SOP Title: Clean room environmental monitoring:

1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

Imperial College Healthcare NHS Trust

Clinical & Investigative Sciences Group (Clinical and Laboratory Haematology)
Quality Management Policy and Procedures

Purpose: To ensure that all GMP areas meet ‘Orange Book’ guidelines for grade A, grade B and
grade C classification.

Scope: Applies to Pharmacy QA staff and all laboratory staff required to work in environmentally
controlled areas.

Departmental Responsibility: JGCCT Date Effective: 30.Dec.09

Author: P. Elsey Review Date: 28.Dec.11

This Copy Number is:

Document Control
The Master Copy of the Quality Manual and Standard Operating Procedure (SOP’s) will be filed in the
Quality Management Office.
Controlled copies are numbered and stamped or water marked “Controlled Copy” in red ink.
Any copies without this red stamp are uncontrolled and should be destroyed. Electronic copy will be
filed within a read only folder on the Trust shared network.

If this SOP appears inadequate or outdated it is the responsibility of all staff to bring this to the
attention of their Supervisor immediately.

Training Record
The training record for this SOP is filed with the master copy of the SOP in the Quality Management
Office.

Security Statement
This SOP is the intellectual property of the SCT Unit within Imperial College Healthcare NHS Trust
and as such, must not be circulated outside of the Trust without written approval from the Quality
Assurance Manager and the Author of this procedure.
_________________________________________________________________________
Contents
Section Subject Page

1.0 Personnel & Responsibilities 2

2.0 Background
2.1 Principles 2
2.2 Purpose of procedure 2
3.0 Definitions 3
4.0 Health & Safety 4
4.1 General Health & Safety 4
4.2 Risk Assessment 4
5.0 Equipment/Documentation 4
6.0 Procedure 5

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 1 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

6.1 Physical monitoring 5

6.2 Manned/Unmanned settle plates 5
6.3 Contact plates and active air sampling 6
6.4 Sessional/Finger dab plates 6
6.5 Results and review of results 6
7.0 Training & Competency Assessment 7
8.0 References 7
9.0 List of Appendices 7
10.0 Revision History 8
11.0 Managerial Approval 8

1.0 Personnel & Responsibilities

Pharmacy QA staff carry out physical monitoring and microbiological monitoring with contact
plates and active air sampling (AAS). All JGCCT staff who have been properly trained and are
deemed to be competent may carry out unmanned/manned microbiological monitoring,
sessional and personnel ‘finger dab’ microbiological monitoring.

Training must be in compliance with the training record accompanying the SOP (Appendix 8).

Any deviations from this SOP must be documented and approved according to SOP
BMTU-QMP-006.

2.0 Background

2.1 Principle

The Imperial College Healthcare NHS Trust Pharmaceutical Quality Assurances Services
carry out physical and microbiological monitoring of the Cellular Therapy Suites (CT1
and CT2). Within each suite are: a grade C support area, grade B clean rooms 1 and 2,
each containing a grade A Heraeus KS12 class II cabinet and Laminar Air Flow (LAF) unit.

Microbiological monitoring is carried out weekly; this includes exposing manned/unmanned

plates, contact plates and active air sampling. Physical monitoring with particle counting is
done every six months. Pharmacy QA services are procured via a Service Level
Agreement (SLA).

For each processing session a settle plate is exposed in the cabinet and finger dab
monitoring is carried out using plates supplied by the pharmacy QA Dept. Plates are
returned to Pharmacy for incubation and reading.

2.2 Purpose of procedure

The manufacture of sterile products for clinical use is carried out in clean areas
maintained to an appropriate cleanliness standard and supplied with air which has been
passed through HEPA filters.

Specifically a grade A environment is required in the local zone for high risk operations.
Normally such conditions are provided by a laminar flow workstation, which should provide
a homogeneous air speed of 0.45m/s +/- 20% at the working position.

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 2 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

A grade B environment is required as a background for grade A operations.

Grade C and D clean areas are for carrying out less critical stages in manufacture of
clinical products.

