Supplementary Training Modules on Good Manufacturing Practice World Health Organization Supplementary Training Modules on Good Manufacturing Practice 31 March, 2017 Sterile Pharmaceutical Products This module deals with the important topic of the production of sterile pharmaceutical products. It is a full day session module divided into three roughly equal parts as follows: General points: Premises, equipment, sanitation, personnel Processing Methods of sterilization and Quality Control In each case, there will be 15-40 minutes of presentation, 45 minutes discussion in groups and 30 minutes feedback to the whole group. There will be two tests covering the whole module that will be taken at the end of the day (or at the start of the next day as appropriate). All that can be achieved with this module is a very basic introduction to the topic. Separate courses lasting several days are needed to cover properly such issues as moist heat sterilization. Annex 6. TRS 902, 2002

World Health Organization Sterile Production World Health Organization 31 March, 2017 Objectives To review basic GMP requirements in the manufacture of sterile pharmaceutical products To review air classifications for activities related to the manufacture of sterile products To review the different types of sterilization methods To review quality assurance aspects in the manufacture and control of sterile products To consider current issues applicable in your country The first objective of this module is to identify and understand the key issues and GMP requirements relating to sterile product manufacture. This type of manufacturing is one of the most complex in the industry. The critical nature of the products in question make this a very important subject indeed. The second objective is to review air classifications for activities related to the manufacture of sterile products. The third is to review the different types of sterilisation methods and the forth is to review quality assurance aspects in the manufacture and control of sterile products We shall also consider current issues applicable in your country.

World Health Organization Sterile Production World Health Organization 31 March, 2017 GMP Requirements for Sterile Products Additional rather than replacement Specific points relating to minimizing risks of contamination microbiological particulate matter pyrogen The first point to be emphasized is that GMP requirements for sterile products are additional to the usual requirements for pharmaceutical manufacture, rather than a replacement for them. The WHO GMP text deals with this subject in a supplementary guideline. The emphasis of all the extra requirements for sterile production is to minimize the risks of contamination by particulates, microorganisms or pyrogens. This is because sterile products are administered to particularly sensitive parts of the body, whether intravenously or intramuscularly as an injection, as an eye ointment or as a wound dressing.

World Health Organization Sterile Production 31 March, 2017 General Considerations Production in clean areas Appropriate standard of cleanliness Filtered air supplied Airlocks for entry Personnel and/or equipment Materials Separate areas for operations component preparation (containers and closures) product preparation, filling, sterilization, etc. A general requirement for the manufacture of sterile products, is that production must be done in clean areas. The manufacture of the products should take place in areas of appropriate standards of cleanliness. We will go into more details on this later. The areas should have air supplied through appropriate filters e.g. HEPA filters. Entry to these areas are through airlocks for personnel and/or equipment, and airlock for goods or materials. There are different operations to be carried out. This includes component preparation, product preparation and filling. Separate areas for these operations are needed. 1.1 – 1-2

World Health Organization Sterile Production 31 March, 2017 Premises Design Avoid unnecessary entry of supervisors and control personnel Operations observed from outside In clean areas, all exposed surfaces: Smooth, impervious, unbroken Minimize shedding and accumulation of particles, microorganisms Permit cleaning and disinfection No uncleanable recesses, ledges, shelves, cupboards, equipment Sliding doors undesirable False ceilings sealed Let us start by looking at some of the recommendations for premises. There are a number of specific requirements for premises that are used for the manufacture of sterile products. Unnecessary entry to all processing areas should be avoided. The design of the premises should support this. It should be possible to observe operations from the outside. Processing takes place in suites of rooms with different classifications, depending on the activities carried out in them. The classifications relate primarily to the supply of air to the rooms. We will be looking at this topic in more detail in the second part of this session. Assess whether the rooms are designed to reduce the accumulation of dust, with all exposed surfaces being smooth, impervious and unbroken. (The trainer may want to show the slides of photographs of suitable and unsuitable premises and finishing). There should also not be excess equipment, cupboards or tools in the area. Doors should also be suitably designed and sliding doors should be avoided in sterile product manufacturing areas, as these cause areas where it is difficult to clean. Ideally there should be false ceilings, which are sealed so that no dirt can fall from the void above. This should also permit access to light fittings from above allowing maintenance without stopping production. Wherever possible, pipes and ductwork should be outside the area, or boxed in. 9.1 – 9.6

World Health Organization Sterile Production 31 March, 2017 Premises In clean areas, all exposed surfaces (2): Proper installation of pipes and ducts, no recesses, no unsealed openings Sinks and drains avoided, and excluded in Grade A and B areas Where installed, design, location, maintenance Effective cleanable traps Air breaks preventing backflow Floor channels open and easily cleanable Wherever possible, pipes and ductwork should be outside the area, or boxed in. Sinks and drains should be avoided if possible and must not be installed in aseptic areas. Drains should have cleanable traps and air breaks to prevent back flow. Floor channels must be open and easy to clean. 9.6.

World Health Organization Sterile Production 31 March, 2017 Premises Changing rooms Designed as airlocks Effective flushing with filtered air Separate rooms for entry and exit desirable Hand washing facilities Interlocking system for doors Visual and/or audible warning system Use filtered air supply to maintain pressure cascade Pressure differential approximately 10 to 15 Pascales Zone of greatest risk – immediate environment Entry to all processing areas should be through airlocks. For personnel, these airlocks generally take the form of changing rooms that have a variable number of interconnecting rooms, depending on the grade of the area. Ideally, separate airlocks should ideally be provided for the entry of materials into the area. Airlocks should be flushed with filtered air. In some facilities, there are different airlocks for entry to and exit from manufacturing areas. This can promote unidirectional flow of personnel and material. Hand washing facilities should only be provided in change rooms, and not in production areas. Filtered air should be supplied to the areas and in such a manner, that the pressure cascade is maintained. There should normally be a pressure differential of 10 to 15 pascal between areas of lower and higher risk. The supply of suitable quality air to sterile manufacturing areas, is very important. Filtered air under positive pressure should be supplied to production areas of sterile products. Verify whether the manufacturer has validation data of aspects relating to airflow patterns, and warning systems indicating failure of air supply (e.g. manometers measuring pressure differentials, or an audible alarm).Check the configuration and maintenance of HVAC and filters. The pressure differentials between areas should be monitored and recorded in accordance with written SOPs. (Note: Trainers should explain with the aid of a flip chart and drawings, suitable layout of premises, indicating air supply and return to areas, desired air flow patterns, design and purpose of air locks, and the concept of pressure differentials between different areas). 9.7 – 9.9

