Design, Construction, Commission, and Qualification of Critical Utility Systems: Part III B Y D AV I D W. V I N C E N T A N D H E R B E RT M AT H E S O N ❖ HEATING, VENTILATION, AND AIR CONDITIONING (HVAC) SYSTEMS INTRODUCTION Whether a parenteral facility is designed for manual or automated operation, environmental control is a critical factor in determining the successful operation of the facility. The design and construction that relates to the clean room must include consideration for: • Air Volume • Air Velocity • Particulate Loading (especially viable organisms) • Temperature • Relative Humidity • Pressure Differentials There are many documents that are helpful guides in determining the requirements for the design and construction of your controlled environmental system. The Federal Standard 209-E is a document intended to provide standardization of definitions and air cleanliness classes for clean rooms. The American Society of Heating, Refrigerating, and Air-conditioning Engineers’ (ASHRAE) handbook is another guide that also can be helpful. During construction, documenting procurement and verifying construction activities are critical components of successful Installation Qualification (IQ). It is important to witness certain tests, such as the Heating, Ventilation, and Air Conditioning (HVAC) duct leak test, and cleaning pro8 Journal of Validation Technology cedures. It is important to collect data on the silicone used for sealing penetrations, on the flooring material, and on the paints that are used on the walls and ceiling. The cleanliness of the job site during construction should be strictly enforced and all ducts should be capped or sealed then cleaned before being used. DESIGN QUALIFICATION A facility’s room classification or design specification should be identified based on the product being manufactured and the processes being used. It is important that the HVAC system meets the required specifications based on the needs or requirements of the products and processes. For example, one would not design a system to meet aseptic conditions if the product to be produced was not meant to be sterile. Therefore, it is important to define your product and process requirements before designing your HVAC system. The clean room classification requirements found in Figure 1 should be considered when designing an HVAC system. CONSTRUCTION QUALIFICATION (CQ) The construction of a pharmaceutical manufacturing facility requires strict adherence to the requirements outlined in the Code of Federal Regulations (CFR) 21, Part 211.42, the current Good Manufacturing Practice regulations (cGMPs) for processing human drugs. A great deal of em- David W. Vincent and Herbert Matheson Figure 1 ______________________________________________________________________________ Airborne Particulate Cleanliness Classes (by cubic meter) Number of Particles per Cubic Meter by Micrometer Size CLASS 0.1 µm 0.2 µm 0.3 µm 0.5 µm 1 µm 5 µm ISO 1 10 2 ISO 2 100 24 10 4 ISO 3 ISO 4 1,000 10,000 237 2,370 102 1,020 35 352 8 83 ISO 5 100,000 23,700 10,200 3,520 832 29 ISO 6 ISO 7 ISO 8 ISO 9 1,000,000 237,000 102,000 35,200 352,000 3,520,000 35,200,000 8,320 83,200 832,000 8,320,000 293 2,930 29,300 293,000 The larger, bolded font in ISO rows five through eight and in columns headed, 0.5 µm and 5.0 µm, denotes classification and particle size usually used in the certification of clean rooms for the Health Care Industries. Note: The new FDA Guideline for Industry "Sterile Drug Products Produced by Aseptic Processing — Current Good Manufacturing Practice," requires testing for only the 0.5 µm particles/m3 sizes during routine monitoring for aseptic processes phasis is usually placed on design compliance with cGMP requirements; this is because the effects of cGMP issues on construction are profound and must be understood by owners, facility operators, and contractors. INSTALLATION QUALIFICATION Although there are many items that require validation during the construction of a new facility, only the items associated with the validation of clean rooms will be discussed here. The IQ is a documented plan for the performance of inspections and the collection of documentation to verify the static attributes of a system. The IQ describes what the system is intended to do, or what its function is, and it summarizes all major components of the system. A complete analysis of the system is performed prior to start-up. A field inspection is performed to check and verify static attributes. HVAC System During the execution of IQ for an HVAC system, the following installation attributes should be verified: • • • • • • • • Utility Connections Air Handling units Ductwork Ventilation and Pressure Airflow Requirements Systems Design codes Insulation Material Damper and Air Volume Control Devices High Efficiency Particulate Air (HEPA) and Pre-filters • Fire Detection System • Direct Digital Control (DDC) System or Building Management Systems (BMS) N o v e m b e r 2 0 0 5 • Vo l u m e 1 2 , N u m b e r 1 9 David W. Vincent and Herbert Matheson Test, Balancing, and Adjustment After the critical utilities IQ has been verified, it is important to conduct the next important step of the qualification: Test, Balancing, and Adjustment (TBA). TBA is the culmination of the long and costly process of designing and constructing an HVAC environmental control system. TBA ensures that the completed installation will produce the environment intended by the original system design and contributes to the continued