Environmental Monitoring: Environmental Monitoring: Large Academic Facility Large Academic Facility

ExperienceExperienceCarlos LeeCarlos LeeQA ManagerQA Manager

Center for Cell & Gene Therapy (CAGT)Center for Cell & Gene Therapy (CAGT)

Baylor College of Medicine Baylor College of Medicine

Houston, TXHouston, TX

ObjectivesObjectives

•• Present our centerPresent our center’’s Environmental s Environmental Monitoring (EM) approach in compliance Monitoring (EM) approach in compliance with applicable regulations / standardswith applicable regulations / standards

•• Describe our EM process in the Cell Describe our EM process in the Cell Processing Facility (CPF)Processing Facility (CPF)

•• Share forms and reports used in our EM Share forms and reports used in our EM documentationdocumentation

Control MonitorProcess

Personnel

Supplies, Reagents, Materials

Facility (Environment)

Equipment

sterility / release testing

personnel monitoring

CoA; release testing

EM, alarm system

maintenance, calibration, EM, alarm system

GMP / GTP Environment

Cleaning & Maintenance are an important step in controlling the environment

Regulations & StandardsRegulations & StandardsCFR Part 211.42 (iv)CFR Part 211.42 (iv) –– a system for a system for monitoring environmental conditionsmonitoring environmental conditions

CFR Part 1271.160 (5)CFR Part 1271.160 (5) –– establishing establishing and maintaining appropriate and maintaining appropriate monitoring systems as necessary to monitoring systems as necessary to comply with the requirements of this comply with the requirements of this subpart (eg., environmental subpart (eg., environmental monitoring)monitoring)

FACT StandardsFACT Standards

Part D2.4Part D2.4 –– Environmental conditions Environmental conditions shall be controlled where appropriate shall be controlled where appropriate for temp., humidity, ventilation, air for temp., humidity, ventilation, air quality and surface contaminatesquality and surface contaminates……

Part D2.4.1Part D2.4.1 -- Where appropriate, the Where appropriate, the Processing facility shall provide Processing facility shall provide environmental monitoring for environmental monitoring for microorganisms.microorganisms.

Part D5.1.17Part D5.1.17 -- Environmental control Environmental control to include a description of EM plan.to include a description of EM plan.

CPF Master FileCPF Master File –– filed with FDAfiled with FDA

Details of design, air handling, lighting, Details of design, air handling, lighting, power, plumbing, room configurationpower, plumbing, room configuration

QM PlanQM Plan

SOPsSOPs

WorksheetsWorksheets

EquipmentEquipment

PersonnelPersonnel

ReportsReports

Our ResponseOur Response

CAGT – current Cell Processing

Facility• Class 10,000 Facility• 9 Production Rooms• Flow Cytometry Laboratory• Centralized Cryobank• Central Supply Management • Barcoding System

CAGT CPF OrganizationAdministrative Directors / Facility Manager

Clerical support

Quality Assurance

Supply Management

Production GroupsStem Cell Processing

Cytotoxic T Lymphocytes (CTL)

Tumor Vaccine

Testing / QC GroupsFlow Cytometry Lab

Quality Control Lab

Quality Control Lab

1 Manager

6 QC Analysts

~2 dedicated to EM activity

Quality Management Plan

Policy indicates what we will do:

Standard Operating ProceduresProcedural:

B03.01 – Environmental Monitoring – provides the specifics – definitions, schedule, limits, alert and action levels

B03.04 – Viable Particulate Counts – covers the use of Biotest RCS Plus Air Sampler

B03.18 – Sterility Monitoring Using RODAC Plates – covers the use of RODAC plates

B03.21 – Environmental Monitoring Using Fallout Plates - covers the use of fallout plates

Equipment Use:

B03.30 – Airborne Particle Counter (Biotest) – describes Biotest Air Sampler

B04.05 – Airborne Viable Particle Counter (Biotest) – describes Biotest RCS Plus Air Sampler

Standard Operating Procedures

Room temp 18 – 27oC

Room humidity 15 – 70%

At minimum, weekly particle & viable counts for each room

Dynamic preferentially over static monitoring – must be done at least monthly.