World Health Organization Sterile Production 31 March, 2017 Premises Pathogenic, highly toxic, radioactive materials Pressure cascade may be different Decontamination procedures – air, equipment, garments Qualification including airflow patterns No risk to the product Warning system to indicate failure in air supply Pressure indicators – results regularly recorded Restricted access – e.g. use of barriers When highly toxic materials are processed, the pressure differential should be such that there is no risk to the product, and no risk to the operators and external environment. In addition, decontamination procedures should be followed (e.g. penicillins, cytotoxic substances). This could be chemical or a combination of air showers and the use of chemical substances. Validation and qualification are essential in the manufacture and control of sterile products, equipment, and premises. Failure in utilities' performance can result in contamination of the products. Warning/alarm systems can assist in indicating failure of air supply. Pressure indicators such as gauges can should be in place to enable monitoring of the pressure cascade. 9.9 – 9.12

World Health Organization Sterile Production 31 March, 2017 Equipment Conveyer belts Effective sterilization of equipment Maintenance and repairs from outside the clean area If taken apart, resterilized before use Use clean instruments and tools Planned maintenance, validation and monitoring Equipment, air filtration systems, sterilizers, water treatment systems You should also check whether the manufacturer uses conveyer belts that pass through a clean and dirty area, to convey components or products. This can only be allowed if the conveyer belt is sterilised before moving into the clean area. Equipment for use in the sterile area should be designed so that it can be operated with the minimum of personnel interference, thus reducing the possibility of contaminating the product. It should also be easily sterilized by moist or dry heat sterilization. Sterilizers should be designed with a door at each end (known as double door autoclaves or double- ended autoclaves) to eliminate the possibility of mixing up sterile and non-sterile materials. This is particularly important for sterilizing components that are going into the filling room. They are loaded in the preparation area and unloaded in the sterile area, although preferably in a buffer room rather than directly in the filling room. It is important that the zone in which the product is to be exposed is protected to the maximum extent possible. This requires the installation of laminar airflow cabinets over the piece of equipment, to ensure a supply of filtered air flowing with positive pressure towards the surrounding areas. It is also necessary to ensure that the locations of the equipment and the operator do not cause a risk to the product by interrupting the flow of filtered air. Where possible, maintenance and repairs of equipment should take place outside the area. However, if this is impossible, it should be done when there is no work going on and should be followed by a complete clean down and disinfection. Tools for such work should be sterilized before being taken into the area. It is even better if a full set of sterilized tools can be stored in the area specifically for this purpose. After maintenance has been completed, there should be a documented procedure for obtaining approval to resume operations in the area. It is permissible to have transport systems to take product from the filling room to the sterilization/finishing area, but there must be a physical barrier across the actual interface between the two areas. 10.1 – 10.5

World Health Organization Sterile Production 31 March, 2017 Equipment Water treatment plants and distribution system Design, construction, maintenance Operation and design capacity Testing programme Water for Injection (WFI) Produced, stored, distributed – prevention of growth of microorganisms Constant circulation at temperature above 70, or not more than 4 degrees Celsius Water of appropriate quality should be supplied by a water treatment plant that is suitably designed, constructed and maintained. You should evaluate the water treatment plant in terms of maintenance and qualification, as well as the monitoring of the quality of the water. The production, storage and distribution of water should be done in such a way that microbial growth is prevented. Evaluate the SOP for water sampling and review the results of the water testing. You should also check the deign of the water treatment plant, the distribution and storage of water. If water is stored in a tank, then the temperature should be kept at about 70 degrees Celsius. Refer the participants also to the additional training module on Water systems. 10.6

World Health Organization Sterile Production World Health Organization 31 March, 2017 Environmental Monitoring - I Microbiological Air samples Surface swabs Personnel swabs The first aspect of microbiological monitoring of the environment relates to the air supplied to the rooms. There are a number of methods for taking samples, but the simplest and most widely used is to place open settle plates of growth medium on the floor for around 2 - 4 hours. (The exact time period has to be developed to suit local conditions – a validation protocol and report should be inspected). The exposure time should not be too short as non-representative results will be obtained. If the exposure time is too long, then the plates can dry out. The number of plates required depends on the classification and use of the room, and can be determined from international standards. The location of the plates will have been determined during validation and will be based on the risk to the product and the level of activity in the area. It is not necessary to obtain zero-growth results from these plates, but a validated pattern of likely contamination will be established and significant deviations need to be investigated. If zero growth is observed, then low levels of bacteria are inoculated onto the plate to demonstrate that it will support growth. Monitoring of surfaces is generally carried out using swabs. Emphasis should be placed on the areas that come into contact with the product. In these areas, zero-growth results are expected. This method of monitoring, carried out before and after cleaning and disinfecting can be used to validate the methods being used. Finally, it is necessary to monitor the micro-organisms that could be shed from the personnel in the clean rooms. Personnel can be the greatest source of contamination. Samples are generally taken by swabs from clothing and by “finger-dabs” onto plates. Sampling should be representative of the situation during operations. So, if the operator normally wears gloves and disinfects them before use, the samples should be taken afterwards. Review the SOP and records of results during your inspection. The trainer can also expand on the current recommendations for monitoring, as reflected in other guidance documents.

