qatar a general benchmark of
Kuwait USA
Oman adequate testing rates involves
Saudi Arabia
at least 10 daily tests per newly
Confirmed cases per million

10,000 South Africa Sweden UAE

France Italy confirmed case
UK
Canada
Norway Finland • A testing rate lower than 10
1,000 Australia daily tests per newly confirmed
Japan South Korea case suggests that there might
be many undetected cases
100 • Among the GCC, Bahrain, Qatar,
Saudi Arabia and the UAE meet
Taiwan the WHO recommendation for
10 an adequate testing rate
1 10 100 1,000 10,000

Daily tests per newly confirmed case

Anyone with symptoms Open public testing

Note: the Omani MoH stopped releasing testing data after 6-Aug.
Sources: Our World in Data (link) and the WHO virtual press conference (link).

© Oliver Wyman 36
FOR A SAFE REOPENING, THE WHO HAS ADVISED THAT THE SHARE OF DAILY TESTS
THAT ARE POSITIVE SHOULD REMAIN AT 5% OR LOWER FOR AT LEAST 14 DAYS

Share of daily tests that are positive Developments

As of 1-Sep, logarithmic scale for y-axis
100,000 • Following the WHO’s suggestion,
Bahrain Qatar a general benchmark of
USA UK Kuwait adequate positivity rates
10,000 UAE South Africa Oman involves a positivity rate that lies
Confirmed cases per million

Saudi Arabia
Italy between 3% and 12%
Canada
Norway
• A positivity rate higher than
Finland
1,000 Australia 12% indicates that insufficient
Japan testing is being carried out,
South Korea which impedes the ability of the
100 government to adequately
monitor the outbreak
Taiwan • Among the GCC, Bahrain, Saudi
10 Arabia and the UAE meet the
0% 6% 12% 18% 24% 30% 36% 42% 48% 54%
WHO recommendation for an
Share of daily tests that are positive
adequate positivity rate
Anyone with symptoms Open public testing
Note: the Omani MoH stopped releasing testing data after 6-Aug.
Sources: Johns Hopkins University Coronavirus Resource Center (link), Our World in Data (link), and the WHO virtual press conference (link).

© Oliver Wyman 37
 Information as of 01/09/20

GROUP TESTING IS A COST-EFFECTIVE WAY OF TESTING INDIVIDUALS

Percentage of daily tests that are positive (positivity rate) in the GCC 1,2 High positivity rates can prevent
10-June to 1-Sep effective group testing
55% • Group testing can prevent testing
from becoming prohibitively
50% expensive for employers and school
administrators3
45%
• However, group testing of up to 5
40% samples at a time is recommended by
the US Food and Drug Administration
35% (FDA) only when the positivity rate is
30% less than 10%4
• For instance, Nebraskan health
25% authorities were forced to stop group
20% testing when their positivity rates
increased to 17%5
15% Maximum • Among the GCC, group testing on the
positivity
10% rate allowed population level would currently be
by FDA for recommended for the UAE, Bahrain,
group testing
5% and Saudi Arabia

0% • However, the high positivity rates of

13-Jun 27-Jun 11-Jul 25-Jul 8-Aug 22-Aug Oman and Kuwait could be due to
their policy of testing those with
Bahrain Kuwait Oman Qatar Saudi Arabia UAE symptoms only6
Note: the Omani MoH stopped releasing testing data after 6-Aug.
Sources: 1. Our World in Data (link); 2. Health ministries’ infographics; 3. University of Southern California (link); 4. The Washington Post (link); 5. Los Angeles Times (link); 6. Our World in Data (link).

