1. Challenges in producing cell- based product for clinical trial – the MyDerm TM experience Angela MH Ng Production Manager Tissue Engineering Centre 13 May 2015 TISSUE ENGINEERING CENTRE UKM MEDICAL CENTRE 1

2. Topics to be covered Key differences of cell & tissue products from drugs Key considerations in GMP production for cell & tissue Process mapping In-process QC – stop or go and alert points Release criteria – third party vs in-house QC Training, Validation (e.g. use testing), Risk assessments and Dry runs before production Protocol deviation – cell performance, material variation, Release of non-conformance product & shelf life limitation MyDerm Production status to date Challenges in meeting various stakeholders’ expectations 2

3. How does GMP for cell & tissue products differ from pharma products? Drugs Cell & Tissue Products StateNon-living (static)Living (dynamic) Cleanliness level SterileNo external contamination Production volume Mass / batchAutologous – customized / single sample Allogenic – batch SOPStrict adherenceMay require some flexibility Product specs BioactivityCell markers profiling but levels differ between samples 3

4. Key considerations in GMP production for cell & tissues 1. Critical materials 2. Critical instruments 3.Critical process points 4.Critical quality control 5.Critical training 6.Critical vendors or contractors 7.Critical stakeholders 8.Resource management 4

5. MyDerm TM Production Patient skin biopsy (1x3cm 2 ) transport to GMP facility Enzymatic digestion process Bilayered skin construct formation using autologous plasma Single cells Implantation on patient in OT Biopsy & bleeding of patient in OT Keratinocytes Fibroblasts Cell culture & expansion using autologous serum Blood Processing to obtain serum & plasma 5

6. 1. Indentify the critical materials - Disposable & material & instrument in direct contact with the product. - Clinical, GMP or further manufacturing grade - Validate specification & performance 6

7. 2. Identify the critical instruments - Direct impact on product -Perform additional validation if PQ not performed or insufficient by the vendor 7

8. 3.Identify the critical process points Media preparation & aliquoting Cells selection & withdrawal of antibiotics in culture Cell number and characteristics Tissue processing & cell culture 8 Final product construction / preparation

9. 4.Build in quality control steps Media preparation & aliquoting Cells selection & withdrawal of antibiotics Final product construction / preparation Tissue processing & cell culture Pre-screening of patient before sampling Microbial contamination test Microscopic observation, microbial contamination test if necessary Microscopic observation & Microbial contamination test Endotoxin, Mycoplasma, Microbial contamination tests Gram staining 9 Cell number and characteristics Microscopic observation (or immunostaining) & Cell count

10. Risk assessments, Process validations and Dry runs before production Risk assessments HIRARC risk matrix Risk assessments for non-GMP reagents (for further manufacturing) Risk assessment for residual antibiotics Dry runs Actual production using human samples to ensure reproducibility Three consecutive passess Use tests Pre-testing on performance of critical reagents e.g. media, enzymes, plasma Random sampling per batch First time pass or three consecutive passess Process simulation to ensure sterility of procedures Three consecutive passes Media fill validations 10

11. MyDerm Process mapping Process Mapping Sample.xls 11

12. 5.Identify Critical training for production personnel 1.GMP Quality system & facility training 2.Specific process training 3.Operator aseptic training & assessment 4.Personal micro-contamination assessment Every 2 years Every 2 months GMP refresher yearly Retraining when necessary e.g. incompetency, new process 12

13. 6.Identify Critical Vendors 1.Critical material suppliers 2.External QC service providers Critical Vendors 1.Provision of certificate of accreditation / compliant e.g. ISO 17025 2.Vendor survey / referrals 3.On site visit Vendor qualification programme 13

14. Clinicians Regulators / Ethics Committee Business / Funding partner Patients GMP Staff Sponsor 7. Critical stakeholders 14

15. 8. What are the resource limitation? Personnel Facility / equipment Financial? Materials Up-to-date Inventory, material expiry, Personnel scheduling and backups External service providers Timing, frequency & capacity Facility maintenance & revalidation schedule Constant monitoring of budget Production capacity 15

16. Clinicians Regulators / Ethics Committee Business / Funding partner Patients GMP Staff Sponsor Challenges in meeting various stakeholders’ expectations 16

17. Clinical Trial TISSUE ENGINEERING CENTRE UKM MEDICAL CENTRE 17

18. SKIN TISSUE ENGINEERING (MyDerm TM ) From bench to bedside 18

19. Proof of Concept 6 pieces of Tissue engineered skin in 3 weeks In 2004, 4 year-old girl with 34% burn; 1 month post burn referred from Johor Bharu Critical stage in ICU – burn unit UKMMC  Full thickness skin loss  1 month post burn + bacteria infection  Limited skin graft for SSG  Faint hope of survival Preliminary Clinical Study 19

20. Knee of left leg Right leg Proof of Concept 20 Preliminary Clinical Study

21. 1 month later Clinical Study Day of Implantation 21 Preliminary Clinical Study

22. 2½ months after implantation Clinical Study 22 Preliminary Clinical Study

23. Clinical Trial Phase I/IIa Commenced September 2013 Indications: Traumatic, Diabetic and Burn wounds 23

24. Case 006 Day 0 Clinical Trial Case 006

25. Day 4 Day 7 Day 14 Day 21

26. Day 28 Day 35

27. Day 48 Day 56 Day 48

28. Case 007 Day 0 Day 7 Day 0

29. Day 7 Day 21 Day 7 Day 14

30. Day 28 Day 35Day 42

31. Day 0 Case 004

32. Day 7

33. Day 72

34. Day 180

35. Case 009 Day 0 Day 45

36. Summary of patient CasesAgeGenderWound sizeDays in productionImplanted MyDerm 00117F150cm2210 (failed in production) 00249M487cm2453x96cm2 00346F8.24cm2381x9.6cm2 004/00514M960cm24710x96cm2 (product variation) 00622M120cm2352x96cm2 00744M46cm2401x96cm2 00858M310cm2373x96cm2 (production variation) 00958M70cm2450 (healed b4 implant) 01023F165cm2350 (healed b4 implant) 01160M110cm2360 (healed b4 implant) 01247M350cm2Still in production 36

37. Final points Know our limitations & critical points Build in alerts & “go & no go” points Contingency management Corrective actions / Planned deviations >> NCR >>>> change control plan Personnel management / backups Resource management Keep an effective inventory database Understand stakeholders’ expectations Effective communication with all stakeholders Continuous improvement NCR trending & keep an open and continuous learning environment 37

38. THANK YOU 38