World Health Organization Sterile Production World Health Organization 31 March, 2017 Environmental Monitoring - II Physical Particulate matter Differential pressures Air changes, airflow patterns Clean-up time/recovery Filter integrity Temperature and relative humidity Airflow velocity The ventilation systems used to supply air to clean rooms have already been referred to. We shall now look at the physical monitoring that is carried out on these systems. Particulate matter counts are carried out with a particle counter that measures the number of particles in a given quantity of air. They should be carried out during validation and at regular intervals thereafter. You can consult ISO 14644 for more details on the methods and locations for monitoring particles. The differential pressures between rooms are measured by means of manometers. The manometers should be calibrated and should provide continuous monitoring. Values should be recorded regularly. The number of air changes within a room is calculated from the air volumes supplied to the room. The calculation should be made during validation and regularly thereafter. The HEPA filter integrity is tested by a number of means. An aerosol generator can be used to send an aerosol across the filter and a photometer used to view it. This will show whether there is any damage to the filter. Additionally, a manometer can be used to measure the pressure differential across the filter. These tests should be carried out when filters are installed and repeated at regular intervals (at least annually). Again, you should verify compliance with this by reviewing the SOP and records to assess compliance with the SOP. The temperature and humidity can be measured by a variety of instruments from the very simple to the very complex. Several of the above parameters can be monitored automatically, and new factories often have sophisticated building management systems (BMS) that not only monitor, but also make adjustments if required. If you are inspecting a factory with such a system, it is worth spending some time checking on the understanding of the personnel regarding this system. It can be all too easy to assume that everything is under control and not notice when something goes wrong. Establish whether any validation had been done to ensure that all the controls and monitors are working as intended?

World Health Organization Sterile Production 31 March, 2017 Sanitation Frequent, thorough cleaning of areas necessary Written programme Regular monitoring to detect resistant strains of microorganisms Chemical disinfection Monitoring of disinfectants and detergents Dilutions Clean containers, stored for defined periods of time Sterilized before use, when used in Grade A or B areas A high level of cleanliness is required in clean areas. Frequent, thorough cleaning of areas necessary according to a written program should be done. Regular monitoring to detect resistant strains of micro-organisms should be done. A program for chemical disinfection and corresponding records should be available. Manufacturers also have to monitor disinfectants and detergents for effectiveness. Preparation of dilutions should be done in accordance with a program and SOP - and records should be available. Disinfectants should be kept in clean containers and stored only for defined periods of time. These should be sterilized before use, when used in Grade A or B areas 3.1 – 3.2

World Health Organization Sterile Production 31 March, 2017 Sanitation Monitoring of clean areas Monitoring of personnel and surfaces after critical operations Frequent monitoring in areas where aseptic operations are carried out Settle plates, volumetric air samples, surface sampling (swabs and contact plates) Sampling methods should not contaminate the area Results considered when batch release is done Monitoring of clean areas, of personnel and surfaces after critical operations should be done. Frequent monitoring should be done in areas where aseptic operations are carried out. Monitoring further includes the use of settle plates, volumetric air samples, surface sampling (swabs and contact plates). Review the SOP to see how the samples are taken, as the sampling methods should not result in contamination of the area. Results if the monitoring should be considered when batch release is done 3.3

World Health Organization Sterile Production 31 March, 2017 Sanitation Limits of detection established Alert and action, and monitoring trends of air quality Table 1. Limits for microbial contamination (Information only) 3.4 The manufacturer should have alert and action limits, and should monitor the trends of results of air quality. The table gives some guidance of limits of microbial contamination when samples are taken.

World Health Organization Sterile Production 31 March, 2017 Personnel Minimum number of personnel in clean areas Especially during aseptic processing Inspections and controls from outside Training to all including cleaning and maintenance staff Initial and regular Manufacturing, hygiene, microbiology Special cases Supervision in case of outside staff Decontamination procedures (e.g. staff who worked with animal tissue materials) Personnel play an important part in ensuring the quality of manufacture. It is also relevant (perhaps in particular) in the manufacture of sterile products. Only a minimum number of personnel should work in clean areas, especially during aseptic processing. As far as possible, all inspections and controls should be done from outside the production rooms. Training should be given to all including cleaning and maintenance staff, and should include initial and regular training on manufacturing, hygiene, and microbiology. Look at the procedure for training, training program, training material and assessment of the personnel. In special cases, when outside staff have to enter the clean areas, they should be supervised. Remember also the previous discussion on decontamination procedures (e.g. staff who worked with animal tissue materials). 8.1 – 8.3

World Health Organization Sterile Production 31 March, 2017 Personnel High standards of hygiene and cleanliness Periodic health checks No shedding of particles No introduction of microbiological hazards No outdoor clothing Changing and washing procedure No watches, jewellery and cosmetics Personnel working in clean areas should maintain high standards of hygiene and cleanliness. They should undergo periodic health checks, wear clothing that do not shed particles, and should take care not to introduce microbiological contaminants in the areas. No outdoor clothing should be brought into clean change rooms. Personnel should follow changing and washing procedures, wear no watches, jewellery and cosmetics 8.4 – 8.6

World Health Organization Sterile Production 31 March, 2017 Personnel Clothing of appropriate quality: Grade D hair, beard, moustache covered Protective clothing and shoes Grade C Hair, beard, moustache covered Single or 2-piece suit (covering wrists, high neck), shoes no fibres to be shed Grade A and B Headgear, beard and moustache covered, masks, gloves No shedding of fibres, and retain particles shed by operators The WHO GMP text specifies the type of clothing that is appropriate for the different grades of rooms. 8.7

World Health Organization Sterile Production 31 March, 2017 Personnel Outdoor clothing not in change rooms leading to grade B and C rooms Change at every working session, or once a day (if supportive data) Change gloves and masks at every working session Disinfect gloves during operations Washing of garments – separate laundry facility No damage, and according to validated procedures Garments should be changed at every working session, or once a day (if supportive data exist through validation studies). Gloves and masks should be changes at every working session Personnel should disinfect their gloves frequently during operations to prevent possible introduction of contaminants (micro) into the areas where they work or touch. Arrangements must be in place for the laundering and sterilization of clean-room clothing. This should be carried out in a controlled environment. If fibres are damaged due to inappropriate cleaning or sterilization, an increased risk for contamination may develop as clothing could shed particles. The use of contract laundries for this purpose, requires an audit by the company to ensure that appropriate procedures are in place. 8.8 – 8.9

World Health Organization Sterile Production 31 March, 2017 Group session 1 You are asked to visit a factory producing the following product lines: Injections in ampoules and vials, including insulin, vaccines and heat-stable pharmaceuticals Sterile eye ointment Describe the type of facility you would expect to find List the typical rooms, their purpose and air classification

World Health Organization Sterile Production 31 March, 2017 Possible Issues Poor design of the building Poor design of the systems, e.g. water, HVAC Flow of personnel Flow of material No validation or qualification Old facilities not complying with current requirements

World Health Organization Sterile Production 31 March, 2017 Possible Issues (continued) Particulate levels/microorganisms Differential pressures Air changes Temperature/humidity