efficient performance of the system after it is in operation. The TBA technician will verify hydrostatic and HVAC balancing, along with air change rates and volumes. Clean room velocities will also be verified during the testing. Clean Room Testing and Certification After the HVAC system has been balanced and accepted, it is now time to certify the clean rooms. This involves the testing and certification of certain physical attributes of the clean room. The clean room testing and certification contractor should perform the following tests: • • • • • • • • • • • DiOctyl Phthalate (DOP) Test of HEPA Filters Noise Levels Light Levels Air Patterns: Parallelism and Unidirectional tests in the aseptic fill area Induction Testing Humidity and Temperature Room Non-Viable Particulate Counts using 209-E calculations (Clean Room Classification) Recovery Time Testing Room Air Change Rates Differential Pressure Air Flows Direction The clean room must meet all the design criteria before the next stage of the validation can be performed. The certifying contractor must formalize all results obtained during the certification process in an official report. 10 Journal of Validation Technology OPERATIONAL QUALIFICATION Once the clean rooms have been certified, the next step of the validation process is the Operational Qualification (OQ). During the execution of the OQ it is important to verify the following steps: 1. Review the HVAC IQ final report, instrument calibration, and operation and maintenance procedures. 2. Review the testing and balancing final report. 3. Review the clean room testing and certification final report (HEPA filter certification). 4. Verify HVAC control functions and alarms. 5. Verify Building Management System controls and communication. 6. Verify pressure differentials and airflows between clean rooms. 7. Complete shutdown and start-up tests to verify that the HVAC systems return to normal conditions. 8. Verify Environmental Control Functions It may be necessary to repeat the particle counts and temperature and humidity test after the shutdown and startup procedure. After the environmental controls have been tested and accepted, the clean rooms are ready for the Performance Qualification (PQ) study. PERFORMANCE QUALIFICATION Microbiological validation of any facility should be executed in three phases, with varying degrees of severity. The initial protocol should cover the baseline environmental sampling plus installation and initial operational qualification of critical systems, beginning just after construction clean-up. The second stage involves the actual validation of systems and equipment, including both static and dynamic environmental testing, once all air-handling systems are balanced and fully qualified. The third and final stage covers the routine Environmental Monitoring Program; Standard Operating Procedures (SOPs), such as, gowning, maintenance, and cleaning procedures; operation limits of test methods; plus any follow-up items generated from the first two stages. The overall intent of the first two phases is to determine the limits and capabilities of the facility and to get a general profile of the resident population of organisms. The infor- David W. Vincent and Herbert Matheson Figure 2 ______________________________________________________________________________ Air Classificationsa Clean Area Classification (0.5 µm particles/ft3) ISO Designationb Microbiological Settling Microbiological Plates Action Levelsc,d Active Air Action Levelsc (diam. 90mm; cfu/4 hours) (cfu/m3) > 0.5 µm particles/m3 100 5 3,520 1e 1e 1000 6 35,200 7 3 10,000 7 352,000 10 5 100,000 8 3,520,000 100 50 a- All classifications based on data measured in the vicinity of exposed materials or articles during periods of activity. b- ISO 14644-1 designations provide uniform particle concentration values for cleanrooms in multiple industries. An ISO 5 particle concentration is equal to Class 100 and approximately equals EU Grade A. c- Values represent recommended levels of environmental quality. You may find it appropriate to establish alternate microbiological action levels due to the nature of the operation or method of analysis. d- The additional use of settling plates is optional. e- Samples from Class 100 (ISO 5) environments should normally yield no microbiological contaminants. Figure 3 ______________________________________________________________________________ USP 1116: Microbial Levels for Surface Monitoring Surface CFU/ 2 in2 Personnel CFU/ 2 in2 Classifications Zone Critical Area 100 (ISO 5) M 3.5 3 3 - gloves 5 - mask/gown Non-critical 10,000 (ISO 7) M 5.5 5 (walls, ceilings, benches, equipment, etc.) 10 (floors) 5 - gloves 1 - mask/gown Support Areas 100,000 (ISO 8) M 6.5 20 (walls, ceilings, benches, equipment, etc.) 30 (floors) 15 - gloves 30 - mask/gown The microbial levels for surfaces samplings are detailed in the following table and are based on USP <1116> requirements. 