© Oliver Wyman 38
THIS TYPE OF TESTING COULD HELP SUPPRESS POTENTIAL SECOND WAVES

Current testing focuses on testing By utilizing group testing, health authorities could vastly increase their
each suspect case individually testing capacities, allowing greater access to testing
• In a group testing approach, samples are grouped together and tested as
• For example, if there are 27 one. Individual testing is only carried out if the group test comes up as
suspect cases, then 27 tests are positive1
performed to rule out COVID-19 – However, test groups must not be too large to avoid the risk of diluting
positive samples and obtaining false negatives1
– The most efficient group size was reported to be 5 samples, with a
maximum of 30 samples per group to allow for confident identification2,3
• Several governments have utilized group testing, which can save chemical
reagents, money, and time4
– Germany and Singapore utilize group testing in nursing homes4
• This uses up a large amount of – In India, the protocol for testing migrant workers and returnees from
finite testing resources, causing abroad involves combining 25 samples in a single group to be tested as
some authorities to restrict testing one5
those showing symptoms – Health authorities in the state of Nebraska turned to group testing when
• Such restrictions are counter- they began to run out of testing reagents6
productive as bypass • Group testing is also useful in group settings such as schools and offices,
asymptomatic and pre- where they can become a recurring feature of back-to-school and back-to-
symptomatic cases and inflate the work programs4
positivity rate
Sources: 1. Bloomberg (link); 2. American Journal of Clinical Pathology (link); 3. The Lancet Infectious Diseases (link); 4. The Washington Post (link); 5. Ministry of Health & Family Welfare (link); 6. NPR (link).

© Oliver Wyman 39
THERE ARE SEVERAL SCIENTIFIC METHODS OF GROUP TESTING THAT COULD BE
UTILIZED
------- positive result
------- negative result
Group testing method A Group testing method B Group testing method C

Samples are distributed into equal Similar to method A, but it adds an extra Method C involves two rounds of
groups, and each group is tested. If a round of group testing before testing testing, Samples are arranged in a square
group’s test result is positive, then each individually, which reduces the total matrix in the second round, where each
sample in that group is re-tested number of people that need to be tested row and column is treated as a group and
individually tested
1st round = 3 tests for 27 people 1st round = 3 tests for 27 people 1st round = 3 tests for 27 people

2nd round = 9 tests for 9 people 2nd round = 3 tests for 9 people 2nd round = 6 tests for 9 people

3rd round = 3 tests for 3 people

This method was used to test the vast

majority of Wuhan’s population, allowing
officials to group test 2.3 million people This method is being trialled by the Rwandan
(with up to 5 samples in each group) and government, potentially cutting the cost of
identify 56 cases in a little over two weeks testing each person from USD 9 to USD 0.75

Sources: Nature (link) and medRxiv (link).

© Oliver Wyman 40
 05. GOVERNMENTS POLICY RESPONSE

01 Latest pandemic developments

02 Viral mutations and comorbidities

03 Second wave prevention

04 National testing policies

05 Governments policy response

06 Re-opening schools

07 Vaccine trials

© Oliver Wyman 41
 THE IMF DOWNWARDLY REVISES ITS ECONOMIC OUTLOOK FOR THE ECONOMIES OF
THE MIDDLE EAST AND CENTRAL ASIA

IMF grouping system of Middle Eastern and Central Asian economies Developments

• The IMF has revised its growth

forecast for the MENAP region,
expecting it to contract by 5.1% in
2020 compared to a 0.5% contraction
CCA oil & gas exporters
in 2019
CCA oil & gas importers
• The IMF’s negative outlook for the
MENAP oil exporters region was influenced by two major
factors:
MENAP oil importers
– Uncertainty around the length of
the pandemic and the associated
economic shutdown
– Potential for renewed volatility in
Projected annual growth in real GDP across the MENAP region global oil markets
% of GDP
• Across the MENAP region, oil
2019 2020
5 3.0 exporters will experience the most
1.9
0.3 0.5 contraction (-7.3%) in 2020, while
0 MENAP oil importers will see the least
-1.1 -0.8
-5 contraction (-1.1%)
-5.7 -5.7
-10 -7.1 -7.3 • A higher economic contraction is
MENAP oil Arab World MENA GCC MENAP oil projected for the GCC (-7.1%) in 2020
importers exporters compared to the Arab World (-5.7%)
CCA: Caucasus and Central Asia; GCC: Gulf Cooperation Council; MENA: Middle East & North Africa; MENAP: Middle East, North Africa, & Pakistan.
Sources: IMF Regional Economic Outlook Update (July 2020) (link).

