Summary of Evaluation and
Documentation Basics
Copyright ©2009 by Gary Fromert, M.S.
PETRI Project, Northampton Community College
After completing this exercise, you should be able to:
1. Recognize the difference between environmental monitoring and environmental
control programs.
2. Demonstrate an understanding of how bioburden is determined.
3. Demonstrate an understanding of how alert and action limits are established.
4. Demonstrate an understanding of what is meant by validation.
Environmental Monitoring describes the microbiological testing undertaken in order to
detect changing trends of microbial counts and micro-flora growth within cleanroom or
controlled environments. The results obtained provide information about the physical
construction of the room, the performance of the Heating, Ventilation, and AirConditioning (HVAC) system, personnel cleanliness, gowning practices, the equipment,
and cleaning operations.
In developing an adequate environmental monitoring program, in this case the
establishment of bioburden, there should be a balance between using resources efficiently
and monitoring at sufficiently frequent intervals so that a meaningful picture can be
obtained. Sources of guidance with respect to monitoring frequencies that are specified
within the United States Pharmacopoeia (USP) <1116> may not be suitable for all
facilities. Some guidance can be obtained from the International Organization for
Standardization’s (ISO) standards: principally ISO 14644 and ISO 14698. However,
these do not always fit with regulatory guidance documents because they apply to
controlled environments across a range of industries other than pharmaceuticals, where
standards can be higher [1].
When establishing an environmental control program, the frequency of monitoring
different controlled areas can be determined based on factors relevant to each specific
area. The establishment of an environmental control program is designed to target
monitoring of critical process steps, formulate alert and action levels, and validate the
process.
This laboratory explores the application of an environmental monitoring and control
program by examining the following key areas: 1) Determination of bioburden, 2)
Establishment of alert and action limits, and 3) Validation and documentation practices.
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Determination of Bioburden [2]
Bioburden testing on the products in the pharmaceutical or medical field provide control
of microbial levels. Bioburden test determines the number of viable microorganisms on a
product. Bioburden testing is a tool for establishing and evaluating many aspects of a
manufacturing process. For the bioburden data to be valid there must be some measure of
the ability of the test procedure to detect the organisms that are or may be present. An
assessment of the bioburden testing procedure is evaluated for its overall ability to
recover organisms.
The method used for microbial monitoring and validation should be capable of isolating
the number and type of organisms that have been deemed significant relative to inprocess system control and product impact for each individual system. Bioburden testing
can be used to:
1) Determine the total number of viable microorganisms in or on a medical device,
container or component after completion of all in-process steps before sterilization.
2) Act as an early warning system for possible production problems which could lead to
inadequate sterilization or possible product recall.
3) Calculate the necessary dose for effective radiation sterilization, and to monitor
product routinely to ensure adequate dosing.
All bioburden methods should demonstrate the ability to recover a broad spectrum of
microorganisms (bacteria, yeast, and molds) from the product. Recovery testing provides
a measure of the ability of the bioburden test procedure to detect organisms that may or
may not be present. The specific bioburden recovery method chosen for a given product
should be validated.
A bioburden procedure is typically designed by selecting appropriate parameters for the
type of product to be tested and the level and types of organisms expected to be present
on that product. A particular bioburden procedure may result in lower or higher recovery
efficiency, based simply on the choice of parameters. Some of the parameters to be
considered are:
1) Sample preparation (e.g., cutting, disassembly).
2) Extract type (e.g., phosphate buffer, USP Fluid D).
3) Agitation method (e.g., mechanical shaking, sonication).
4) Extract handling (e.g., plating, filtration).
5) Media type (e.g., trypticase soy agar, Sabouraud agar).
6) Incubation conditions (e.g., 30°–32°C, 5 to 7 days).
The choice of parameters for the test design must take into account the test sample
material, which can have a significant impact on the recovery of organisms. For example,
the same test parameters would most likely not be chosen for a liquid injectable and a
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patient drape, simply because of the material differences. Furthermore, the choice of
parameters should consider the expected types and levels of organisms. A bioburden
procedure designed for an ultraclean pharmaceutical would not be optimum for a cotton
surgical dressing. Lower levels of organisms require different extract-handling techniques
(for example, procedures involving filtration versus those involving plating). And, of
course, the types of organisms expected to be present on a particular item affect the
selection of media type and incubation conditions.
There are three reasons to conduct a bioburden recovery test:
1) Evaluate the test procedure.
2) Assess antimicrobial qualities of the product.
3) Establish a recovery factor for the test.
Unfortunately, there are very few standards or guidelines available that address bioburden
recovery testing. Nonetheless, each of these guidelines tends to be more applicable to
either pharmaceutical industry products or the medical device industry and its products.
Establishment of Alert and Action Limits [3]
When establishing alert and action limits for routine biological monitoring of cleanroom
operations, companies often implement alert and action limits based only on the
biological sampling data. This may result in frequent alert and action responses because
the data gathering sequence was too short to provide the range of reasonably expected
results.