World Health Organization Sterile Production 31 March, 2017 Two categories of manufacturing operations: Terminally sterilized prepared, filled and sterilized Aseptic preparation some or all stages There are two main categories of manufacturing operations, relating to the methods of sterilization: The nature of the product determines the manufacturing and sterilization requirements, as we will see later on. The types of sterilization are listed on this slide. The first type is terminally sterilized products. These are products that are tolerant to sterilization in their final containers. This usually means they are process tolerant; for example, they are stable when exposed to heat or gamma-irradiation, so they can be manufactured and filled under clean rather than aseptic conditions. The key task here is to reduce the bioburden to a minimum so that the challenge to the sterilization process will be as low as possible. This is the method of choice for sterile manufacture where possible. Some materials and products cannot be terminally sterilized by exposing them to heat. They are manufactured under clean conditions, and then filtered into containers in the filling room where they are filled under aseptic conditions. All components, such as primary containers, must be sterilized before they are introduced into the filling area. Sterile filtered production should only be considered if all methods of terminal sterilization are impossible. Some products are produced from sterile starting materials. In this case, manufacture and filling are both carried out under aseptic conditions, with components sterilized before use. 1.3

World Health Organization Sterile Production 31 March, 2017 Manufacture of sterile preparations Classification of clean areas Manufacturing operation in an appropriate environment cleanliness level Minimize risks – particulate and microbiological contamination – product and material Meet classification "at rest" (i.e. "completed installation, equipment installed and operating, but no operating personnel present"). During the inspection, you have to verify that the operations for the manufacture of sterile products are carried out in the correct grade or class of air. Precautions should be taken to prevent possible contamination with particulate matter and microorganisms. This applies to products, materials including primary packaging materials. The manufacturer should demonstrate that the areas meet the required classification, This must be done through monitoring including particles and microorganisms. Normally, this is done while the area is "at rest". Monitoring should also be done during operations. 4.1

World Health Organization Sterile Production 31 March, 2017 Manufacture of sterile preparations For sterile pharmaceutical preparations: Grade A Local zone, high risk operations, e.g. filling, aseptic connections Usually UDAF systems used Grade B Background environment to grade A (in case of aseptic preparation and filling) Grade C and Grade D Clean areas for less critical operations Operations should be done in areas as follows: Grade: This is the critical zone, and high risk operations should be carried out in Class A areas including filling and aseptic connections. Usually, Unidirectional Air Flow is used to achieve the required class with appropriate filtration of air (e.g. HEPA). Grade B is normally the background to Grade A areas. 4.1

World Health Organization Sterile Production 31 March, 2017 Air Classification System This table is taken from the WHO GMP text and describes four classifications A - D. The different grades are defined in terms of the maximum permitted number of particles per cubic metre of air (at two different sizes). The WHO text also contains values for microbial contamination of the various grades. They have been included in the text for information and are not intended to represent specifications. We will talk later about how these characteristics are measured. They are attained by means of a ventilation system in which air is passed through a series of filters. The generally accepted design is for two pre-filters and a HEPA (high efficiency particulate air) filter at the outlet into the room. The air inlet is usually located at a high level in the room, whereas the extract is at a low level. The filtered air supply must be maintained at positive pressure to the surrounding areas. Airflow patterns must be designed so that they do not distribute particles into the area where the product is exposed. An alarm system, in the case of air supply failures, should be installed. During the inspection, you have to evaluate records and results from the manufacturer in which it is established and proven, that a claimed grade is achieved. 3.1

World Health Organization Sterile Production 31 March, 2017 Manufacture of sterile preparations To reach Grade B, C and D, the number of air changes should be appropriate to the size of the area, number of personnel, equipment present Minimum of 20 air changes per hour Clean up time about 15-20 minutes Good airflow pattern in the area HEPA-filtered air Suitable methods to determine particulate matter and micro- e.g. EU, ISO, Japan, USA To reach Grade B, C and D, the number of air changes should be appropriate to the size of the area, number of personnel, and number and type of equipment present. A minimum number of 20 air changes per hour and a clean up time of about 15 – 20 minutes is recommended. A good air flow pattern in the area is necessary and should eb proven e.g. by means of a smoke test. HEPA filtered air should be supplied to the areas. Suitable methods to determine particulate matter and micro should be used as described in various guidelines E.g. EU, ISO, Japan, USA 4.1 – 4.2.

World Health Organization Sterile Production 31 March, 2017 Manufacture of sterile preparations Control particulate during operation Monitoring during operation Alert and action limits for particulate and micro Action taken when exceeded Area grades should be proven (e.g. validation runs, media fills, environment, time limits – based on microbiological contamination/bioburden found) The manufacturer should control particulate matter during operation to prevent contamination of the product. Therefore, to assist and ensure control, monitoring during operation is necessary. As there are alert and action limits for particulate and micro defined by the manufacturer, the operators have to stop working in case the condition is out of limits. Action should be taken when the limits are exceeded, e.g. cleaning and/or sanitization. Area grades should be proven through qualification and validation (e.g. validation runs, media fills, environment, time limits). Limits should be based on microbiological contamination/bioburden found. 4.3 – 4.5

World Health Organization Sterile Production 31 March, 2017 Airborne particulate classification This table gives a comparison of the various classifications for areas in terms of airborne particulate classification 4.1