1 Adjacent to critical area, 2 Support Areas - Product N o v e m b e r 2 0 0 5 • Vo l u m e 1 2 , N u m b e r 1 11 David W. Vincent and Herbert Matheson mation for these studies can then be used to develop a routine environmental monitoring program that provides the highest probability of detecting any failure or problems, while still being manageable for operating and testing personnel. The data in Figure 2 is based on the new FDA Guideline for Industry “Sterile Drug Products Produced by Aseptic Processing — current Good Manufacturing Practice,” for routine monitoring of aseptic processes. After the PQ study is completed, the data is reviewed and a final report is written summarizing the results. The information from the PQ final report is than used to establish a routine environmental monitoring program. Baseline Sampling The initial sampling for the baseline is intended to get a general profile of the microbial population before cleaning. This sampling usually involves taking random sampling throughout the clean rooms. The sampling of the controlled environments involves high levels of samples and sampling frequencies, often using two selective growth media for both surface and air monitoring, (Sabouraud Dextrose Agar (SDA): for molds and yeast and Tryptic Soy Agar (TSA): for bacteria). This is done to check the sub-population of organisms and to determine which sample sites are the “hot-spots.” Since gases are used in the application and production of pharmaceutical drugs and can have a direct impact on product quality, they are considered critical systems. Gases are used in various manufacturing processes. Gases are typically used to transfer fluid products from one location to another and in the manufacturing processes. The most commonly used gases in the pharmaceutical industry are the following: • Carbon Dioxide • Nitrogen • Clean, Dry Compressed Air Static and Dynamic Sampling This stage of the validation involves performing three static and dynamic state studies. The sample locations are pre-determined based on the clean room particle count studies and results from the baseline study (hot-spots). Again, duplicate samples with different media and incubation temperatures and times should be used. This stage of the validation is also used to qualify the cleaning procedures based on the data from both the baseline (before cleaning) and the static and dynamic states studies. It is important to maintain accurate facility maintenance and cleaning logs. The information from these logs will be compared with the environmental results to determine whether the cleaning and maintenance procedures are acceptable. The personal gowning and operator aseptic technique should also be validated during the PQ study. The following conditions should be tested and monitored during the Performance Qualification Study: Other gases such as helium, oxygen, and argon may also be used. This article will discuss only those gases most commonly used in the Pharmaceutical Industry that may come in contact with the product. • • • • • • • 12 Viable and Non-Viable Airborne Particulates Viable Surface Samples Temperature and Relative Humidity Magnehelic Gauge Readings Manufacturing Personnel Gowning Aseptic Media Fills Building Management System Trending Data Journal of Validation Technology PHARMACEUTICAL GAS SYSTEMS INTRODUCTION VALIDATION OF GASES SYSTEM Gas System Design Since gas systems can be used for various manufacturing processes, the design of the system can be considered straightforward. The application for which these gases will be used should be the major consideration during the design phase. The following are some considerations for the design of gas systems: • • • • • • • • • Safety Issues (Oxygen) Materials of Design Fabrication Code Requirements Product or Process Demands Testing Requirements Installation Requirements Functional and Control Requirements Gas Purity David W. Vincent and Herbert Matheson Pharmaceutical Compressed Air System Figure 4 ___________________________________________________ Basic Gas System The following are some components that usually are a part of gas systems: Storage Tank Dessicant Filter • Compressor Inlet Air Filter • Inlet Silencers • Compressor (oil free) • Intercooler • After-cooler • Mechanical Separator • Air Receiver • Coalescing Pre-filter • Desiccant Air Dryer • Particulate After Filter • Activated Carbon Oil Vapor Adsorbed • Compressor Motor • Instruments • Control Panel • Distribution System Note: The pharmaceutical compressed air system should be capable of delivering 100% oil free air. Ambient Vaporizer Source Valve Cryogenic Gas Gas Backup Cylinders Particulate Removing Filter Point of Use with filters Point of Use with filters Pharmaceutical Gas Systems • Cryogenic Storage Tank • Desiccant Air Dryer • Particulate Filters • Point of Use Filter • Distribution Systems • Control Panel The diagram shown in Figure 4 illustrates a basic gas system, including a cryogenic storage tank in which the gas supply refills on a regular basis. The ambient vaporizer brings the gas to usable temperature since it is stored at a very low temperature. The desiccant filter is used to remove any moisture from the system. The particulate removing filters eliminate any foreign particulate matter from the system before it reaches the point of use. The 0.2 µm hy- Point of Use with filters Particulate Removing Filter Point of Use with filters Point of Use with filters drophobic filter is used to remove any microbial contaminants at the points of use. The distribution system should also have pressure regulators and measuring devices at all points of use to adjust and monitor the pressure of process gas. There is also a backup system that will supply gases on an emergency basis when the main supply tank is depleted. Depending on the sophistication of the system, there may be an alarm generated when the major supply tank is empty which alerts the supply company of the problem. N o v e m b e r 2 0 0 5 • Vo l u m e 1 2 , N u m b e r 1 13 David W. Vincent and Herbert Matheson CONSTRUCTION QUALIFICATION OPERATIONAL