COVID-19 Vaccination Failure Point Analysis - Deloitte
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COVID-19 Vaccination Failure Point Analysis JULY 2021
Introduction Document Overview Purpose The purpose of this document is to provide a starting point for discussions around the effectiveness of COVID vaccination efforts and key points of failure / leading practices related to logistics. This was developed based on interviews conducted with Deloitte practitioners that have served organizations related to vaccinations across 7 countries, representing counties across North America, EMEA and APAC. Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 2
Document Overview
Contents
Topic Description
Introduction
Points of Failure A detailed look at the potential failure points and leading practices related to COVID-19 vaccine logistics strategy across five key areas
Bottleneck Layers An overview of four bottle neck layers at vaccination sites with corrective and preventative action examples for each
Key Themes A summary of the key themes which emerged during stakeholder interviews related to the vaccination value chain including specific examples from different
regions and organization types
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 3Introduction Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 4
Failure Mode Analysis Framework
Root cause failures for a CV-19 vaccine logistics strategy can be divided into five key areas relating to Manufacturing, Site
Operations, Market Dynamics, Shipping, and Data Management
Primary cause of failure Secondary cause of failure
Manufacturing Site Operations Data Management
Off-shore Stakeholders Refresh Rate
Centralized Location Throughput Eligibility Criteria Scheduling Vaccine Product Experience Level
Strategy Real Time Systems Integration
Facility Patient Readiness
Notification Requirements
Infrastructure Temp
De-centralized On-shore Unforeseen Circumstance Integration w/ Administration
Operating Hours Shutdown Databases Data Formats
Storage Requirements Mgmt System
# of Units Produced Availability Training Location Timing Data Interoperability
Materials Duration
Staff Allocation Collection
/ Delivery Automated Data Analytics
Batch Metrics
Non-compliance w/ Protocols Label / Barcode Driver Access Location Type Throughput Cybersecurity
Documentation Release Schedule Readers
Infrastructure Temp Availability Training Site Strategy
Security
# of CMO’s & Suppliers
Storage Requirements Operating Hours Shutdown Counterfeit
Staff
Vendor Management
Materials Duration Non-compliance w/ Protocols
Root Cause Failures of a CV-19
Vaccine Hesitancy Inventory
Chain of Custody Management
Vaccine Logistics Strategy
Expanded Access Approved EUA Shelf-life Strategy Manufacturing Release
Population Courier Network Organizer
Shipment Window
Marketing License Approval
# of Countries # of Sites Planning & Implementation
Primary Secondary
Clinical Trials / Size
Labelling Contract Broker
Investigational
# of Patients Growth Rate
By End User By Supplier
Other Vax Manufacturers Freight Capacity 2-D Barcode
Export / Import Physical Dimensions Site Management Tracking /Monitoring
Competition / Restrictions
Packaging By Courier By Developer Data Loggers / Temp Probes
Union Strikes Organized Crime
Courier Capacity
Political Affairs Scope of Usage Type Provider Intra-site Handling
Supply Diversions Temp / Humidity
Civil Unrest Cold Storage Distance from Storage to
Natural Disasters Transfer Capability Administration Location
Physical Conditions
Disease Variants Contents
Market Dynamics Shipping / Documentation # of Units Product Format
Distribution
Adapted from Source: "Logistics by design: a framework for advanced therapy developers to create optimal Logistics Platforms," by S. Ellison and R. McCoy, 2018, Cell & Gene Therapy Insights, 2059-7800, p. 1027
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 5Points of Failure Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 6
Point of Failure: Manufacturing
Potential Points Of Failure Leading Practices
Staff / Training AR / VR Training Opportunity
Scaling vaccine manufacturing requires additional resources (especially New technologies have been leveraged to expedite the training process
operators) with the correct certifications and extensive training in order to without sacrificing valuable time on the manufacturing floor
produce vaccines that are releasable
Forward Projection of Deliveries
Vendor Management As vaccine supply and manufacturing capacity stabilize, vaccine
As part of scaling production, several manufacturers have set up new manufacturers are giving governments better forecasts and added
manufacturing networks with CMO’s across the globe, which could prove visibility to their vaccine deliveries, which in turn helps these agencies
difficult to manage from a data visibility and control perspective structure their downstream processes
