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Risk Identification For Aseptic Processing
Risk Identification For Aseptic Processing
2. Risk control: Identify a leader and necessary resources; and specify a timeline,
deliverables and appropriate level of decision-making for the risk
Risk reduction
Risk acceptance;
Review of Risk Assessment Concepts for FMEA and HACCP
› Risk control: The following questions need to be asked
What can be done to reduce or eliminate risks?
What is the appropriate balance among benefits, risks and resources?
Are new risks introduced as a result of the identified risks being controlled?
› b) Description/attributes
Assumes comprehensive understanding of the process and that critical process
parameters (CPPs) have been defined prior to initiating the assessment tool
ensures that CPPs will be met.
Assesses potential failure modes for processes, and the probable effect on
Outcomes and/or product performance
Once failure modes are known, risk reduction actions can be applied to eliminate,
reduce or control potential failures
Highly dependent upon strong understanding of product, process and/or facility
under evaluation
Output is a relative “risk score” for each failure mode
Module 03 Attachment No. 2.doc,
Module 03 Attachment No. 3.doc
Risk_Analysis.pdf
HACCP: Hazards analysis and critical control
points
› Potential applications
Better for preventative applications rather than reactive
Great precursor or complement to process validation
Assessment of the efficacy of CPPs and the ability to consistently execute
them for any process
› Description/attributes
Identify and implement process controls that consistently and effectively
prevent hazard conditions from occurring
Bottom-up approach that considers how to prevent hazards from occurring
and/or propagating
Emphasizes strength of preventative controls rather than ability to detect
QRM application during validation and qualification
› QRM principles can be used to narrow the scope of IQ, OQ and PQ to cover only the
essential elements that can affect product quality. It can also be used to determine the
optimal schedule for maintenance, monitoring, calibration and requalification.
Fill reproducibility – rejection( with lock) for no fill and no stopper- fill container &stopper container counter
Change parts design for fitting and removing with minimum use of tooling
- Design of ease of cleaning and removing of metallic fragments generated by the crimping process
› The investigators noticed during the inspection one of the operators sanitizing his hands
with (b)(4) immediately prior to conducting his own personnel monitoring sampling. Your
personnel monitoring program should include appropriate sampling and practices to
reflect whether personnel maintain asepsis during sterile drug manufacture.
› In addition, the (b)(4) “Dynamic Airflow Visualization” video provided in your firm’s
response shows an operator spraying his hands with (b)(4)(b)(4)(b)(4)% directly over
the air viable microbial plate. This practice is unacceptable because the environmental
monitoring results from plates sprayed with (b)(4) may be inaccurate and may not reflect
the actual microbiological environment of the Class 100 (ISO 5) room.
› Your firm has not thoroughly investigated the failure of a batch or any of its components
to meet its specifications whether or not the batch has already been distributed [21
C.F.R. 211.192]. For example,
› The inspection documented that (b)(4) Injection, batch # (b)(4), failed the sterility test.
Your quality control unit repeated the test on a new sample to confirm the original result
prior to initiating an investigation. The quality control unit’s decision to perform a retest
without conclusive assignable laboratory cause is not in accord with USP <71> and is
an unacceptable practice
FDA Warning Letters
› FDA response
› Please include in the response to this letter a copy of your final sterility failure
investigation report for (b)(4) Injection, batch # (b)(4). Your response should include a
detailed explanation of your root cause analysis and the corrective actions implemented to
prevent recurrence of the event(s) that lead to the contamination of the lot. Your firm
should also indicate if a media fill was conducted as part of your sterility failure evaluation.
If so, provide a copy of the media fill protocol and report as part of your response to this
letter. Also include a list of all lots of sterile drug products manufactured at your facility that
initially failed the sterility test, and that were released based on a passing re-sample or re-
test result. Provide the product name, original test and re-test date, microorganism
isolated and product destination.
FDA Warning Letters
› Your firm has not established appropriate written procedures designed to prevent
microbiological contamination of drug products purporting to be sterile [21 C.F.R.
211.113(b)]. For example,
› a. During the aseptic filling of two injection batches on filling line (b)(4), where (b)(4)
injection for the U.S. is filled, employees
› were observed following poor aseptic techniques. Specifically, movements inside the
class A area were not slow and deliberate; operators and an engineer were observed
with exposed facial skin during the filling operation; and a force was observed in a class
B (ISO 6) area and was then used to remove fallen ampoules from the aseptic
processing line in the class A (ISO 5) area.
› b. Employees who perform critical duties in your aseptic filling line (b)(4) did not
participate in an (b)(4) line qualification (process simulation) during 2010, 2009, and
2008.
› c. The tubing ends used to connect the solution tanks to the filling line (b)(4) are not
protected prior to sterilization to reduce the potential of contamination after sterilization,
and prior to the aseptic connection.
› d. The disinfectant efficacy studies have not been completed for three of the (b)(4)
disinfectants used to sanitize surfaces in the sterility testing suite and production aseptic
core filling line (b)(4).
› Your response indicates corrective action through training employees, equipment
purchase, and procedural improvements. However, your response fails to specifically
address the observed deficiencies and whether the products already distributed have
been evaluated.