QUALIFICATION The construction of a pharmaceutical company’s process gas system requires strict adherence to the requirements outlined in 21 CFR, 211.42, the current Good Manufacturing Practices (cGMPs) for processing human drugs. The construction of gas systems should also include the requirements of local, state, and federal codes and regulations. The Food and Drug Administration (FDA) guidelines, published to assist in the construction and design of Compressed Medical Gases, should be used. The next step is to verify that the gas systems are functioning according to design specifications. During the execution of the OQ it is important to complete the following steps: INSTALLATION QUALIFICATION The IQ describes what the system is intended to do, or what its function is, and it summarizes all major components of the system. A complete analysis of the system is performed prior to start-up, and field inspection is performed to check and verify static attributes. Gas System During the execution of the IQ for gas systems, the following installation attributes should be verified: • • • • • • • • • • • • • Utility Connections Drawings (“as-built”) Materials of Construction Distribution Systems In-line Filters Storage Tank Systems Design and Safety Codes Valves Alarms and Control Devices Backup System Major Components Point of Use Filters Components, Tagged and Labeled 1. Verify that the gas distribution system has been cleaned. 2. Review the hydrostatic test data. 3. Review the filter integrity test data. 4. Verify the gas system control functions and alarms. 5. Verify the points of use design pressures. 6. Verify the backup system and safety features. 7. Verify the critical instrumentation calibration. After the Operational Qualification’s tests have been completed and accepted, the gas systems are ready for the Performance Qualification (PQ) study. PERFORMANCE QUALIFICATION The PQ is performed to verify that the gas systems deliver high quality gas that will meet the manufacturing quality specifications and to establish the baseline information on the performance of the gas systems used in the manufacturing areas. This study will also include qualifying three lots of gas supplied by the vendor and thirty consecutive days of testing to qualify the compressed gas system. Acceptance Criteria The performance qualification testing shall be performed on three lots of nitrogen supplied by the vendor. Thirty consecutive days of testing will be completed to qualify the compressed gas system. Gas and Compressed Air samples collected during the PQ test period shall meet the criteria detailed in Figure 5. Processing Samples for Testing Sample the process gases as outlined in this PQ procedure. Collect the appropriate equipment, Draegar tubes, and glass sampling cylinders, and clearly mark them for sampling tracking purposes. Only the gas identity test requires a sampling container. The other tests (oil mist, dew point, bioburden, and particulate tests) are performed in situ using specific portable pieces of equipment. 14 Journal of Validation Technology David W. Vincent and Herbert Matheson Figure 5 ______________________________________________________________________________ Test Criteria for Gases Samples Item Criteria ˚C 3 See Figure 6 ______________________________________________________________________________ Clean Room Classification of Particle Sizes Environmental Particulate Sizes Classification 0.5µ and greater Test Equipment and Materials • Equipment and materials necessary to perform purity analysis • Equipment and materials necessary to perform dew point determination • Equipment and materials necessary to perform Heterotrophic Plate Count (HPC) using the Matson/Garvin or SMA sampler • Equipment and materials necessary to perform oil mist testing • Equipment and materials necessary to perform measured gas flow • Equipment and materials necessary to perform particulate counts (particle count diffuser) 5.0 µ and greater Sampling and Test Procedures Assemble all necessary equipment and materials. Perform dew point, oil mist, particle counts, and HPC tests at each sample port according to the standard sampling schedule. Obtain Certificate of Analysis (C of A) for the three lots of gas used during validation. Verify the C of A by sampling each lot at the source, and at critical points of use, such as at sterile filling machine. Verify that they all meet specifications in accordance with the United States Pharmacopoeia (USP) standards and that the lot has been released from quarantine. Sampling Method 1. Use aseptic technique when gathering all samples. 2. Flush each port for at least 10 - 15 seconds (with the valve fully open) before sampling. 3. Flow meter should be set to correct flow rates when testing. 