Clean area classification is based on:

A. Maximum permitted number of particles/m3 equal to or above

At rest In operation
Grade 0.5um 5um 0.5um 5um
A 3500 0 3500 1
B 3500 0 350000 2000
C 350000 2000 3500000 20000
D 3500000 20000 not defined not defined

B. Maximum limits for microbiological monitoring of clean areas during operation

Grade air sample settle plates contact plates Glove print

cfu/m3 (diam 90mm) (diam 90mm) 5 fingers
cfu/4hrs cfu/4hrs cfu/glove
A <1 <1 <1 <1
B 10 5 5 5
C 100 50 25 -
D 200 100 50 -

These definitions are further qualified in:

Annex 1. Rules and Guidance for Pharmaceutical Manufacturers and Distributors

2007. ISBN 978 0 85369 719 0

Monitoring procedures are used to determine the level of compliance as part of

commissioning of new premises and ongoing in existing facilities to determine the
facility as fit for purpose in terms of:

 Physical structure, mechanics and electric’s re: clean room air plant.
 Effective cleaning strategies.
 Working practices.

Appropriate alert and action limits should be set for the results of particulate and
microbiological monitoring.

3.0 Definitions

JGCCT- John Goldman Centre for Cellular Therapy

AAS - Active Air sampling
SLA - Service Level Agreement

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 3 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

QA - Quality Assurance
LAF - Laminar Air Flow
CFU - Colony Forming Unit
MBSC - Microbiological Safety Cabinet
BPC - Background Particle Counter
HEPA - High Efficiency Particulate Air (filter)
DLI - Donor Lymphocyte Infusion
CML - Chronic Myeloid Leukaemia

4.0 Health & Safety

4.1 General Health & Safety

All staff must follow safe practice for dealing with biological materials as stated in the Imperial
College Healthcare NHS Trust Infection Control Policy, Section 2: Universal Infection control
including safe handling and disposal of sharps, sharps injuries and exposure to blood and
body fluids, spillage and waste.

Refer to departmental COSHH and risk assessments as listed under materials and equipment.
Avoid needle stick injuries by following departmental guidelines on correct use and disposal of
needles (RA8003). All human derived products should be treated as potential biohazards
(CA6).

4.2 Risk Assessment Status

Is a risk assessment required for the use of this procedure Yes □ No √

5.0 Equipment/Documentation

5.1 Pharmacy QA staff are responsible for provision of calibrated physical monitoring
and active air sampling equipment.

5.2 Typtone soya agar plates are supplied by Pharmacy QA Dept.

5.3 Pharmacy QA will supply a written report of physical monitoring activities.

5.4 Manned/unmanned settle plate forms and labels (filed in Suites Microbiology QC and
Cleaning Schedules blue folder in QA lab) – required for weekly monitoring:

Appendix 1 Locations of Weekly Settle Plates

Appendix 2 Manned/Unmanned Settle Plate Forms
Appendix 3 Manned/Unmanned Settle Plate Labels

5.5 Contact and Air Sampling Plates Form, is supplied by Pharmacy when results are
available one week after they have been performed. Reports are left in ‘Stem Cell for
Collection’ folder in Pharmacy QA Dept. (Appendix 4 Contact and Air Sampling Plates
Form).

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 4 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

5.6 Sessional/Finger dab plates record and results form:

Appendix 5 Sessional/Finger Dab Plates and Results Form FRM-JGCCT-149
Appendix 6 Settle and Finger Dab Labels

5.7 Results of weekly manned/unmanned settle plates, contact plates and active air
sampling are entered onto spreadsheets located on the shared drive at
S:\StemCell\STEMCELL\Others\weekly micro monitoring\weekly micro-monitoring.
Originals are filed in the filing cabinet underneath desk in the 2nd floor lab office.
5.8 Individual staff members have spreadsheets, located on the shared drive at
S:\StemCell\STEMCELL\Others\weekly micro monitoring\sessional and personnel
monitoring, assigned for cumulative entry of their own results. Original results of
sessional/finger dab plates are filed in the relevant patient files.