Batch Metrics Cloud-Based Data Solutions
If vaccine manufacturers are still using paper batch records, the disposition A cloud-based data transfer solution enables manufacturers to
process could be slowed down substantially and cause a bottleneck in the streamline their production process and better coordinate between the
vaccine manufacturing process parent pharma companies and their CMO’s
Strategy Facility Vendor Management
De-centralized Centralized Throughput Operating Hours # of CMO’s & Suppliers
Off-shore On-shore Location Shutdown
Manufacturing
Release Schedule Non-Compliance w/ Availability Temperature Materials
# of Units Produced
Protocols
Documentation Training Infrastructure Duration
Batch Metrics Staff Storage Requirements
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 7Point of Failure: Market Dynamics
Potential Points Of Failure Leading Practices
Vaccine Hesitancy Understand Vaccine Hesitancy
While the reasons behind vaccine hesitancy vary by market and population Rather than supporting a vaccine mandate for employees, employers
group – whether it be mistrust of government, safety concerns, or religious should work with employees to better to understand where the hesitancy
reasons – all vaccination stakeholders will have to combat these notions in is coming from, and then address the different causes
order to reach herd immunity
Personalize Invitations
Making vaccination invitations personalized can be a key tool in boosting
Export / Import vaccine confidence and willingness to get vaccinated
Restrictions on imports / exports of vaccines and related supplies have
become a key concern for both manufacturers and vaccination programs, as
the global scope of the vaccination effort could be hindered by these policies Leverage Community-Based Vaccinators
For indigenous tribes that are more likely to be vaccine hesitant, having
the vaccinator be someone within that tribe or leveraging community
leaders can increase trust in the vaccination process
Natural Disasters & Weather
Governments and public health agencies have been eager to distribute
vaccines as they arrive rather than build vaccine inventories, which means Stockpile Ancillary Supplies to Mitigate Delays
that any disruptions in the supply chain due to weather or other natural Sites have suggested keeping a 20-day stockage of ancillary supplies to
events could lead to shortages and throw off supply forecasts mitigate against supply delays; some sites are ordering a 5% overage on
ancillary supplies (especially needles / syringes) to build this stockpile
Competition / Restrictions Market License Approval Natural Disasters Disease Variants
Other Vax Manufacturers Freight Capacity EUA Expanded Access
Courier Capacity Clinical Trials / Approved
Investigational
Market Dynamics
Growth Rate Union Strikes Organized Crime
# of Sites Vaccine Hesitancy
# of Patients Civil Unrest
# of Countries
Size Population Political Affairs Import / Export
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 8Point of Failure: Site Operations
Potential Points Of Failure Leading Practices
Staff / Training Develop Wait List
As vaccination efforts and vaccine supply have scaled in certain To mitigate appointment no-shows, smaller vaccination sites have
jurisdictions, the next bottleneck sites have hit is finding enough certified developed wait lists for those who can be contacted “last minute” and
and trained vaccinators to administer vaccines are willing to come in and get vaccinated with the extra doses
Expand Scope of Vaccinators
In order to increase the total throughput of a vaccination program
Site Strategy without sacrificing non-COVID related medical care, jurisdictions have
Jurisdictions have voiced concerns around how to select sites that will not leveraged military personnel, pharmacy techs, veterinarians, and other
interfere with other medical efforts (i.e. COVID care and non-COVID related such professions to help administer vaccinations
medical care), will be accessible to large swaths of the population, and will
be able to scale up throughput as vaccine supply increases Utilize Vaccine Supply Control Tower
Certain jurisdictions have used personnel & systems to monitor vaccine
supply at each site and then shift supply between close-by sites to ensure
that maximum throughput is achieved, and no vaccine is wasted
Patient Readiness & Scheduling
For several jurisdictions, the scheduling process and technology are brand Market-Based Site Strategy Approach
new or adapted for COVID, which has made it a pain point across markets. In planning out vaccination sites, some markets have focused on
Patients have booked multiple appointments in some cases, and other leveraging GP offices that are well known and close to the priority
times, due to supply variability, appointments have been cancelled populations, while others have had employers fund and lead vaccination