4. Take microbial, dew point, particle counts, as well as oil mist and nitrogen purity samples from specified sample valves. N o v e m b e r 2 0 0 5 • Vo l u m e 1 2 , N u m b e r 1 15 David W. Vincent and Herbert Matheson 5. Perform viable and nonviable particulate testing at worst-case sampling point, usually the point farthest away from the source. Data Analysis The testing of gas systems for microbial count may not give any beneficial information if certain environmental conditions for the systems are not recreated during incubation. For example, if a sample from a nitrogen gas system is taken and incubated aerobically, certain organisms may not grow in those conditions (oxygen environment). It would be more logical to incubate the growth media in the same environmental conditions to which the organism is accustomed. Therefore, under certain conditions, anaerobic monitoring may be acceptable for monitoring certain types of gases. Most companies test for microbial contaminants using TSA, which is incubated aerobically and at 30˚ - 35˚C for 48 - 72 hours. This may not be effective in isolating organisms that may not survive under these environmental conditions. When performing this test, consider what you are trying to accomplish. If it is to verify that the gas is free from microbial contaminants, then proper growth conditions should be simulated. Also, most organisms will not survive in the harsh environments created by certain gas production and storage. Whatever test method is used to detect microbial contaminants, it should be properly validated. ROUTINE MONITORING PROGRAM FOR CRITICAL UTILITIES Once the PQ is completed, the “real time” validation of the critical utilities begins. Usually, the PQ study is performed over a short period of time and with intensive sampling. But the routine environmental monitoring is performed during the life of the facility and usually involves less intense sampling. The data collected from routine environmental monitoring programs includes: seasonal variations and manufacturing activities along with maintenance and cleaning activities. The most effective environmental monitoring programs are the ones with clear and precise procedures. 16 Journal of Validation Technology Routine Environmental Monitoring Program When establishing a routine environmental monitoring program, the data for the PQ study should include the starting point for determining the sampling sites and frequencies of testing. It is also important to have an accurate drawing indicating the sampling sites. The program should also include environmental worksheets to record the test results. The worksheet data can be entered into a computer-aided software program, which can be used to trend and perform queries on environmental data. Establishment of Alert and Action Limits Alert Limits - The concentration of viable and non-viable particulate in a controlled environment that, when exceeded, signals a potential drift from normal operating conditions. Action Limits - The concentration of viable and non-viable particulate in a controlled environment that, when exceeded, signals a potential drift from normal operating conditions, and which requires an investigation and corrective action. Alert and action limits are usually derived statistically from historical data. These limits are conservative measures designed to signal potential drift from historical or design performance characteristics. The establishment of alert and action limits should be written and utilized in a consistent, non-arbitrary manner. It is important to remember that alert and action levels should not be extensions of the product specifications. If an alert level is exceeded, corrective action may not be required, but records should show that the excursion was recognized. If the alert levels consistently exceed their set limits, an investigative action should be taken. If an excursion occurs above an action level, at minimum, one should review the data. Additional action should be taken in the form of an investigation, and corrective and alert notices to responsible parties and departments should be completed and delivered to those parties. When an action limit is exceeded, an investigation and corrective action should be performed. A list of the types of actions to be taken follows; actions should be appropriate to the situation and should not necessarily be limited to these suggestions: David W. Vincent and Herbert Matheson • Generate an Environmental Deviation Report (EDR) form. • Issue an Alert Notice. • Investigate the Environmental Deviation. • Perform Corrective Action. • Resample Out of Limit Locations. • Review maintenance and cleaning logs. • Perform gram stain/identification of isolated organism(s). • Determine sensitivity of isolate to disinfectant being used. • Review risk of product contact. filled out under the following or similar circumstances: Water Systems 1. When a QC sample consistently exceeds alert limits for all QC test results 2. When a QC sample of water exceeds the action level for bacterial count 3. When a QC sample of water exceeds the action level for endotoxin limits 4. When a QC sample of water exceeds the limit for USP chemistry 5. When a possible minor malfunction in the water system is observed When acceptable levels are re-attained, no further action is usually required. The results from the retest are recorded on the Environmental Deviation Report form, disposition as Pass, and filed for future reference. If the retest indicates that acceptable levels have not been met, the Quality Control (QC) Department will initiate an Investigation Report to Directors of Quality Assurance (QA) and Manufacturing with a description of the deviation. It is the responsibility of the Manufacturing or Facility Department to conduct an immediate investigation and to initiate corrective actions to restore the area to normal operating conditions. QA is responsible for evaluating the impact of the conditions on product quality. After corrective actions have been taken, the affected location(s) should be retested at least three times. Acceptable levels are re-attained if three consecutive re-tests meet acceptable levels. Once the system is again in compliance, QA is responsible for releasing the system to