6.0 Procedure

6.1 Physical monitoring

6.1.1 Imperial College Healthcare Pharmacy QA Dept. carries physical monitoring

out on a six monthly basis for CT1 and CT2 alternatively. This will be scheduled
in advance and will take half a day per clean room to perform.

6.1.2 Physical monitoring determines the following operational characteristics:

 Room pressure differentials

 Air flows and room air changes
 Room particle counts
 Cabinet particle counts
 LAF particle counts

6.1.3 Continuous particle monitoring is ongoing at three sites in each clean

room, monitored by the Pharmagraph System (refer to SOP BMTU-JGCCT-110
Pharmagraph System - Operation and Management):

 MBSC – class II cabinet

 LAF – also referred to as hood in Pharmacy monitoring documents
 BPC – background particle counters

6.2 Manned/Unmanned settle plates

6.2.1 Eighteen settle plates are exposed at the locations shown in Appendix 1.
Manned/Unmanned plates are exposed on alternate weeks by laboratory staff
for a minimum of 2 hours.

6.2.2 Plates are taped closed and taken to Pharmacy QA Dept. for incubation and
reporting of results. Warning and action limits were set by the Pharmacy QA
Dept. after trend analysis (see Appendix 2).

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 5 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

6.3 Contact plates and active air sampling

6.3.1 This is carried out by Pharmacy QA staff, normally on Fridays and will take
approximately 30 minutes per suite. From September 2009 JGCCT staff will on
occasion do contact plates as requested by Pharmacy QA

6.3.2 Contact plates are taken at the same sites as plates are exposed (see
Appendix 1). Warning and action limits were set by Pharmacy QA Dept. after
trend analysis (see Appendix 4).

6.3.3 Active air sampling is carried out at three sites in each clean room: cabinet,
hood (LAF) and floor. Each room has AAS done once a month (in practice over
the first and second weeks of the month). Warning and action limits were set by
Pharmacy QA Dept. after trend analysis (see Appendix 4).

6.4 Sessional/Finger dab plates

6.4.1 These are carried out for the following processes:

 Preparation of cryoprotectant (freeze mix) – indicate FM on forms
and labels
 Harvest cryopreservation – indicate cryo on forms and labels
 Spinning of CML and DLI – indicate spinning on forms and labels

6.4.2 Three plates are used:

 One is exposed inside the Class II cabinet for the duration of the
session
 One each for left and right hand finger dabs at the end of the
session. Finger dabs are performed by placing the tip of each finger
on the agar plate and rolling the tip from one side to the other.

6.4.3 Plates are labelled (Appendix 6), taped closed and taken together with a
completed Sessional/Finger Dab Plates Results Form (Appendix 5) to
Pharmacy QA Dept. for incubation and reporting of results. Warning and action
limits were set by Pharmacy QA dept. after trend analysis (see Appendix 5).

6.5 Results and review of results

6.5.1 Physical monitoring results are presented in a report to the JGCCT

Director.

6.5.2 All other results are made available for collection on the original form, from the
Pharmacy QA Dept. in the ‘Stem Cell for Collection’ folder.

6.5.3 Results are entered on relevant spreadsheets on the shared drive, see 5.7 and
5.8.

6.5.4 Out of compliance results for sessional and personnel monitoring;

warning/action limits exceeded, are reviewed by Head of Processing/Quality
and appropriate action taken.

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 6 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

6.5.5 Out of compliance results for weekly monitoring; warning/action limits

exceeded, are reviewed by Head of Processing/Quality. The event is given an
action Ref. No. and a Report and Action Form completed (Appendix 7.)

6.5.5 Operational compliance and trends are monitored by the Head of Quality and
reviewed at QA review meetings.

7.0 Training and Competency Assessment

Type of Training Staff previously trained with respect to SOP BMTU-JGCCT-

036 v3.0, read SOP but no additional training required (unless
no routine procedures carried out for twelve months). New
staff are required to read the Primarius GMP Training Course,
Module 4: GMP Facilities and Monitoring Procedures, and
there will be demonstration of the procedures. The trainee will
be observed and assisted until competent.
Method of competency Competency will be judged and reviewed at intervals defined
assessment for “procedure” in the JGCCT Training Manual and Checklist.
List Staff required for Training All JGCCT staff
and Competency Assessment
Who is to perform this training Heads of Processing/Quality Dept.
Evidence Log of Complete the Training Record and Competency Assessment
Training/Competency (Appendix 8). Sign off in the staff member’s Training
Assessment Manual/Checklist.