© Oliver Wyman 42
 FURTHER DETERIORATION OF NON-OIL GROWTH AND FISCAL BALANCES IS EXPECTED
IN 2020

MENAP oil exporters MENAP oil importers GCC countries

% of GDP % of GDP % of GDP
10 10 10
5.6
5 3.2 3.9 3.5 5 3.0 5 2.4
1.8 1.8 2.1 3.0
0.5
0 0 0
-0.8 -1.1
-2.9 -2.1 -2.9
-5 -4.4 -5 -4.6
-5 -3.9
-5.4 -5.5 -5.2
-10 -7.3 -6.8 -10 -7.3 -7.8 -10 -7.1 -7.6 -8.0
-9.1 -8.7
-11.4 -10.5
-15 -15 -15
2019 2020 2021 2019 2020 2021 2019 2020 2021

CCA oil and gas exporters CCA oil and gas importers Arab world
% of GDP % of GDP % of GDP
10
6.2 5.9
4.6 5.3
5 4.2 3.5
5 5 1.9 3.0 3.5 3.0
0.8 1.4
0 0 0
-0.9 -1.1 -1.1 -1.4
-5 -4.5
-3.3 -5 -4.6 -4.4 -5 -3.2
-5.9 -5.4 -5.6 -5.7
-6.9 -5.9
-10 -10 -7.3 -8.0 -10 -5.2 -9.4
-10.2 -11.1
-15 -15 -15
2019 2020 2021 2019 2020 2021 2019 2020 2021

Real GDP (annual growth) Non-oil growth Current account balance Overall fiscal balance
CCA: Caucasus and Central Asia; GCC: Gulf Cooperation Council; MENAP: Middle East, North Africa, & Pakistan.
Sources: IMF Regional Economic Outlook Update (July 2020) (link).

© Oliver Wyman 43
 Information as of 01/09/20

THE CRISIS HAS HEAVILY IMPACTED THE GCC COUNTRIES, MOST OF WHOM ARE
MAJOR FOOD IMPORTERS

Bans on food exports Impact of bans on food importers

• To protect their domestic food supplies, several • Such trade restrictions are a threat to the food
major food exporters have introduced temporary security of major food importers, and the share
bans on food exports, including basic staples of restricted flows in food imports was
such as maize, rice, and wheat significantly higher in the Middle East

Restrictions on food exports linked to COVID-19 Disruption of food imports among major importers
Select exporters, from Mar-20 to Sep-20 % share, cumulative
Exporter Mar Apr May Jun Jul Aug Sep Banned exports
Algeria Rice, fresh produce 25%
Armenia Rice, cereals, onions
Belarus Rice, cereals, onions 36% 18%
Egypt Pulses 11% 2%
14%
Ghana Soybeans 43%
7%
Kazakhstan Rice, cereals, onions 8%
39%
Kyrgyzstan Rice, cereals, onions 13%
Russia Rice, cereals, onions 11% 6%
8%
Turkey Lemons
Ukraine Buckwheat
19%
Tuesday 1-Sep

Sources: CGIAR (link) and the International Food Policy Research Institute (link).

© Oliver Wyman 44
 Working estimates Information as of 28/08/20

POLICY RESPONSES TO COVID-19

Key policy responses Examples of key policy responses

1-Jan to 28-Aug
Area of response Fiscal
Country Fiscal Monetary Exchange rate Stated amount • Personal expense relief
Bahrain1 ✓ ✓ $11.5 BN
BHD 4.3 BN • Tax exemption
Kuwait1,2 ✓ ✓ $18.1 BN • Mortgage loan flexibility
KWD 5.5 BN
Oman1 ✓ ✓ $20.8 BN • Reduced government spending
OR 8 BN
Qatar1,3 ✓ ✓ $20.6 BN
QAR 75 BN
Monetary and macro-financial
Saudi Arabia1 ✓ ✓ $35.8 BN
SAR 134 BN • Reduced interest rates
UAE1 ✓ ✓ $77.6 BN
AED 284 BN • Reduced capital & liquidity requirements
China1 ✓ ✓ ✓ $995 BN • Purchase of treasuries
¥6.84 TR
France1 ✓ ✓ $552 BN • Private sector debt relief
€462 BN
Italy1,4 ✓ ✓ $962 BN
€805 BN
Exchange rate and balance of payments
$118 BN
Singapore1 ✓ ✓ S$161 BN • Adjusted exchange rate
$230 BN
South Korea1,5 ✓ ✓ ✓ ₩270 TR • Raised ceiling on cross-border financing
$972 BN
UK1,6 ✓ ✓ £726 BN • Removed restrictions on investment quota