World Health Organization Sterile Production 31 March, 2017 Processing Minimise contamination – all stages including before sterilization and during processing No unsuitable materials, e.g. live microbiological organisms Minimize activities staff movement controlled and methodical avoid shedding of particles Temperature and humidity comfortable Containers and materials in the area At all times during processing, there should be measures to ensure that contamination of product, material and components, is minimized. No unsuitable materials should be used in the areas. All furniture and fittings should be of metal or plastic rather than wood. Paper may need to be used in the area, e.g. for batch documentation, but this should be kept to a minimum. Bonded paper or lint-free paper is available. Paper should not be used in a grade A area at all. Alternatives include plastic sheets and permanent markers. It goes without saying that extras such as calendars and notices should be excluded. The processing of preparations containing live micro-organisms is not allowed in the same facility as other pharmaceuticals. Products with dead organisms can be processed in the same facility providing validated procedures for inactivation and cleaning are used. During processing in sterile areas, it is important that the amount of activity is kept to a minimum. This is one area where you will have to spend time to observe the activities of the personnel.The greatest source of contamination in a sterile area is the personnel. Validated automization of processes with fewer people in the area, could minimise the risk of contamination. Processing areas should be built with plenty of inspection (glass) windows to limit the number of persons who need to go into the room during processing. The temperature and humidity in the areas should be controlled to ensure that the integrity of materials is mainteianed, and the operators are also comfortable (considering the nature of the garmetns they should wear in the areas). No unsuitable materials should be used in the areas. All furniture and fittings should be of metal or plastic rather than wood. Paper may need to be used in the area, e.g. for batch documentation, but this should be kept to a minimum. Bonded paper or lint-free paper is available. Paper should not be used in a grade A area at all. Alternatives include plastic sheets and permanent markers. It goes without saying that extras such as calendars and notices should be excluded. The microbiological contamination load or bioburden for starting materials prior to sterilization should be kept to a minimum. There should be limits when monitoring has shown that they are needed. Extreme care must be taken with materials that have been sterilized in the area for use in aseptic production, such as primary containers and filling machine parts. After removal from the sterilizer, they should be stored in a way which maintains their sterility (examples: in laminair airflow, triple wrapping etc.). All packs should be marked with the date of sterilization and there should be a procedure setting out how long an item can remain in the area before it needs to be resterilized. There must also be a validated maximum storage period between the preparation of a bulk solution and its sterilization or filtration through a bacteria-retaining filter. 4.15 – 4.16, 4.20 – 4.21

World Health Organization Sterile Production 31 March, 2017 Processing Validation – should not compromise the processes Aseptic process validation: Sterile media fill (“broth fills”) Simulate actual operation – intimate as closely as possible Simulate worst expected condition Use appropriate medium/media Sufficient number of units - e.g. equal to batch size (small batches) acceptable limit investigations Revalidation: periodic and after change New processing procedures validated Revalidation after significant changes And regular intervals Validation is an essential part of GMP. Validation is a very important part of sterile product manufacture. Validation is required for new processes, equipment, premises and personnel. Re-validation is also required, periodically and after change of processes, equipment or maintenance. Let’s look at some GMP and validation requirements specifically for aseptic processing. Sterile media fill (“broth fills”) with nutrient media supporting microbial growth is a valuable part of the validation process. It simulates the actual operation. During the inspection of the micro laboratory, you should establish whether appropriate media are used. When reviewing the records and results of the broth fill, establish whether a sufficient number of units e.g. at least 3000 had been filled, whether acceptable limits had been set (not more than 0,1% contaminated units) and whether any investigations are performed when there is contamination. Revalidation should be performed at periodic intervals, and after any significant change to equipment, processes or materials. 4.17, 4.18, 4.28

World Health Organization Sterile Production 31 March, 2017 Processing Water sources, water treatment systems and treated water Monitored regularly Chemicals Biological contamination Endotoxin Water specification Records of results and action taken Treated water and the equipment used to produce it should be monitored regularly for biological and chemical contamination and for the presence of endotoxins. Evaluate the SOP and recorded results of monitoring the water. Determine whether there is provision made for any corrective action should the results indicate problems with the quality of the water. 4.19

World Health Organization Sterile Production 31 March, 2017 Processing Components, bulk product containers and equipment fibre generation no recontamination after final cleaning stage properly identified sterilized when used in aseptic areas Used in clean areas, passed through double-ended sterilizers or use triple wrapping Gas used to purge solution or blanket a product – passed through a sterilizing filter Components, bulk product containers and equipment used should not generate any fibres and should not re-contaminate the area after final cleaning, or become contaminated after cleaning. They should be sterilised when used in aseptic areas. When sterilized, these should be passed through double ended sterilizers or use triple wrapping should be used to prevent recontamination. Gas used to purge solution or blanket a product has to be passed through a sterilising filter 4.22 – 4.23

World Health Organization Sterile Production 31 March, 2017 Processing Bioburden monitored Products: Before sterilization Working limits established Solutions to be filtered before filling (especially LVP) Pressure release outlets – hydrophobic microbiological air filters Starting materials – microbiological contamination should be minimal Monitored as per specification The microbiological contamination load or bioburden for starting materials prior to sterilization should be determined and kept to a minimum. There should be limits specified in specifications and evidence of testing. The microbiological contamination of products should be kept to a minimum. Large volume parenterals should be passed through a micro-organism retaining filter immediately before sterilisation. Where solutions are stored in sealed vessels, make sure that the pressure release outlets are protected with hydrophobic air filters. There should be a minimum or no containers or other materials in the area, liable to generate fibres due to the risk of contamination. Extreme care must be taken with materials that have been sterilized in the area for use in aseptic production, such as primary containers and filling machine parts. After removal from the sterilizer, they should be stored in a way which maintains their sterility (examples: in laminar airflow, triple wrapping etc.). All packs should be marked with the date of sterilization and there should be a procedure setting out how long an item can remain in the area before it needs to be re-sterilized. The stage of processing should thus be identified (e.g. proper labelling). 4.26, 5.3

World Health Organization Sterile Production 31 March, 2017 Processing Time intervals: Components, bulk containers, equipment Washing and drying and sterilization; and sterilization and use As short as possible Time limit validated Time intervals: Product Start of preparation of solution and sterilization (filtration) Maximum time set for each product When reviewing the batch manufacturing documents and other relevant documentation, establish whether the manufacturer has validated the time intervals between washing, drying and sterilisation for components, containers, and equipment. The time interval between sterilisation and use as well as the storage conditions must have been validated. As far as production is concerned, the time intervals between preparation and sterilisation should be as short as possible and a maximum time for each product must be set by the manufacturer. You could verify this for each individual product, by requesting the validation report for the product. The batch manufacturing document should reflect this time limit, based on the validation data. 4.23 - 4.24

World Health Organization Sterile Production World Health Organization 31 March, 2017 Group session 2 Considering the same factory as in the previous group session, discuss the process of sterilization. List all the items that will need to be sterilized (and indicate the choice of sterilization process). What are the key features you should find in each sterilization situation? Discuss the relevance, need, and the extent of qualification and validation required. We are now going to move into our second group session. Considering the same factory as in the previous group session, discuss the process of sterilization. List all the items that will need to be sterilized (and indicate the choice of sterilization process). What are the key features you should find in each sterilization situation? Discuss the relevance, need, and the extent of qualification and validation required.