efforts for their employees & surrounding communities
Patient Readiness Allocation Collection / Delivery Staff
Unforeseen Circumstance Scheduling Specialist Instructions Location Availability
Non-Compliance w/
Eligibility Criteria Driver Access Timing Training Protocols
Site Operations
Type Shutdown Infrastructure Duration
Throughput
Operating Hours Temperature Materials
Location
Vaccine Product
Site Strategy Storage Requirements Experience Lead
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 9Point of Failure: Shipping / Distribution
Potential Points Of Failure Leading Practices
Intra-site Handling Thaw Centrally then Distribute
Last-mile distribution challenges have been a concern across markets and Smaller vaccination sites often do not have the cold storage capabilities
vaccination site types, which is complicated by varied inventory, demand, to keep certain vaccines in inventory, and therefore several jurisdictions
and cold-chain storage capabilities among sites are thawing the vaccines at a centralized hub and then distributing to the
smaller sites
Cold-Chain Logistics
Detailed Cold-Chain Strategy
As the scope of vaccination efforts expand to rural and underdeveloped
To prevent vaccine spoilage due to temp diversions, strategies include
regions, maintaining the cold chain for vaccines is going to be a focal point
putting clear instructions on pallets, QR codes on the vials to track its
for manufacturers and public health agencies alike, as wasted or spoiled
progress, placing an alarm on the storage container, and connecting the
vaccine could hinder the vaccination effort and diminish public confidence
vaccination program’s data infrastructure with temperature tracking
devices
Supply Diversions
Given the high value currently placed on vaccines due to supply vs. the
global demand, it is expected that organized crime and other such groups
will attempt to divert, steal, or counterfeit supply
Physical Conditions Packaging Labeling Shipment Window
Site Mgmt
Supply Diversions Type 2-D Barcode Shelf-Life
Temp / Humidity Physical Dimensions Manufacturing Release
Provider Primary Secondary Inventory Strategy
Shipping / Scope of Usage
Distribution By end user
Documentation Distance from
Storage to By developer Courier Networks
Product Cold Storage By supplier Organizer
Format Administration Data loggers / Contract
# of Units Transfer
Site By courier Temp probes Broker
Capability Chain of Custody
Contents Intra-site Handling Tracking / Monitoring Planning & Implementation Management
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 10Point of Failure: Data Management
Potential Points Of Failure Leading Practices
Data Interoperability National Immunization Registrar
Consolidating and transferring data across stakeholders and systems has Leveraging one centralized database for patient immunization records
been a ubiquitous issue for vaccination programs, which has led to a lack would allow for easy tracking of who has received a vaccine, which
of data visibility (for who has been vaccinated), inaccurate supply vaccine they received, and whether they received the first or second
forecasts, and an inability to perform reporting and analytics
Real-Time Systems Integration Consistent Data Reporting Requirements
Aligning on data reporting and formats would assist jurisdictions in
Due to the de-centralized nature of most healthcare systems’ technology
managing different technology systems between sites and localities, and
infrastructure, getting near real-time data has been almost impossible,
would enable easier data analysis on the back-end
which means that decision-makers are basing their choices off lagged or
inaccurate data
Flexible Technology Solutions
Given the rapid pace to scale up vaccination efforts, technology solutions
which are adaptable and can integrate with various systems, both old and
new, have proven critical to vaccine program success
Data Interoperability Security
Data Formats
Databases Cybersecurity
Integration w/ Administration Counterfeit
Mgmt System
Data Management
Stakeholders
Notification
Requirements
Refresh Rate
Real-Time Systems Integration Automated Data Analytics
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 11Bottleneck Layers Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 12
Bottleneck Layers Identified at Vaccination Sites
Bottleneck Description Corrective Actions Taken Potential Preventative Actions
Sites have limited visibility into • Pharma companies & CMO’s have • Implement inventory strategy that smooths vaccine supply to sites
Vaccine Supply how much supply they will get collaborated to increase supply • Clear communications strategy around allocation decisions & supply
(On-Hand & and when it will arrive, which • Federal governments have increased window forecast
1
Forecast impacts their appt scheduling, for allocation visibility
Visibility) staffing, and overall throughput