8.0 References

1. Rules and Guidance for Pharmaceutical Manufacturers and Distributors 2007

ISBN 978 0 853369 719 0

2. SOPs:

BMTU-JGCCT-065 Aseptic technique

BMTU-JGCCT-110 Pharmagraph system - Operation and management
BMTU-JGCCT-092 Gowning procedure and access to cellular therapy suites
BMTU-JGCCT-152 Hand cleaning and gloving procedure

9.0 List of Appendices

Appendix 1 Locations of Weekly Settle Plates

Appendix 2 Manned/Unmanned Settle Plate Forms
Appendix 3 Manned/Unmanned Settle Plate Labels
Appendix 4 Contact and Air Sampling Plates Form
Appendix 5 Sessional/Finger Dab Plates and Results Form
Appendix 6 Settle and Finger Dab Labels
Appendix 7 Results Out of Limits – Report and Actions
Appendix 8 Training Record and Competency Assessment

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 7 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

10.0 Revision History

Issue Change
1.0 Refer to original SOP for more details
2.0 Minor alterations after review
3.0 Annual review. Minor changes, add Appendix 7, update
‘Orange Guide’ reference
4.0 Major - Substitute JGCCT for SCIL
Add the following statement to 6.3.1 ‘From September 2009
JGCCT staff will on occasion do contact plates as requested
by Pharmacy QA’

11.0 Managerial Approval

Name Printed Signature Title Date

Author:
P. Elsey
Penelope Elsey Head of Quality 2/12/09
Reviewers
J.G. Davis JGCCT Director 02/12/2009
John Davis
Head of
S. Loaiza Sandra Loaiza 3/12/09
Processing
JGCCT Medical
A. Rahemtulla Amin Rahemtulla 15/12/09
Director
QA Manager
K. Patel Kirtash Patel 22.Dec.09

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 8 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

Appendix 1 Locations of Weekly Settle Plates

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 9 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

Page 2 of 2

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 10 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

Appendix 2 Manned/Unmanned Settle Plate Forms

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 11 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

Page 2 of 2

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 12 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

Appendix 3 Manned/Unmanned Settle Plate Labels

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 13 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

Page 2 of 2

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 14 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

Appendix 4 Contact and Air Sampling Plates Form

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 15 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

Appendix 5 Sessional and Finger Dab Plates and Results Form

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 16 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

Appendix 6 Settle and Finger Dab Labels

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 17 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

Appendix 7 Results out of Limits – Actions and Reports

John Goldman Centre for Cellular Therapy

Environmental Monitoring

RESULTS OUT OF LIMITS - REPORT AND ACTIONS

Pharmacy QA Monitoring Action Ref. No. Date of event:

Details of event:

Action taken:

Follow up action:

Sign off

1. Head of Processing:………………………………… Date:………..

2. Head of Quality:……………………………………… Date:………..

Review at Quality Review Meeting Date:

Comments

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 18 of 19

SOP Title: Clean room environmental monitoring:
1. Physical monitoring
2. Unmanned/manned microbiological monitoring
3. Sessional and personnel ‘finger dab‘ microbiological
monitoring

SOP Type: Procedure

Appendix 8 Training Record and Competency assessment

SOP No: BMTU-SCIL - 036 __________________ Version: 3.0____________ SOP Type: Procedure

SOP Title: Clean room environmental monitoring

Trainee:____________________________________________Trainer:_________________________________Date_____________
The following table constitutes the Record of Training - Training Status and Competency, in this procedure, for the personnel detailed below.

Date Trainee Trainee Date Supervisor / Supervisor / Trainer Competency Assessment Method.
Training Name Signature Training Trainers to sign, if Trainee is
Started Completed Signature Competent in SOP.

SOP No: BMTU-JGCCT-036 Issue No: 4.0 Page 19 of 19