World Health Organization Sterile Production World Health Organization 31 March, 2017 Possible Issues Autoclave - no pressure gauge Autoclave - no temperature recorder Autoclave - superheated steam Clean room - pressure differentials Exposure for settle plates Interlocks turned off Rusty Laminar airflow cabinets HEPA filters not checked regularly There are a number of areas where you might expect to find problems: Autoclave - no pressure gauge Autoclave - no temperature recorder Autoclave - superheated steam Clean room - pressure differentials Exposure for settle plates Interlocks turned off Rusty Laminar airflow cabinets HEPA filters not checked regularly

World Health Organization Sterile Production 31 March, 2017 Sterilization Methods of sterilization: Moist or dry heat Irradiation (ionizing radiation) Sterilizing gaseous agents (e.g. ethylene oxide) Filtration with subsequent aseptic filling Whenever possible: Terminal sterilization by heat in their final container - method of choice We are now going to talk about sterilization in more detail, with particular reference to the different methods of sterilization. There are a number of available methods, each of which has advantages and disadvantages. Heat sterilization should always be the preferred method if it can be used. Methods of sterilization include: Moist or dry heat Irradiation (ionizing radiation) Sterilising gaseous agents (e.g. ethylene oxide) Filtration with subsequent aseptic filling 5.1 – 5. 2

World Health Organization Sterile Production 31 March, 2017 Sterilization Validation All sterilization processes Special attention when non-pharmacopoeia methods are used Non-aqueous or oily solutions Before the method is adopted – its suitability and efficacy demonstrated with desired conditions: All parts of the load Each type of load Physical measurements and biological indicators (where appropriate) Verified at least annually and after change Records maintained Validation of all processes and the method of sterilization is essential, particularly as sterility testing is always a destructive test and can only be carried out on a sample of the batch. You should look very carefully at validation results for any methods that are not in accordance with national standards or pharmacopoeia, or for materials and products that are not solutions. If there are changes in the sterilization method, they must be validated. The manufacturer must have data to support its decision for the sterilisation process. The suitability and efficacy in achieving the desired sterilising conditions in each part of load, and each type of load must have been validated. This validation is done initially and repeated at least annually and after change. 5.4 – 5.5

World Health Organization Sterile Production 31 March, 2017 Sterilization For effective sterilization: Whole of the material subjected to the treatment Biological indicators: Additional method of monitoring Storage and use, quality checked through positive control Risk of contamination To ensure that the sterilization is effective, the whole load of material has to be subjected to the treatment. Biological indicators (BIs) can be considered as part of the monitoring of the sterilization process. Their use should always be controlled to prevent contamination of the facility and product with live micro-organisms. The manufacturer should have proper control over the storage and use of BIs. Their quality should also be checked through positive control. Don't forget that there is a risk of contamination in case of uncontrolled handling, breakage etc. 5.6 - 5.7

World Health Organization Sterile Production 31 March, 2017 Sterilization Differentiation between sterilized and not-yet-sterilized products Each basket/tray or other carrier, properly labelled Name of material Batch number Sterilization status Use of autoclave tape Sterilization records for each run – approved as part of the batch release procedure It is very important that a company has effective methods for separation of sterilized and unsterilized materials. Ideally, sterilizers should be double-ended, so that there is no cross-flow of products or materials. Containers should be clearly labelled with relevant information, and indicators such as autoclave tape or irradiation discs can be used. However, it is important to remember that these indicators only show that a load of material has passed through the sterilizer. They are not in themselves proof of sterility. I am sure that some of have have seen examples where sterilized and not-sterilized products were stored next to each other where there had been a possibility of a mix-up, or where batch documentation had been completed and signed in advance, indicating that products had been sterilised (but in fact, had not yet been through the sterilising process). Always verify the stage in the production process against the batch documentation. 5.8 - 5.9

World Health Organization Sterile Production 31 March, 2017 Terminal Sterilization Sterilization by heat Sterilization by moist heat Sterilization by dry heat Sterilization by radiation Sterilization by gases and fumigants It is not possible to deal with all the aspects and requirements for sterilisation in the basic module. The information provided here is only a brief introduction. It is recommended that the novice inspector should have an experienced inspector with him/her or an expert, when performing an inspection of sterile product manufacture. An expert adviser should be considered for an in-depth assessment. Let us now look at the different methods of sterilisation. We will first look at the basic principles of heat sterilisation, and then review the different methods. Methods of Terminal Sterilization Sterilization by heat Sterilization by moist heat Sterilization by dry heat Sterilization by radiation Sterilization by gases and fumigants 6

World Health Organization Sterile Production 31 March, 2017 Terminal Sterilization Sterilization by heat Recording of each cycle, e.g. time and temperature chart Temperature: validated coolest part Check from second independent probe Additional chemical or biological indicators Heating phase: Sufficient time for the whole load Determined for each load Cooling phase: After sterilization cycle Precautions to prevent contamination Sterilized cooling fluid/gas Sterilization by heat There should be recording of each cycle, e.g. time and temperature chart as part of the monitoring process of the sterilization cycle. The temperature should be monitored from the point that was validated as the coolest part of the sterilizer. It is advisable that a check is done from second independent probe. Additional chemical or biological indicators should be used. There is a heating phase – and sufficient time for the whole load to reach the required temperature should be allowed. This should be determined for each load. After sterilization, there is a cooling phase. What precautions can a manufacturer take to prevent contamination during this cooling phase? Use of sterilized cooling fluid/gas? Verify that all sterilization cycles are monitored using appropriate recording equipment. The accuracy and precision of the equipment should have been validated. This is applicable to at least monitors for temperature and time. This must provide a record of all the cycle parameters. The probes for determining temperature must be situated at the coolest part of the loaded chamber so that they are recording the worst case situation. A second independent probe should also be placed in the same position. The charts from these recorders must form part of the batch processing records. The recording of the cycle time should not commence until this heating period has been completed.The manufacturer should also show that any leaking container would not be approved for release or use. 6.2 – 6.3