USA1,7 ✓ ✓ $2.96 TR • Opened bilateral swap line

Sources: 1. IMF Policy Tracker (link); 2. Kuwait News Agency (link 1, link 2); 3. Qatar e-Government (link); 4. Bloomberg (link 1, link 2); 5. Reuters (link); 6. Business Insider (link); 7. Financial Times (link).

© Oliver Wyman 45
COMPENSATION AND BENEFITS (C&B) PROGRAMS ACROSS THE GCC ARE BEING
REEVALUATED TO ENSURE MAXIMUM VALUE-FOR-MONEY

• C&B program adjustments were more prevalent

among local organizations (81%) compared to their 87% 70%
international peers (53%)
• The Life Sciences sector was the most resilient to Expect a moderate to Plan to or have already
COVID-19, as 87% of organizations in this sector high impact on financial adjusted one or more
performance C&B elements
report no changes to their C&B programs
• The Engineering, Construction, & Real Estate sector
was the least resilient to COVID-19, as 90% of 36% 27%
organizations in this sector report taking actions
across one or more C&B programs Have considered or taken Have already made
• In terms of changes already made, the most actions involving reductions to the base
terminations, hiring salary, with a 20-25%
prevalent actions involved reductions to the base freezes, and employee median reduction on
salary, suspension of salary increases, and furloughs allowances
reduction of employee headcount
• With regard to changes planned, the most prevalent 20% 17%
actions involve reduction of employee headcount,
suspension of salary increases, and changes to
leave policy Have taken action on Have made changes to
2020 salary increases their leave policy
Note: Survey sample comprised 522 subsidiaries, belonging to 168 groups, across various industries and operating in the GCC.
Source: Mercer (link).

© Oliver Wyman 46
 06. RE-OPENING SCHOOLS

01 Latest pandemic developments

02 Viral mutations and comorbidities

03 Second wave prevention

04 National testing policies

05 Governments policy response

06 Re-opening schools

07 Vaccine trials

© Oliver Wyman 47
 Information as of 18/06/20

CONFIRMED CASES ARE UNEQUALLY DISTRIBUTED AMONG AGE GROUPS ACROSS

COUNTRIES, WITH CHILDREN UNDER 19 LESS AFFECTED THAN OTHER AGE GROUPS

Australia1 England2 Iceland3

% share of confirmed cases % share of confirmed cases % share of confirmed cases
0 to 9 2 0 to 9 1 0 to 5 2
10 to 19 3 10 to 19 1 6 to 17 8
20 to 29 21 20 to 29 8 18 to 29 21
30 to 39 16 30 to 39 10 30 to 39 16
40 to 49 13 40 to 49 12 40 to 49 20
50 to 59 16 50 to 59 15 50 to 59 17
60 to 69 16 60 to 69 11 60 to 69 12
70 to 79 10 70 to 79 14 70 to 79 3
>80 3 >80 28 >80 1

Japan4 South Korea5 Sweden6

% share of confirmed cases % share of confirmed cases % share of confirmed cases
0 to 9 2 0 to 9 1 0 to 9 1
10 to 19 2 10 to 19 6 10 to 19 2
20 to 29 17 20 to 29 27 20 to 29 11
30 to 39 15 30 to 39 11 30 to 39 14
40 to 49 16 40 to 49 13 40 to 49 16
50 to 59 16 50 to 59 18 50 to 59 19
60 to 69 11 60 to 69 13 60 to 69 12
70 to 79 10 70 to 79 7 70 to 79 9
>80 11 >80 4 >80 17
Sources: 1. Department of Health (link), 2. Government Digital Service (link), 3. Directorate of Health (link), 4. Toyo Keizai Online (link), 5. COVID-19 Dashboard (link), 6. Public Health Agency of Sweden (link).