Manufacturing. Clean Steam Systems 1. When a QC sample consistently exceeds alert limits for all QC test results 2. When a QC sample of clean steam condensate exceeds the action limits for bacterial count 3. When a QC sample of clean steam condensate exceeds the action limits for endotoxin levels 4. When a QC sample of clean steam condensate exceeds the action limits for USP chemistry 5. When a possible minor malfunction in the water system is observed Corrective Action Program for Critical Utility Systems The purpose of a corrective action program is to investigate critical system failures, to report and document these failures, and to make the necessary corrective action to bring the system into compliance. The following program is applicable to critical utility systems, which include: controlled environmental Heating, Ventilation, Air Conditioning (HVAC), Purified Water, Water-For-Injection (WFI), Process Gases, and Clean Steam systems. Program Procedures An environmental investigation applies to any situations not considered an immediate threat to a critical system, but which, if allowed to continue, may become serious. An Environmental Deviation Report (EDR) must be HVAC Systems 1. When a QC sample consistently exceeds alert limits for all QC test results 2. When a questionable condition (such as sanitation, or potential contamination) in the core and associated areas is observed 3. When an environmental monitoring sample exceeds the action level for microbial or particulate counts 4. When a temperature or humidity reading is outside the specified range 5. When a pressure differential reading is outside the specified range 6. When a possible minor malfunction in the HVAC system is observed Gases Systems 1. When a QC sample consistently exceeds alert limits for all QC test results 2. When gas system test results are outside the specified range 3. When a QC sample of gas exceeds the action level for bacterial count 4. When dew point exceeds the action level N o v e m b e r 2 0 0 5 • Vo l u m e 1 2 , N u m b e r 1 17 David W. Vincent and Herbert Matheson 5. When a QC sample for gas purity fails 6. When a QC sample of gas exceeds the action level for oil mist Investigation and Corrective Action The following steps should be taken: 1. QA and the responsible Facility (facility related) or Production (process or equipment related) Department will investigate the system and recommend corrective action. 2. Document the proposed corrective action on the Environmental Deviation Report (EDR) form. 3. The facilities or production manager will sign the EDR form and return it to QA for review and approval of corrective action. 4. Perform the corrective action immediately, if possible. If the action requires planning, materials, or time to implement, perform it as soon as possible. 5. QA will review the proposed corrective action and any subsequent QC retesting data. If the investigation or the data shows that the system is in control, QA will sign the form, distribute copies, and file the QA copy of the form. 6. Distribute copies to QA, Facility Manager, Production, and the system and product files. Manufacturing Alert Notice for Action Limit Failures A Manufacturing Alert Notice applies to any situation that is considered an immediate threat to a critical system or process equipment and that may have a direct impact on the quality of the product. A manufacturing alert notice is issued to the Manufacturing Department notifying them that a system may or may not be used (depending on the circumstance and severity of the problem) until corrective action has been taken to bring it back into compliance. A manufacturing alert notice form must be filled out under the following or similar circumstances: 1. When two or more retest samples exceed the action limits 2. When a questionable condition (such as sanitation, or potential contamination) is observed 3. When a possible minor or major malfunction in the utility system that could possibly compromise the integrity of the production area is observed 4. When a QC test sample exceeds the action limits 5. When a system is still not in compliance after the first environmental corrective action or investigation was taken 18 Journal of Validation Technology Corrective Action Program An Environmental Deviation Report form is initiated immediately when action levels are exceeded. A number is assigned to the deviation for traceability. The number consists of three groups of digits: the first group represents the system, the second group represents the year, and the third group is an assigned sequential number (e.g., Environmental Monitoring: EM-05-01; Water-For-Injection: WF-05-01; Clean Steam: CS-05-01; and Nitrogen Gas: NG-05-01). The Manufacturing Manager, or appropriate individual(s), is immediately notified of the type of deviation; the appropriate corrective action is taken and the manager’s signature and the date are obtained. An Environmental Deviation Report form will usually include the following sections: Section 1 1. EDR number 2. System affected 3. Location where levels have been exceeded 4. Room number Section 2 1. Sample Type (surfaces, viable or non-viable airborne particles) 2. System Sampled (Gas, WFI, Purified Water, Clean Steam, HVAC) 3. Area Classification (if applicable) Section 3 1. Initial Sample Data 2. QC Test Results (collection data, site, sample data action levels) 3. Recommended Corrective Actions (if applicable) Section 4 1. Corrective Actions Taken (requires a description of the action taken) Section 