World Health Organization Sterile Production 31 March, 2017 Terminal Sterilization Sterilization by moist heat (heating in an autoclave) Water-wetable materials only, and aqueous formulations Temperature, time and pressure monitored Temperature recorder independent of the controller Independent temperature indicator Drain – temperature recorded from this position Regular leak test when vacuum is part of the cycle Material allows for removal of air and penetration of steam All parts of the load in contact with steam Quality of the steam – no contamination Sterilization by moist heat (heating in an autoclave) The method can be used for water-wettable materials only, and aqueous formulations. During sterilization, the temperature, time and pressure should be monitored. The temperature recorder should be independent of the controller. An additional independent temperature indicator can be used. If the autoclave is fitted with a drain, then the temperature should be recorded from this position. A regular leak test should be done when vacuum is part of the cycle Material used to pack materials / product should allow for the removal of air and penetration of steam All parts of the load has to come in contact with steam to ensure sterilization. You have to check that the manufacturer has procedures, specifications, and test methods to ensure that the quality of the steam used is acceptable and that it cannot be an accidental source of contamination 6.4 – 6.6

World Health Organization Sterile Production 31 March, 2017 Terminal Sterilization Sterilization by dry heat For non-aqueous liquids, dry powders Air circulation in the chamber Positive pressure in chamber to prevent entry of non-sterile air HEPA filtered air supplied When removing pyrogens, challenge tests validation (using endotoxins) Sterilization by dry heat This method is used mainly for non-aqueous liquids and dry powders. Air is circulated in the chamber and there should be a positive pressure in chamber to prevent entry of non-sterile air. The air should be filtered through a HEPA filter When removing pyrogens (e.g. sterilization and depyrogenation of glass ampoules), challenge tests have to be done. The validation includes the use of endotoxins. 6.7

World Health Organization Sterile Production 31 March, 2017 Terminal Sterilization Sterilization by radiation Suitable for heat-sensitive materials and products confirm suitability of method for material ultraviolet irradiation not acceptable Contracting service – ensure validation status, responsibilities Measurement of dose during procedure Dosimeters independent of dose rate quantitative measurement number, location and calibration time-limit Biological indicators only as additional control Radiation sensitive colour discs Sterilization by radiation Suitable for heat sensitive materials and products. The manufacturer has to confirm the suitability of this method for material. Ultraviolet irradiation not acceptable. When the manufacturer is contracting the service out to a contract acceptor, the manufacturer still has to ensure the validation status and specify the responsibilities. Measurement of dose during procedure should be done. The dosimeters should be independent of dose rate quantitative measurement number, location and calibration time-limit Biological indicators can be used only as additional control measure. Radiation sensitive colour discs can be used 6.8 – 6.10

World Health Organization Sterile Production 31 March, 2017 Terminal Sterilization Sterilization by radiation (2) Information forms part of the batch record Validation to cover effects of variation in density of packages Handling procedures to prevent misidentification of irradiated and non-irradiated materials Each package to have a radiation-sensitive indicator Total radiation dose administered within a predetermined period of time All the information of the sterilization should form part of the batch record Validation should cover the effects of variation in density of packages, as the packaging material can have an influence on the effectiveness of the sterilization. Handling procedures to prevent misidentification of irradiated and non-irradiated materials should be in place. Each package should have a radiation-sensitive indicator. The total radiation dose should be administered within a predetermined period of time. 6.10 – 6.13

World Health Organization Sterile Production 31 March, 2017 Terminal Sterilization Sterilization by gases and fumigants Only when no other method is suitable e.g. ethylene oxide, hydrogen peroxide vapour Validation: Also prove the gas has no damaging effect on product Time and conditions for degassing (specified limits) - residue Direct contact with microbial cells essential Nature and quantity of packaging materials Humidity and temperature equilibrium Monitoring of each cycle with biological indicators time, pressure temperature, humidity and gas concentration Sterilization by gases and fumigants Gas and fumigants should only be used when no other method is suitable. Materials used include ethylene oxide, hydrogen peroxide vapour. Validation here is essential, and the manufacturer also has to prove that the gas has no damaging effect on product Time and conditions for degassing (specified limits) should be specified, as there should be no residue remaining on the product. In this process, direct contact with microbial cells is essential and therefore here also the nature and quantity of packaging materials play an important role in ensuring effectiveness of the sterilization method. Humidity and temperature equilibrium should be reached and each cycle should be monitored with biological indicators. Other parameters to be monitored include time, pressure, temperature, humidity and the gas concentration. 6.14 – 6.20

World Health Organization Sterile Production 31 March, 2017 Terminal Sterilization Sterilization by gases and fumigants (2) Post-sterilization storage – controlled manner Ventilated conditions Defined limit of residual gas Validated process Safety and toxicity issues One of the problems with ETO is the residues that are left behind at the end of the cycle. The processing cycle must include a validated degassing period, where the load must be stored in a suitably ventilated room under quarantine. The gas is explosive in air at relatively low concentrations and results in significant residues in the product that need to be removed before the batch can be passed. The load should be stored in a ventilated area after sterilization. The product should not be released until the residual gas has fallen to the defined level. There should be validation data for this process. This method is used for plastic items such as medical devices that are both heat and radiation-sensitive. The cycle is a combination of time, temperature, humidity and gas concentration. The first three parameters are generally recorded directly, while the last is recorded indirectly. The volume of gas used is also calculated by weighing the cylinders before and after the cycle to cross-check that the amount used is as expected. If you are going to inspect a facility using ETO gas, then specialist support should be considered 6.21

World Health Organization Sterile Production 31 March, 2017 Terminally sterilized products Trainer to discuss the tabel 4.6 – 4.7

World Health Organization Sterile Production 31 March, 2017 Terminally sterilized products Trainer to discuss the tabel 4.8 – 4.9

World Health Organization Sterile Production 31 March, 2017 Aseptic processing and sterilization by filtration Aseptic processing Objective is to maintain the sterility of a product, assembled from sterile components Operating conditions so as to prevent microbial contamination What do you think are the aspects that require careful attention? Aseptic processing and sterilization by filtration Aseptic processing We have already discussed the fact that terminal sterilization of a product is preferable as it reduces the risk of and provides more assurance of sterility. However, for some types of products, this is not possible. Another method to prepare a sterile products then is to maintain the sterility of a product, assembled from sterile components. All operating conditions should be such to prevent microbial contamination. What do you think are the aspects that require careful attention? 7.1 – 7.2