There are an increasing number • Leverage military staff (although certification • Adjust / waive regulations to streamline certifications for add’l
Number of of vaccinators needed at sites, will still be an issue) vaccinators
2 Certified which requires getting them • Discontinue certain non-COVID related • Explore capacity of jurisdiction and potential opportunities to expand
certified in the jurisdiction and medical work scope
Vaccinators potentially taking them away
from other medical work
As vaccination efforts expand • Certain jurisdictions have thawed or • Plan cold-storage footprint and distribution strategy (e.g. centralized
outside of population dense reconstituted the vaccine centrally and then store/thaw site)
Cold-Chain areas, there will be increased distributed to the smaller sites • Invest in add’l cold-storage capabilities
3 pressure to maintain the cold • Prioritize vaccines with less restrictive cold-chain req’s to rural /
Storage
chain in places without much smaller areas
storage infrastructure
Jurisdictions will have to find a • Open up GP practices for vaccinations since • Plan and structure vaccination sites to provide access for all populations
balance between maximizing they are usually closer to the desired • Design de-centralized strategy to leverage smaller sites focused on
throughput at vaccination sites populations certain populations (e.g. large places of employment)
Vaccination Site and ensuring all populations will • Leverage mobile sites that can be stood up
4
Accessibility be able to access the site and taken down quickly
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 13Vaccination Levers and Constraints for Government
Overview of Vaccination Levers for Governments to Consider Tradeoffs between Levers
You generally get two without incremental time or
Inventory Control technology investments
UK Start UK Trend Maintaining centralized control of
vaccine inventory to prevent
US Start US Trend vaccination sites from hoarding doses • High Throughput + Inventory Control
In order to keep tight grips on inventory while increasing throughput,
this can ultimately lead to vaccine supply being concentrated in
population dense and affluent areas. These areas have an easily
accessible and willing population as well as the technology infrastructure
to maintain oversight of vaccine supply, but at the expense of vaccine
Connected distribution equity.
Levers in
Vaccination • Equitable Distribution + Inventory Control
Effort Pushing equitable distribution of vaccine is already a difficult task given
the discrepancy in resources available to different populations, but also
adding in the layer of inventory control makes the process even more
tedious. It will be more difficult to scale up throughput across the
country while still maintaining both equity and oversight
High Throughput + Equitable
Distribution
• High Throughput + Equitable Distribution
A focus on maximizing throughput and equitable distribution will mean
that the government will most likely have to “open the floodgates” for
vaccine distribution and enroll a higher number of vaccine providers.
Vaccination Volume Distribution Equity This lack of control could lead to wastage, fraud, and hoarding and the
Ensuring that vaccines are being
Driving the highest throughput for country would be more impacted by manufacturing delays or other
distributed and administered equitably
vaccinations by closing the gap between supply shocks
across population demographics and
doses available and doses administered
rural / urban areas
It is important for governments to clearly define and communicate the priorities of their vaccination program to inform their vaccine distribution strategy and
gain public trust
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 14Key Themes Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 15
Four themes have emerged as we’ve spoken to Deloitte stakeholders
Bottleneck Access & Willingness Staffing & Resource Availability Emergency Preparedness Ecosystem Management
& Planning
Is there enough vaccine supply for the Are there enough certified vaccinators Is there a backup plan in case of weather How does data flow between public and
population, do the vaccination sites to meet demand, do stakeholders delays or natural disasters, do sites have private stakeholders, who is responsible for
reach all populations, and does the have enough staff to keep up with processes in place in case of equipment maintaining the vaccination systems, and
population want to get vaccinated data reporting requirements or technical failure, and how to mitigate how are decisions made between local and
and logistics against fraud, theft, and counterfeit federal stakeholders
• Market Dynamics • Manufacturing • Manufacturing / Site Operations • Manufacturing
− Population − Staff, Strategy − Facility − Vendor Management