During certain manufacturing processes: particle, viable, fallout plates followed by RODAC plates post activity.

Monitoring of BSC monthly

Air Particles :Alert limit > 8,000 to < 9,999 per cu. ft.

Action Limit > 10,000 per cu. ft.

BSC Air Particles: Alert limit > 80 to < 99 per cu. ft.Action Limit > 100 per cu. ft.

Viable Counts:Alert limit > 0.4 CFU per cu. ft. (>2-5 colonies/plate)

Action Limit > 0.5 CFU per cu ft. and other limits exceeded

BSC Viable Counts: Alert limit < 0.142 per cubic ft (>2-5 colonies/plate)Action Limit > 0 142 per cubic ft (>5

Environmental Monitoring procedure – the essentials:

TerminologyClass 10,000: means that there should be <10,000 particles of >0.5 um diameter per cubic foot of air (less than 0.5 viable organisms per cubic foot of air)

Dynamic (Static) Counts: Dynamic means when room or equipment is in use (static = not in use)

Particle Counts (non viable): particles that are not living (may include dead microorganisms). Obtained using air samplers that passes the particles over light. Amount of light scatter depends on the size.

Viable particle counts: Living microorganism. Obtained using a rotating air sampler which deposits particles, using centrifugal force, onto an agar strip.

RODAC plate: (Replicate Organism Detection and Counting) plate – dome shaped agar surface that is pressed onto a flat surface. The plate is incubated to check for growth of microorganisms.

Fallout Plates: agar plates placed open faced inside the working area (BSC) – captures viable microorganisms that may fall or settle onto the agar.

EM Schedule

Form: Particle Counts

Document for each room:

At least, weekly particle counts Includes temp and humidity

Dot plot graph provide quick visual

Form: Non-Viable & Viable Particle Counts

Document for each room/site

At least, weekly particle counts Includes temp and humidity

Form: Non-Viable & Viable Particle Counts

In event that the alert or alarm is reached

Documentation of remedial action

Form: Rodac Plates

Document for each site tested

Timing of sampling

Read timing

Outcome

Form: Rodac Plates

In event that the alert or alarm is reached

Documentation of remedial action

Form: Fall-Out Plates

Document for each site tested

Timing of sampling

Read timing

Outcome

EM Cultures

Incubator temp set at 32 (30-35oC)

Cultures held and read at 2 -4 days &/or 7 days.

Positive cultures are sent out for speciation.

Alarm/Monitoring SystemPart of the EM Plan

• Continuous monitoring of incubators – temp and CO2 level

• Continuous monitoring of LN Banks, mechanical freezers, refrigerators

Reporting Forms

What do we do with the info?Action on Alert/Alarm Levels: • Cleaning: strategy, schedule, agents

• Closure: quarantine, decommission, replace

• Monitoring: strategy, schedule, frequency

• Training: cleaning, CPF and/or QC staff

Incident Reports / Variances

Issuance of Quality Alerts

Data reviewed, plotted, analyzed

Reporting of data

Example Quality Alert

Purpose:

• Alert staff of current or ongoing issues

• Reminder of lab’s policies or procedures

Data reviewed, plotted, analyzed

weekly particle counts

semi-annual graphs

Floor Plan with EM Data

Data reviewed, plotted, analyzed

Temp & Humidity graphs

Ranges: temp 17 -23C , humidity 19 – 61%

Excerpt from 2008 Quality

Report

Review of trending of particle counts over time

CAGT – future Cell Processing Facility

• Class 10,000 Facility• 13 to 16 Production Rooms (CPF)• Centralized Cryobank• Central Supply Management • Barcoding System

Improvements in monitoring

• Increased security – card & code access

• Air pressure differentials

• Continuous particle counts

• Temp/humidity

Summary

•• EM is a EM is a ““livingliving”” process process –– need to adapt need to adapt to changes in the environment and in the to changes in the environment and in the manufacturing processesmanufacturing processes

•• Plan for EM Plan for EM –– adopt procedures and adopt procedures and forms to help document, evaluate and forms to help document, evaluate and determine course of actiondetermine course of action

•• Summarize and analyze data Summarize and analyze data –– report report results. Review and revise EM plan as results. Review and revise EM plan as needed.needed.