© Oliver Wyman 48
CHILDREN APPEAR BE LESS SUSCEPTIBLE TO INFECTION AND TRANSMISSION
COMPARED TO ADULTS

COVID-19 infection in children

• Children consistently make up less than 2% of Children (0-19) comprised less than 5.2% of the first 7,755
laboratory confirmed cases (link)
total reported case numbers despite making up
nearly a quarter of the world’s population1 Children (0-18) comprised less than 0.8% of 4,695
confirmed cases in the Madrid region (link)
• Although children are less likely to be tested as
Children (0-18) comprised 1.2% of the 22,512 confirmed
their symptoms are less severe than those in cases reported as of 17-Mar (link)
adults, this finding that children are less Children (0-18) comprised 1.7% of 142,082 cases reported
susceptible has been confirmed in countries between 12-Feb to 2-Apr (link)
with widespread community testing such as Children (0-19) comprised 1.3% of 72,314 cases reported
Australia, Iceland and South Korea1,2,3 until 11-Feb (link)

COVID-19 transmission in children A COVID-19-positive child in the French Alps did not
transmit the virus to anyone despite coming into contact
• Children are unlikely to transmit COVID-194 with 172 people (link)
• Evidence cited by the Dutch government No cases of secondary transmission among 735 students
suggests that children play a minor role in the and 128 staff who came into contact with 9 COVID-19-
positive students in school (link)
transmission of COVID-19, as it is mainly spread
between adults and from adults to children5 No cases of secondary transmission occurred from 3
COVID-19-positive children in school, even during high-risk
activities such as music lessons and choir practice (link)

Sources: 1. Royal College of Paediatrics and Child Health (link), 2. CDC (link), 3. medRxiv (link), 4. National Institute for Public Health and the Environment (link).

© Oliver Wyman 49
THE TYPE OF SOCIAL SETTING HAS A SIGNFICANT IMPACT ON TRANSMISSION
PATTERNS

Age-specific social contacts differed across settings

• In Wuhan, COVID-19 transmission in the early

stages mainly took place within households and
public/community places
In households, the In the workplace, social
• According to a study1 of six representative
majority of social contacts were dominated
Chinese cities (including Wuhan), this could be contacts occur between by young and middle-
explained by both households and public/ individuals from different aged adults (23-44 years
community spaces involve intensive contacts age groups old)
between individuals of different age groups
• In contrast, the majority of social contacts in
schools and workplaces occur between
individuals of the same age group
• Another study2 of transmission patterns in China,
found that children 0-14 years old were less In schools, the majority of In public/community
susceptible to SARS-CoV-2 infection than all social contacts occurred spaces, social contacts
other age groups, with individuals over the age between children in the occur between
of 65 most susceptible to infection same age group individuals from different
age groups

Sources: 1. The Lancet (link), 2. Science (link).

© Oliver Wyman 50
 Information as of 01/09/20

SCHOOL CLOSURE POLICIES HAVE VARIED THROUGHOUT THE LOCKDOWN, BUT MOST
COUNTRIES ARE PLANNING TO REOPEN SCHOOLS IN SEPTEMBER

First confirmed case School closure School reopening Planned school reopening
Days
closed* Jan Feb Mar Apr May Jun Jul Aug Sep Oct
France 112
Italy 191
Europe

Norway 60
Spain 176
Sweden 0
UK 162
Bahrain 188
Kuwait 184
Middle East

Oman 170
Qatar 175
KSA 176
UAE 173
Africa

South
159
Africa
WHO declares a Public WHO declares a
Health Emergency of pandemic No government Recommendation Requirement to Requirement to
measures to close schools close some schools close all schools
International Concern
Note (*): number of days from school closure to 31-Aug or school reopening (for France, Norway and South Africa).
Sources: Our World in Data (link) and the University of Oxford (link).