Primary Causes • Site Operations • Site Operations • Market Dynamics • Site Operations
of Failure − Facility, Patient Readiness − Staff, Strategy − Natural Disasters − Intra-site handling
• Data Management
• Shipping − Data interoperability, real-time
− Physical Conditions, systems integration
Shipment Window
• Population • Staff (Manufacturing) • Facility (Manufacturing / Site Ops) • Vendor Management
− Vaccine Hesitancy − Availability, Training − Shutdown − # of CMO’s and Suppliers
Secondary • Facility • Strategy (Manufacturing) • Natural Disasters (Market Dynamics) • Intra-Site Handling
Causes of − Location, Operating Hours − Offshore, De-Centralized Physical Conditions (Shipping) − Cold-Storage Transfer Capability, Distance
− Payload shock, temp / humidity from Storage to Site
Failure • Patient Readiness • Staff (Site Operations)
− Eligibility Criteria, Scheduling − Availability, Training • Shipment Window (Shipping) • Data Interoperability
− Shelf-life, manufacturing release − Databases, Data Formats
• Facility (Site Operations) • Real-Time Systems Integration
− Type, Throughput − Stakeholders
Stakeholders • Federal & Local Health Agencies • Vaccine Manufacturers • Vaccine Manufacturers
• Vaccine Manufacturers
Impacted • Vaccination Sites • Federal & Local Health Agencies • Federal & Local Health Agencies
• Federal & Local Health Agencies
• Healthcare Providers • Vaccination Sites • Vaccination Sites
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 16Access & Willingness
Is there enough vaccine supply for the population, do the vaccination sites reach all populations, and does the population
want to get vaccinated
What we’ve heard around…
Vaccine Supply & Forecasts Vaccination Strategy Vaccine Hesitancy
• Supply has been very unstable with certain • We are leveraging 15 smaller vaccination sites and then the local • Our mobile unit has only 25% of the 75+ population we
vaccines. We are working on a two-week forecast pharmacies, which is a different strategy from testing where we targeted signed up for vaccination. This can be attributed to a
window, and that has led to stakeholder used mass sites. We have found it is more effective to have lack of computer literacy, promotion / comms failure, and
management challenges – EMEA Vax Site places close to people so they can walk – EMEA Vax Site general distrust – USA Vax Site
• Since governments are not keeping inventory of • Companies are reluctant to allow employee downtime for • Important to get community leaders onboard, but not always
vaccines, any shipping delays will be a bigger deal vaccination, so they want the programs brought to them. going to be easy. Our team went to one church and the pastor
and will have an immediate impact on vaccine Logistically, this has been a lot easier with larger corporations, said he would tell his congregation not get vaccinated – USA
supply – Vax Manufacturer so they are seeing higher allotments of vaccine – EMEA Vax Vax Site
Stakeholder
• We have the opposite issue to shortages – vaccine • For the most part, our indigenous populations will be hesitant
supplies are arriving at a rate faster than expected, • Communication to eligible individuals has been a bottleneck, as to get vaccinated unless it is done by someone in their tribe –
so our initial user volume assumptions are broken we currently send personalized invitations via mail – EMEA Vax APAC
and has led to technology scaling issues – APAC Vax Stakeholder Vax Stakeholder
Stakeholder
• Our government has struggled to determine when is the right
time to address vaccine hesitancy: should we start now or
wait until supply ramps up? – EMEA Vax Stakeholder
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 17Staffing & Resource Availability
Are there enough certified vaccinators to meet demand, do stakeholders have enough staff to keep up with data
reporting requirements and logistics
What we’ve heard around…
Number of Vaccinators Stakeholder Management Resource Training
• A federal agency came in and staffed their site with • It is amazing how users can find ways to not follow standard • Call center staffing and training has been a large burden,
military vaccinators, but it was difficult going operating procedures, leading to data issues such as recording especially when dealing with people who are not computer
through the bureaucracy of the state’s certification two vaccinations against the same individual. This shows the literate – USA Mass Vax Site
process to make sure everyone has the same need to human-proof the technology – APAC Vax Stakeholder
• For operators, training has been a big concern in terms of
training / licenses – USA Vax Site
• Stakeholder management and internal communication has scaling vaccine production. Batches cannot be released if the
• Currently vaccinators are only certified healthcare been a key concern, as there have been patients arriving at operator does not have certain certifications, which can take a