FDA Warning Letters
› Your firm used dried/desiccated media agar plates for environmental monitoring
testing used to support the release of batches. On November 15, 2011, you
documented that 155 of a total of 247 media plates evaluated (more than 50%)
were dried. The use of dried agar plates, which do not reliably support microbial
growth, to recover microbial contamination is inadequate.
›
b) On November 14, 2011, the FDA investigator observed desiccated
environmental monitoring plates in your incubators. However, your analysts only
recorded the results as dried media but not the counts from the plates (if any). On
this same day, the FDA investigator observed plate “(b)(4),” sampled on November
9, 2011, to have growth of 1 Colony Forming Unit (CFU). However, your firm
documented the result of this plate’s reading as "SAUSEN MEDIUM", dry medium,
and failed to report the microbial growth.
›
c) Your environmental monitoring data for January 2009 through October 2011
contains documentation of only two action limit excursions in the Grade A
manufacturing areas. In apparent contradiction, during an FDA visit to your
microbiology laboratory on November 14, 2011, nine plates, collected as part of the
environmental monitoring program from the Grade A manufacturing area were
found inside an incubator in the microbiology laboratory with visible growth of
microorganisms.
FDA Warning Letters
› The operator of filling line F200 was observed leaning over the top of (b)(4) containing filled
opened sterile vials during the loading of the (b)(4), thereby blocking the unidirectional airflow
over the open vials.
› b) The operator was observed compromising the connection’s sterility of the filling line by
exposing the (b)(4) to the Grade B area during this aseptic connection with no further (b)(4) of
the line after its installation.
› c) During the set-up for the filling line, water sprayed from the filling line directly onto an
operator, which wet his gown. The operator continued line setup activities without re-gowning
until instructed to stop by firm management after an FDA investigator pointed out the concern.
› d) Uncovered (b)(4) are not maintained under Grade A conditions during their movement from
the (b)(4) located in Room (b)(4) to their Grade A staging area near the F200 filling line in
Room (b)(4). The (b)(4) are transported through a Grade B area to their staging
area. Additionally, during the filling operation, the operator was observed removing the (b)(4)
and (b)(4) from their Grade A staging area through a Grade B area to the Grade A area, where
the (b)(4) and (b)(4) are loaded with vials, and placed on a (b)(4). These (b)(4)
FDA Warning Letters
› Your firm failed to conduct adequate investigations of three media fill failures in the
aseptic filling line used to produce sterile products. Your firm uses (b)(4) vials to fill
(b)(4), which is shipped to the US market. Your firm performed the last successful
media fill using the (b)(4) vials on November 28, 2010, Lot (b)(4), and the last
successful media fill lot for (b)(4) vials on February 26, 2011.
› Significantly, the three media fill failures on filling line F200 occurred from May to
September 2011. While the last successful (b)(4) media fill on this line (F200) was
conducted on November 28, 2010, your firm released batches manufactured on this
same filling line between November 28, 2010 and February 26, 2011. Your firm failed
to adequately evaluate the impact of the contamination hazards revealed by these
media fill failures on commercial batches (e.g., (b)(4)).
› b) Your investigation concluded that the probable root cause for the media failure was
the contamination of Media Fill Lot (b)(4) by an earlier media fill Lot (b)(4) that had
failed. In your response, you attribute these two media fill failures to the testing of your
(b)(4) Vessel (b)(4) procedure, and proposed changing the (b)(4) and revising your
procedures. Your firm’s investigation found that both of these media fills were
contaminated with Burkholderia cepacia. Your investigation was not extended to other
areas of the aseptic operation. For example, deficient design or control of rooms,
equipment, or the Water for Injection (WFI) system, may also have caused the
introduction of these water-borne microbes to the aseptically processed vials.
Environmental Monitoring
› Physical
› Particulate matter
› Differential pressures
› Air changes, airflow patterns
› Clean up time/recovery
› Temperature and relative humidity
› Airflow velocity
washing of glass containers and rubber stoppers should be validated for endotoxin
removal/NACl removal
In clean rooms:
› Position plates directly under HEPA filters
› Position plates well away from human activity
› Use “old” plates that are dehydrated
› Do not monitor filling machine set-up
› Do not use Sabouraud Dextrose media when fungal spores are likely to be present
In water testing:
› Run water at the test point for 5 min. (Production won’t do that)
› Store the water sample as long as possible before testing (cells attach to container
walls)
› Use the pour plate method
› Use the incorrect medium
In the sterility test:
› Allow the membrane filter to dry out under vacuum
› Place filter in the oxidised layer of Thioglycollate medium
› Use old Thioglycollate that is fully oxidised
Contamination sources
› Raw material suppliers
› Inadequate cleaning
› Personnel
› Inadequate procedures
› Inadequate processe Environment
External Sources:
› Use of re-circulated air from the manufacturing area, provided no cross contamination
risk.
› Careful selection of filters to match particular application
› Careful location of fresh air intakes.
› Location of the facility.
Container preparation
› Four forms of contamination
Bioburden: Viable microbiological count CFU
Endotoxins:Pyrogenic cell wall materials resulting from growth
and degradation of microorganism
Extraneous particulates: Solid particulate matter resulting from
container manufacturing, packaging and staging processes
glass fragment)
Extraneous chemicals: e.g: excess quantities of surface
treatment chemicals