Alert and Action levels are established based on historical data gained from routine
monitoring. As process control indicators, alert and action levels are designed to allow
remedial action to occur that will prevent a process from deviating completely out of
control and producing a product that is unfit for its intended use. Alert and action levels
should be derived from an evaluation of historic monitoring data called a trend analysis.
When environmental limits have been exceeded, actual product test data may be far
below product limits. In this scenario, companies create a reaction/response cycle based
on arbitrarily imposed limits from original environmental sample results for the process
validation. The escape from this cycle is to float limits upward based on correlation of
new environmental data with product data collected at the same time. This approach
allows a two-way street within which manufacturers can operate.
When system controls are inadequate to provide safe and efficacious products, then the
controls must be tightened. Conversely, when system controls far exceed those required
for adequate control of a production area, the identified limits may be loosened, based on
actual correlated test data. The principles and concepts of statistical process control are
useful in establishing Alert and Action levels and in reacting to trends.
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An Alert level in microbiological environmental monitoring is that level of
microorganisms that shows a potential drift from normal operating conditions. Exceeding
the Alert level is not necessarily grounds for definitive corrective action, but it should at
least prompt a documented follow-up investigation that could include sampling plan
modifications. Alert levels are usually based on historical information gained from the
routine operation of the process in a specific controlled environment.
An Action level in microbiological environmental monitoring is that level of
microorganisms that when exceeded requires immediate follow up and, if necessary,
corrective action.
These levels are usually re-examined for appropriateness at an established frequency.
When the historical data demonstrate improved conditions, these levels can be reexamined and changed to reflect the conditions. Trends that show a deterioration of the
environmental quality require attention in determining the assignable cause and in
instituting a corrective action plan to bring the conditions back to the expected ranges.
However, an investigation should be implemented and an evaluation of the potential
impact this has on the product should be made. Data generated by microbiological testing
should be monitored for trends with alert and action levels designed to allow trends to
form before critical action is taken.
In a new facility, these levels are generally based on prior experience from similar
facilities and processes; and at least several weeks of data on microbial environmental
levels should be evaluated to establish a baseline.
Validation and Documentation Practices [4]
Process Validation is defined as the action taken to demonstrate, and to provide
documented evidence that a process will, with a high degree of assurance, consistently
achieve the desired and intended results. Validation has also been considered to have
three aspects, or possible strategies - Prospective Validation, Concurrent Validation, and
Retrospective Validation.
1. Prospective validation applies to new processes and new equipment, where studies are
conducted and evaluated, and the overall process/equipment system is confirmed as
validated before the commencement of routine production.
2. Concurrent validation applies to existing processes and equipment. It consists of
studies conducted during normal routine production and can only be considered
acceptable for processes which have a manufacturing and test history indicating
consistent quality production.
3. Retrospective validation applies to existing processes and equipment, and is based
solely on historical information. Unless sufficiently detailed past processing and control
records are available, retrospective validation studies are unlikely to be either possible or
acceptable. For example, it would be necessary to establish that the process had not been
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modified and that the equipment was still operating under the same conditions of
construction and performance as documented in the historical records. Maintenance
records and process change control documentation would be necessary to support any
such claim. Furthermore, the incidence of process failures, and records of rejects and/or
reworking would need to be carefully evaluated for evidence of inconsistency in the
process. Manufacturing, maintenance, testing and calibration data would all need to
demonstrate process uniformity, consistency and continuity.
There are three critical validation concepts for establishing process validation:
1) The overall process is understood.
2) The equipment is appropriately specified and designed, equipment is properly installed
and maintained, and the equipment is operating as specified and designed.
3) The process can be validated.
Validation involves establishing documented evidence which provides a high degree of
assurance that a specific process will consistently produce a product meeting its
predetermined specifications and quality attributes. The FDA demands that biotech and
pharmaceutical manufacturers prove that processes will consistently do what they are
proposed to do. Although the FDA doesn't define the type or format of documentation
required to validate each system, certain formats are accepted and expected.
A Validation Plan, sometimes called a Master Plan, is a clear and concise explanation of
management philosophies and expectations concerning the validation programs.
Specifically, it will outline responsibilities for each phase of the system design and the
implementation process.
Protocols are written records clearly defining the objectives and methods that will be
used for the validation programs. An important part of the protocol is the description of
the testing method including who will test the system, how they will test it and what data
is to be collected and reported.
Protocol changes are documented requirements specifying who and how changes to
parameters, thresholds, and acceptance criteria are made after approval. It is not
impossible to make changes after or during testing, but these changes must be properly
implemented and approved to be validated.
Specifications are written to clearly and completely describe what a system will do. It
will include all measurable and meaningful operating parameters. This document is
reviewed and approved by responsible personnel at the manufacturer's facility before
implementation.
The Factory Acceptance Test requires a document describing specific inputs that must be
activated with the resultant outputs they produce for every step of the process. This
document allows for management sign off or confirmation that each part of the entire
system has been tested.
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This is an extremely brief summary of validation documentation requirements needed for
process systems within the pharmaceutical industry. Such documentation must be highly
customized for each manufactures process.