© Oliver Wyman 51
THE SAFE REOPENING OF SCHOOLS HIGHLY DEPENDS ON THE LEVELS OF COVID-19
SPREAD IN THE COMMUNITY

Early on in the pandemic, it appeared that SARS-CoV-2 might behave differently in children, and they were thought to
be less infectious due to their milder symptoms. However, several studies show that, once children become infected,
they are no less infectious than adults. In places with ongoing community spread, spillover of infections to schools is a
serious threat that could further increase community transmission.1

Reopening schools in areas Reopening schools in areas

with low community spread with high community spread

• In South Korea and Australia, schools • In Jerusalem, schools reopened when

reopened when community spread was low1 community spread was high1
• An analysis of 11,000 school-aged children in • 10 days after reopening, a major COVID-19
Seoul found no sudden increase in pediatric outbreak occurred in a single high school that
cases after school reopening2 resulted in the infection of 153 students and
• Similarly, an analysis of school reopenings in VS 25 staff members4
New South Wales found that only 25 out of • 87 additional infections occurred outside the
7,700 schools reported an initial COVID-19 school due to contact with infected students4
infection3 • A leading factor in the mass outbreak was an
• The success of school reopenings in both extreme heat wave (above 40 °C ), during
countries can be attributed to the strong which the school exempted students from
public health response that involved high wearing masks indoors and continuously
levels of testing and effective contact tracing1 operated indoor air-conditioning4
Sources: 1. Nature (link); 2. medRxiv (link); 3. The Lancet Child and Adolescent Health (link); 4. Eurosurveillance (link).

© Oliver Wyman 52
SAFE SCHOOL REOPENING REQUIRES A WELL-COORDINATED STRATEGY FOR LARGE-
SCALE TESTING, EFFECTIVE CONTACT-TRACING, AND ENFORCED ISOLATION

A study in The Lancet focused on the Model estimates at 68% tracing and 18% Model estimates at 68% tracing and 18%
optimal strategy for school reopening testing in a full reopening scenario testing in a part-time reopening scenario
200,000 200,000
• Mathematical modelling was used to
estimate the impact of different
150,000 150,000
school reopening scenarios in the UK
• Results showed that increased levels 100,000 100,000
of testing combined with effective
contact tracing and isolation was
50,000 50,000
crucial to prevent a second wave
• If British schools are reopened in 0 0
September without sufficient levels of
testing and contact tracing, a second
wave is likely to occur in December
2020 Model estimates at 68% tracing and 75% Model estimates at 68% tracing and 75%
testing in a full reopening scenario testing in a part-time reopening scenario
• This second wave would be 2 to 2.3 200,000 200,000
times the size of the first COVID-19
wave in the UK
150,000 150,000
• In the absence of sufficient testing
and contact tracing, a second wave 100,000 100,000
would still occur even if school
children were assumed to be only
50,000 50,000
half as infectious as adults
0 0
Jan-20 Jul-20 Jan-21 Jul-21 Jan-22 Jan-20 Jul-20 Jan-21 Jul-21 Jan-22
Source: The Lancet Child and Adolescent Health (link).

© Oliver Wyman 53
 07. VACCINE TRIALS

01 Latest pandemic developments

02 Viral mutations and comorbidities

03 Second wave prevention

04 National testing policies

05 Governments policy response

06 Re-opening schools

07 Vaccine trials

© Oliver Wyman 54
THE WHO SOLIDARITY TRIAL REDUCES THE TIME FOR TEST TREATMENTS AND
VACCINES BY 80%

SOLIDARITY trial for treatment candidates SOLIDARITY trial for vaccine candidates
• Around 15% of COVID-19 patients require hospitalization, • On 27-Apr, the WHO announced that the SOLIDARITY trial
causing hospitals to become overwhelmed would also focus on vaccine development
• Treatments to reduce hospitalization time and free up • As of 28-Aug, 143 vaccines are under pre-clinical investigation,
hospital beds are in critical need while 33 vaccines are undergoing clinical evaluation
• On 21-Mar, the WHO announced a global megatrial of the Stage of Estimated
four most promising COVID-19 treatments clinical Developer completion
evaluation date
• The aim of this trial is twofold:
i. To repurpose drugs already approved for other diseases, Inovio Pharmaceuticals (link) Apr-21
1
bypassing the years required to develop and test a new drug
ii. To investigate unapproved drugs that have performed well Moderna, Inc. (link) Sep-21
in animal studies against other deadly coronaviruses
1/2 BioNTech SE (link) Aug-20
• The four treatments that will be tested are: Sinovac Biotech Ltd. (link) Dec-20
1. Remdesivir, an unapproved drug that was originally University of Oxford (link) May-21
developed to combat Ebola
Sinopharm Group (link) Nov-21
2. Lopinavir/ritonavir combined, an approved combination
drug used to treat HIV infection Sinopharm Group (link) Nov-21
3. Lopinavir/ritonavir combined with interferon-β, an
unapproved combination developed to treat MERS 2 CanSino Biologics Inc. (link) Jan-21
4. Hydroxychloroquinone and chloroquine, approved drugs
that are used to treat rheumatology conditions and malaria