5 1. Retest Sample Data 2. QC Test Results (collection data, site, sample data action levels) 3. EDR Disposition (re-sampling results: pass or fail) Section 6 1. Other Action Taken (if applicable) 2. Results Acceptable (no further steps required) 3. Not Acceptable (investigation continues) David W. Vincent and Herbert Matheson After the investigation is completed, any supporting documentation should be included as a part of the final investigation report. Maintain a history file on each system to determine whether there are any recurring failures that may require modification or redesign of the system. Water Systems Corrective Action Corrective actions for pretreatment water, Purified Water, and Water-For-Injection systems may be included, but are not limited to, the following: • Additional sampling and testing • Review and repeat sanitization procedures • Review sampling and testing technique • Review validation data • Check on possible unusual events during sampling and testing • Review 0.2mm filter and tank vent filter integrity test results • Review maintenance and sanitization logs • Perform gram stain identification of isolated organism(s) • Steam-In-Place (SIP) entire system • Inspect all major components on the pretreatment, purified, and WFI systems • Review risk of product contact Corrective Action For Clean Steam System Corrective actions for clean steam systems may include, but are not limited to, the following: • Additional sampling and testing • Review sampling and testing techniques • Review validation data • Check on possible unusual events during sampling or testing • Review WFI test results • Review maintenance logs • Perform gram stain identification of isolated organism(s) • Check sampling condenser • Review risk of product contact Corrective Action For HVAC System Corrective actions for controlled environments may include, but are not limited to, the following: • Additional sampling and testing • Review and repeat sanitation procedures • Review sampling and testing techniques • Review validation data • Retrain clean room personnel on proper techniques • Check on possible unusual events during sampling or testing • Review pressure differential information • Review clean room and HEPA filter certification data • Review maintenance and cleaning logs • Perform gram stain identification of isolated organism(s) • Determine sensitivity of isolate to disinfectant being used • Review risk of product contact Corrective Action For Gas Systems Corrective actions for gas systems may include, but are not limited to, the following: • Additional sampling and testing • Review sampling and testing technique • Review validation data • Check on possible unusual events during sampling and testing • Review point of use filter integrity test results • Review maintenance logs • Perform gram stain identification of isolated organism(s) • Review Certificate of Analysis from vendor • Review risk of product contact No further action is required when acceptable levels are re-attained. Record retest results on the Environmental Deviation Report form, disposition as Pass, and file for future reference. If retest indicates that acceptable levels have not been met, initiate another Investigation Report to Directors of QA and Manufacturing with the description of the deviation. It is the responsibility of Manufacturing to conduct an immediate investigation, and to initiate corrective actions to restore the area to normal operating conditions. QA should be responsible for evaluating the impact of the conditions on product quality. After corrective actions have been taken, the affected location(s) will be retested at least three times. Acceptable levels are re-attained if three consecutive re-tests meet acceptable levels. N o v e m b e r 2 0 0 5 • Vo l u m e 1 2 , N u m b e r 1 19 David W. Vincent and Herbert Matheson Revalidation of Critical Systems Revalidation will occur when any significant changes or alterations occur to any above systems, (e.g., construction, changing and adding new HEPA filters, and modification of WFI, gas, and clean steam system). The extent of the testing will be determined on a case-by-case basis and will be properly documented and filed. Revalidation for a critical utility should be performed annually or semi-annually depending on the criticality of the system. The revalidation SOP should be written to include the extent of testing and the system under the program. CONCLUSION As facility construction costs continue to escalate, healthcare companies will struggle with the challenge of meeting regulatory requirements and running a profitable business. The “current” in cGMP requires continuous improvement, so Industry must persist in searching for methods that reduce costs and improve efficiency. As life science professionals, we should never allow ourselves to become complacent about investigating and employing new approaches and technologies in our industry. The integration of qualification activities into the commission phase can be a cost effective method for bringing critical utilities online. The most effective method of ensuring the quality of any product is through a strong, routine environmental monitoring program. Alert and action limits are the heart of the monitoring program. The FDA Guidelines state: “Maximum microbial limits should be established along with a definite course of action to be taken in the event that samples are found to exceed the limits.” There is no real continuity within the industry when it comes to the validation of most critical utility systems. The inspection of these systems varies from inspector to inspector. This is why it is important to use the regulatory guideline documents when writing and executing critical utility system validation protocols. This article is just one example of how critical systems can be validated or qualified. There are many methods of qualifying critical utility systems, but a sound, logical approach is the basis of any good method. ❏ (This concludes “Design, Construction, Commission, and Qualification of Critical Utility Systems.” The first part of this article, An Overview of Critical Utility Systems, appeared in the May 2005 issue of this Journal. The second part, “Water Systems,” appeared in the August 2005 issue.) 