personnel (e.g. doctor, nurse), but there is vaccination sites which are not prepared to serve them – EMEA long time to obtain – EMEA Mfg Stakeholder
increased momentum to include pharmacy workers Vax Stakeholder
as well – EMEA Vax Site
• We originally underestimated the number of
vaccinators required, which has led to staffing
issues and a lack of clarity around processes –
EMEA Vax Stakeholder
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 18Emergency Preparedness & Planning
Is there a backup plan in case of weather delays or natural disasters, do sites have processes in place in case of equipment
or technical failure, and how to mitigate against fraud, theft, and counterfeit
What we’ve heard around…
Supply Delays Equipment Failures Fraud, Theft, & Counterfeit
• Weather has been a huge factor on logistics, as • It has been a rare occurrence, but in a few instances the site • In middle-income countries, we have already seen issues
there have been weeks we receive no doses and had needles & syringes that were failing as part of the ancillary around diversions of supply and counterfeit. This will require
others where we receive double the number of materials package from federal government. Therefore, the site more investment to keep supply chain secure –
doses – USA Mass Vax Site order always includes a 5% overage – USA Mass Vax Site Vax Manufacturer
• Our site keeps a 20-day stockage of ancillary
supplies to mitigate against supply delays – USA
Mass Vax Site
• Our government was originally building a vaccine
inventory buffer to mitigate supply variability, but
then had to end the effort due to political pressure
– EMEA Vax Site
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 19Ecosystem Management
How does data flow between public and private stakeholders, who is responsible for maintaining the vaccination systems,
and how are decisions made between local and federal stakeholders
What we’ve heard around…
Data Interoperability Data Ownership Stakeholder Responsibilities
• The jurisdiction’s scheduling tool was not built to • We have had a lot of confusion around which systems we should • Even now we are still trying to figure out the governance
interface with other systems, which has led to be using, who should be trained, and who should have access – structure between federal and local agencies. Usually, all
issues around false links / appointments being USA Vax Site healthcare policy decisions are centralized, and the local
made as well as an inability to pull data out on the agencies are responsible for implementing the policy – APAC
• With separate and independent supply chains set up across the
back end to do analysis – USA Vax Site Vax Stakeholder
globe, it has been difficult to determine what data is in their
• Each local health agency has their own system for control and what isn’t – Vax Manufacturer • The federal government put all the last-mile responsibility on
logging administration data, and there is very little local agencies and did not assist with facilitating the data
• Data regulations have been inhibiting the exchange of data
data interoperability with federal systems, which exchange, which has made the process increasingly difficult –
across the country and between medical professionals and
could be a big issue as they scale – APAC EMEA Vax Site
government stakeholders – EMEA Vax Site
Vax Stakeholder
• The federal & local systems do not connect, which
has resulted in manual efforts to ask for data and
switch it over to the other system – EMEA Vax Site
Copyright © 2021 Deloitte Development LLC. All rights reserved. COVID-19 Coalition 20This presentation contains general information only and Deloitte is not, by means of this presentation, rendering accounting, business, financial, investment, legal, tax, or other professional advice or services. This presentation is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional advisor. Deloitte shall not be responsible for any loss sustained by any person who relies on this presentation. About Deloitte Deloitte refers to one or more of Deloitte Touche Tohmatsu Limited, a UK private company limited by guarantee (“DTTL”), its network of member firms, and their related entities. DTTL and each of its member firms are legally separate and independent entities. DTTL (also referred to as “Deloitte Global”) does not provide services to clients. In the United States, Deloitte refers to one or more of the US member firms of DTTL, their related entities that operate using the “Deloitte” name in the United States and their respective affiliates. Certain services may not be available to attest clients under the rules and regulations of public accounting. Please see www.deloitte.com/about to learn more about our global network of member firms. Copyright © 2021 Deloitte Development
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