Laboratory Review
1. Explain what is meant by an environmental monitoring program.
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2. Explain what is meant by an environmental control program.
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3. What is the purpose of bioburden testing?
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4. What is required for a bioburden procedure to be valid?
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5. What can bioburden testing be used for?
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6. All bioburden methods should demonstrate the ability to:
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7. What can have a significant impact on the recovery of organisms in a bioburden test?
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8. What reasons are there to conduct a bioburden recovery test?
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9. Establishment of Alert and Action levels are based on:
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10. Alert and action levels are derived from an evaluation of historic monitoring data
called:
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11. When system controls are inadequate to provide safe and efficacious products,
control levels should be?
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12. When system controls far exceed those required for adequate control of a production
area, the identified control levels should be?
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13. An Alert level in microbiological environmental monitoring is:
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14. An Action level in microbiological environmental monitoring is:
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15. When the historical data demonstrate improved conditions, alert and action levels can
be?
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16. Process Validation is defined as:
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17. What are the three aspects or possible strategies that process validation must be
considered to have?
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18. What are the three critical validation concepts for establishing process validation?
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19. What is necessary to provide a high degree of assurance that a specific process will
consistently produce a product meeting its predetermined specifications and quality
attributes.?
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20. What is a Validation Plan?
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Glossary
Glossary of relevant terms taken from USP <1116> Microbiological Evaluation of Clean
Rooms and Other Controlled Environments [2].
Action Levels - Microbiological levels in the controlled environment, specified in the
standard operating procedures (SOPs), which when exceeded should trigger an
investigation and a corrective action based on the investigation.
Alert Levels - Microbial levels, specified in the standard operating procedures (SOPs),
which when exceeded should result in an investigation to ensure that the process is still
within control. Alert levels are specific for a given facility and are established on the
basis of a baseline developed under an environmental monitoring program. These Alert
levels can be modified depending on the trend analysis done in the monitoring program.
Alert levels are always lower that Action levels.
Bioburden - The total number of microorganisms detected in or on an article.
Commissioning of a Controlled Environment - Certification by engineering and
quality control that the environment has been built according to the specifications of the
desired cleanliness class and that, under conditions likely to be encountered under normal
operating conditions (or worst-case conditions), it is capable of delivering an aseptic
process. Commissioning includes media-fill runs and results of the environmental
monitoring program.
Corrective Action - Actions to be performed that are in standard operating procedures
(SOPs) and that are triggered when certain conditions are exceeded.
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Environmental Monitoring Program - Documented program, implemented through
standard operating procedures (SOPs), that describes in detail the procedures and
methods used for monitoring particulates as well as microorganisms in controlled
environments (air, surface, personnel gear). The program includes sampling sites,
frequency of sampling, and investigative and corrective actions that should be followed if
Alert or Action levels are exceeded. The methodology used for trend analysis is also
described.
Out-of-Specification Event - Temporary or continuous event when one or more of the
requirements included in standard operating procedures (SOPs) for controlled
environments are not fulfilled.
Risk Assessment Analysis - Analysis of the identification of contamination potentials in
controlled environments that establish priorities in terms of severity and frequency and
that will develop methods and procedures that will eliminate, reduce, minimize, or
mitigate their potential for microbial contamination of the product/container/closure
system.
Sampling Plan - A documented plan that describes the procedures and methods for
sampling a controlled environment; identifies the sampling sites, the sampling frequency,
and number of samples; and describes the method of analysis and how to interpret the
results.
Standard Operating Procedures (SOPs) - Written procedures describing operations,
testing, sampling, interpretation of results, and corrective actions that relate to the
operations that are taking place in a controlled environment and auxiliary environments.
Deviations from standard operating procedures (SOPs) should be noted and approved by
responsible managers.
Trend Analysis - Data from a routine microbial environmental monitoring program that
can be related to time, shift, facility, etc. This information is periodically evaluated to
establish the status of pattern of that program to ascertain whether it is under adequate
control. A trend analysis is used to facilitate decision-making for requalification of a
controlled environment or for maintenance and sanitization schedules.
Validation - In the medical device, pharmaceutical and biotechnology manufacturing
industries, validation refers to establishing documented evidence that a process or system,
when operated within established parameters, can perform effectively and reproducibly to
produce a medicinal product meeting its pre-determined specifications and quality
attributes (from European Union Good Manufacturing Practices Guide, Annex 15).
Regulatory bodies in the U.S., European Union, and Japan (amongst many others) require
validation, causing it to become its own sub-industry supporting the pharmaceutical,
biotechnology, and medical device industries.
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References
[1] Sandle, T., Environmental Monitoring Risk Assessment, Journal of GXP Compliance,
January 2006, Volume 10, Number 2
[2] Bryans, T., Alexander, K., Using Recovery Tests to Assess Bioburden Procedures,
MDDI, October 2002
[3] U.S. Pharmacopeia 31NF26, Chapter <1116> Microbiological Evaluation of Clean
Room and Other Controlled Environments. Rockville, MD 2008
[4] Pharmaceutical Validation Documentation,
http://www.superiorcontrols.com/nws/pharma_valid_doc.html
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