Sources: Science (link) and the WHO (link 1, link 2).

© Oliver Wyman 55
 AN EFFECTIVE VACCINE AGAINST SARS-COV-2 WILL IDEALLY PRODUCE LASTING
ANTIBODIES

Antibodies against SARS-CoV-2 recognize the virus and allow the immune Background
system to destroy it before it can multiply to vast numbers
• A vaccine stimulates the immune
system to produce antibodies
against a disease
• Antibodies are disease-specific
proteins that tag germs or
infected cells for attack by the
Antibodies immune system
• Efforts to produce a vaccine are
complicated by news that SARS-
CoV-2 antibodies are not long-
lasting
• This means that any potential
vaccine against SARS-CoV-2
would only grant short-term
immunity, requiring repeated
vaccinations over the course of a
year

Sources: CDC (link 1, link 2); New England Journal of Medicine (link); Scientific Animations (link); The Guardian (link); The New York Times (link).

© Oliver Wyman 56
STILL, POTENTIAL COVID-19 VACCINES MUST BE THOROUGHLY TESTED FOR ANY
NEGATIVE SIDE-EFFECTS BEFORE WIDESPREAD ROLLOUT

Current vaccine candidates utilize different parts of SARS-CoV-2, mainly its Background
genetic material (RNA) and surface proteins, to generate antibodies
• Since the SARS and MERS
pandemics of 2003 and 2012,
scientists have warned of the
need for governments to
prioritize the development of
vaccines against emerging
coronaviruses
• Historically, coronavirus vaccine
Hemagglutinin- development has been
esterase dimer
challenged by evidence of
antibody-dependent
Envelope
enhancement (ADE)
RNA • In ADE, the weak binding of
antibodies to a virus enhances
its entry into human cells,
causing more severe infection
Spike glycoprotein • Therefore, it is of the utmost
importance for any vaccine to
undergo all stages of clinical trial
Sources: Financial Times (link); Nature (link); Nature Reviews Microbiology (link); Scientific Animations (link); The New York Times (link). investigations
© Oliver Wyman 57
 Information as of 31/08/20

THE RECENTLY APPROVED RUSSIAN VACCINE BYPASSED PHASE III TRIALS, WHICH
ARE ESSENTIAL FOR IDENTIFYING NEGATIVE SIDE EFFECTS

COVID-19 vaccine candidates currently under development

PRECLINICAL PHASE I PHASE II PHASE III EARLY APPROVAL*

89 vaccines 23 vaccines 14 vaccines 9 vaccines 3 vaccines
CanSino Biologics
Limited military use

Gamaleya
Research Institute
Widespread use

Sinovac Biotech
Limited use

Preclinical testing Phase I safety trials Phase II expanded trials Phase III efficacy trials Early approval
The vaccine is given The vaccine is given The vaccine is given to The vaccine is given to Trial results are
to animals to see if to a small number of hundreds of people to thousands of people reviewed, and the
an immune response people to confirm see if it acts differently to see how many vaccine can be
is produced animal results, test in different age and become infected approved for
safety, and identify ethnic groups compared to people widespread or
required dosage who received a limited use
placebo treatment

Note (*): vaccines have been given early approval before completing Phase III trials.
Sources: Bloomberg (link); The New York Times Coronavirus Vaccine Tracker (link); WHO (link).

© Oliver Wyman 58
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