20 Journal of Validation Technology ABOUT THE AUTHORS David W. Vincent has over 25 years experience in the Biopharmaceutical Industry with 19 years dedicated to the fields of validation and engineering. He has a B.S. degree in Microbiology and Mechanical Engineering Technology; Mr. Vincent has consulted for many companies both nationally and internationally. He has presented many training seminars and has written numerous articles and technical guides regarding validation topics. Mr. Vincent teaches “Validation Program for the Pharmaceutical, Biotechnology, and Medical Device Industries” at San Diego State University (SDSU) for their Regulatory Affairs Master Degree program. Currently, Dave is the Chief Executive Office (CEO) for Validation Technologies Incorporated (VTI), a worldwide validation and technical services company. VTI is also a certified commissioning company that offers commissioning and startup functions for the Healthcare Industry. Dave can be reached by phone at 800-930-9222, by fax at 858673-3677, or by e-mail at [email protected]. (Web site is located at www.validation.org) REFERENCES 1. Center for Drugs and Biologics, Center for Devices and Radiographic Health, “Guidelines on General Principles of Process Validation,” FDA Rockville, Maryland, 1987. 2. “cGMP Compliance in Architecture and Construction of Biopharmaceutical Manufacturing Facilities” BioPharm, Prepared January-February, 1993. 3. “Code of Federal Regulations Section 21 Parts 200 to 299 and Parts 600 to 799,” Food and Drug Administration (FDA). 4. “Guidelines for Bulk Drug Manufacturers,” Food and Drug Administration (FDA). 5. Center for Drug Evaluation and Research, Center for Biologics Evaluation and Research, Office of Regulatory Affairs, “Guidelines on Sterile Drug Products Produced by Aseptic Processing,” FDA Rockville, Maryland, June 1987. 6. PDA Environmental Task Force, “Fundamentals of a Microbiological Environmental Monitoring Program,” Vol. 44, Supplement 1990. 7. The Institute for Applied Pharmaceutical Sciences, “Microbiological Control and Validation,” March 7-9, 1994. 8. Powell-Evans, K., “Streamlining Validation: Value Added Qualifications.” Institute of Validation. December 2000. Newsletter. David W. Vincent and Herbert Matheson IVT is Currently Accepting Nominations For This Year’s 9. Graham C. Wrigley and Jan L. du Preez, Ph.D., “Facility Validation: A Case Study for Integrating and Streamlining the Validation Approach to Reduce Project Resources” Journal of Validation Technology Volume 8, Number 3, May 2002, pp: 214-235. * References noted above apply to the entire three-part article and represent both specific references and suggested reading. Article Acronym Listing ASHRAE American Society of Heating, Refrigerating and Air- Conditioning Engineers, Inc. BMS Building Management System CFR Code of Federal Regulations CFU Colony Forming Units cGMP Current Good Manufacturing Practice CoA Certificate of Analysis CQ Construction Qualification DDC Direct Digital Control DOP DiOctyl Phthalate EDR Environmental Deviation Report EM Environmental Monitoring FDA Food and Drug Administration HEPA High Efficiency Particulate Air HPC Heterotrophic Plate Count HVAC Heating, Ventilation, and Air Conditioning IQ Installation Qualification ISO International Organization for Standardization OQ Operational Qualification PDA Parenteral Drug Association PQ Performance Qualification QA Quality Assurance QC Quality Control SDA Sabouraud Dextrose Agar SIP Steam-In-Place SMA Sterilizable Microbial Atrium SOP Standard Operating Procedure TBA Test, Balancing, and Adjustment TSA Tryptic Soy Agar USP United States Pharmacopoeia WFI Water-For-Injection MICROBIOLOGIST OF THE YEAR 2005! ★ ★ ★ ★ ★ • • • • NOMINEES WILL BE JUDGED IN ONE OR MORE AREAS INCLUDING: MICROBIOLOGICAL ADVANCES ACHIEVEMENTS IN MICROBIOLOGY DEDICATION TO INDUSTRY INDUSTRY CONTRIBUTION This new award program is being created to recognize and honor industry’s most talented microbiology professionals. As recipient of this honor, the Microbiologist of the Year will receive: ✓ IVT’s Microbiologist of the Year 2005 Award ✓ The opportunity to be the honored guest of the 2005 banquet and award ceremony ✓ Complimentary registration to IVT’s Microbiology of the Year Event in 2006 ✓ A feature article and biography in Pharmaceutical Technology published by Advanstar Communications, Inc. ✓ A special announcement in IVT’s brochure and program guide on the MICROBIOLOGY EVENT OF THE YEAR 2006 ✓ A free one-year subscription to IVT’s Journal of Validation Technology or Journal of GXP Compliance TO LEARN MORE VISIT: w w w. i v t h o m e . c o m / n o m i n a t e N o v e m b e r 2 0 0 5 • Vo l u m e 1 2 , N u m b e r 1 21
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