World Health Organization Sterile Production 31 March, 2017 Aseptic processing and sterilization by filtration Aseptic processing (2) Careful attention to: Environment Personnel Critical surfaces Container/closure sterilization Transfer procedures Maximum holding period before filling Careful attention should be paid to ensure that there is no risk of contamination due to: Environment Personnel Critical surfaces Container/closure sterilization Transfer procedures Maximum holding period before filling The trainer can facilitate discussion around these points 7.3

World Health Organization Sterile Production 31 March, 2017 Aseptic preparation Discuss the table 4.10, 4.11, 4.14

World Health Organization Sterile Production 31 March, 2017 Aseptic preparation Discuss the table 4.10 – 4.13

World Health Organization Sterile Production 31 March, 2017 Sterilization by filtration Through a sterile filter of 0,22 µm or less, into previously sterilized containers remove bacteria and moulds not all viruses or mycoplasmas Consider complementing with some degree of heat treatment Double filter layer or second filtration advisable, just before filling - no fibre shedding or asbestos filters Filter integrity testing immediately after use also before use if possible For some types of products, such as vaccines and insulin, sterilization by heat is not possible. In this case, sterilization by filtration into a previously sterilized container can be used. The filter should have a nominal pore size of no more than 0.22µm. However, it should be remembered that although these filters can remove bacteria and moulds, viruses and mycoplasmas might not be removed by this method. In order to reduce the risks associated with the filtration method, double filtration may be advisable. There is usually a pre-filter before the main one anyway, but in addition, a final filter, just prior to filling, should also be used where possible. Fibre shedding filters and asbestos filters may not be used. There should be documented evidence of filters integrity tests having been performed after use and in some cases also before use. This requires the use of equipment such as a bubble-point tester. In addition, validation of the method will have produced standard times and pressure differentials for a given volume of liquid. Any variations from this should be noted and investigated. 7.4 – 7.7

World Health Organization Sterile Production 31 March, 2017 Sterilization by Filtration (2) Validation to include Time taken to filter a known volume Pressure difference to be used across the filter Significant differences to be noted and investigated, recorded in batch records Integrity of gas and air vent filters checked after use, other filters at appropriate intervals Validation should include the time taken to filter a known volume of product and the pressure difference to be used across the filter. If during routine production, any significant differences are noted, these should be investigated, and recorded in batch records. Integrity of gas and air vent filters should be checked after use, and other filters at appropriate intervals 7.7

World Health Organization Sterile Production 31 March, 2017 Sterilization by Filtration (3) Same filter not used for more than one working day, unless validated No filter interaction with product, e.g. removal of ingredients releasing substances into product Filters should not be used for more than one working day, unless longer use has been validated. Filters should further not interact with the products, including removal of ingredients or releasing of substances into the product. 7.8 – 7.9

World Health Organization Sterile Production 31 March, 2017 Quality Control Samples for sterility testing should be representative From parts of the batch, most at risk Aseptic filling – at beginning and end of batch filling, and after interruptions Heat sterilized – coolest part of the load Sterility of the batch ensured through validation Validated sterilization cycle Media fill Sterility test procedure as per pharmacopoeia, and validated for each product Batch processing records, sterility testing records, environmental records should be reviewed In this final part of the module, we are also going to look at the quality control. Testing for sterility is a destructive test, and one cannot test every ampoule that comes from the batch. It is therefore necessary to ensure that samples for sterility testing are representing the batch, and where possible, the worst case scenario. Samples should be taken from parts of the batch that are most at risk. These are: Aseptic filling - at beginning and end of batch filling, and after interruptions Heat sterilized – coolest part of the load. As sterility of the batch can not be ensured through testing, it has to be ensured through validation. This includes qualification of the equipment, supporting systems, process and sterilization cycle. For aseptic processes, media fills have to be done at regular intervals. The sterility test procedure should be as per pharmacopoeia, and validated for each product. Batch processing records, sterility testing records, environmental records should be reviewed as part of the batch evaluation and release procedure. 2.1 -2.2

World Health Organization Sterile Production 31 March, 2017 Quality Control Endotoxin testing for injectable products Water for injection, intermediate and finished product Always for large volume infusion solutions Pharmacopoeia method, validated for each product Failure of the test – investigation Corrective action Injectable products should also be tested for Endotoxin levels. This includes tests on Water for injection, intermediate and finished product. It should always be done for large volume infusion solutions. The Pharmacopoeia method should be used and it should be validated for each product In case of failure of the test, a thorough investigation has to be done, the cause identified and recorded, and corrective action taken to prevent possible recurrence. 2.3

World Health Organization Sterile Production 31 March, 2017 Finishing of products Containers closed by means of validated methods Samples checked for integrity Maintenance of vacuum (where applicable) checked Parenteral products inspected individually Visual inspection under suitable and controlled conditions: illumination and background eyesight checks of operators allowed frequent breaks Other methods: validated, and equipment performance checked at intervals results recorded The closing and sealing of containers of sterile products, should be done in accordance with validated methods. Review the validation protocols and reports for the sealing of the containers such as ampoules and vials. You should further evaluate how the manufacturer takes samples of products to check the integrity of the seals. Evaluate the SOP and compliance with the SOP for this process. When containers are sealed under vacuum – samples should be taken and tested at regular intervals as specified in the SOP or batch document. Parenteral products should be individually inspected for foreign particles, pieces of glass, cracks and other contaminants. You should inspect the area where the inspection is performed to assess whether the inspection is done visually or by using automated equipment. When visual inspection is done, assess whether this is done under illumination and background, whether operators have regular eyesight checks, regular breaks are given to rest their eyes, and whether their performance had been validated. (Trainer can elaborate). If automated equipment is used, then the equipment should have been subjected to validation/qualification. 11.1 – 11.3

World Health Organization Sterile Production World Health Organization 31 March, 2017 Group session 3 Considering the same factory as in the previous group sessions, devise a plan for monitoring of the facility. List the parameters to be tested, tests to be used, acceptance criteria and frequency of testing. We now move into the final group session. Using the same hypothetical factory as before, review all the monitoring that will be required. List the parameters that need to be tested, the tests that should be used and the acceptance criteria. Finally, propose a programme for the monitoring that covers the frequency for each different test. (Refer to the supplementary notes giving an outline of the sort of responses that may be expected)