Pe 009 17 GMP Guide Xannexes

PHARMACEUTICAL INSPECTION CONVENTION
PHARMACEUTICAL INSPECTION CO-OPERATION SCHEME
PE 009-17 (Annexes)
25 August 2023
GUIDE TO GOOD MANUFACTURING

PRACTICE FOR MEDICINAL PRODUCTS
ANNEXES
© PIC/S 2023
Reproduction prohibited for commercial purposes.
Reproduction for internal use is authorised,
provided that the source is acknowledged.
Editor: PIC/S Secretariat

14 rue du Roveray
CH-1207 Geneva
e-mail: [email protected]
web site: https://www.picscheme.org
PE 009-17 (Annexes) 25 August 2023

Table of contents
ANNEXES
Annex 1 (Manufacture of sterile medicinal products) 1

Document map 1
Scope 2
Principle 2
Pharmaceutical Quality System (PQS) 5
Premises 6
Barrier technologies 9
Cleanroom and clean air equipment qualification 12
Disinfection 15
Equipment 16
Utilities 17
Water systems 18
Steam used as a direct sterilising agent 19
Gases and vacuum systems 20
Heating and cooling and hydraulic systems 20
Personnel 20
Production and specific technologies 24
Terminally sterilised products 24
Aseptic preparation and processing 24
Finishing of sterile products 27
Sterilisation 29
Sterilisation by heat 32
Moist heat sterilisation 32
Dry heat sterilisation 34
Sterilisation by radiation 35
Sterilisation with ethylene oxide 35
Filter sterilisation of products which cannot be sterilised in their final container 36
Form-Fill-Seal (FFS) 40
Blow-Fill-Seal 42
Lyophilization 45
Closed systems 46
Single Use Systems (SUS) 47
Environmental and process monitoring 48
General 48
Environmental and process monitoring 49
Environmental monitoring – total particle 50
Environmental and personnel monitoring – viable particle 52
Aseptic process simulation (APS) (also known as media fill) 54
Quality control (QC) 59
Glossary 61
Annex 2A
(Manufacture of advanced therapy medicinal products for human use) 67
Scope 67
Principle 71
Part A: General guidance 72
Supplimentary provisions to PIC/S GMP Guide Part I 73
Chapter 1 Pharmaceutical quality system 73
Chapter 2 Personnel 73
Chapter 3 Premises and equipment 74
PE 009-17 (Annexes) -i- 25 August 2023

Table of contents
Chapter 4 Documentation 78
Chapter 5 Production 79
Chapter 6 Quality control 90
Chapter 7 Outsourced activities 95
Chapter 8 Complaints and product recall 96
Part B: Specific guidance on selected product types 97
Common glossary to Annex 2A and 2B 100
Annex 2B
(Manufacture of biological medicinal substances and products for human use) 107
Scope 107
Principle 109
Part A: General guidance 111
Personnel 111
Premises and equipment 111
Animals 114
Documentation 115
Production 115
Starting and raw materials 116
Seed lot and cell bank system 118
Operating principles 119
Quality control 121
Part B: Specific guidance on selected product types 122
Annex 3 (Manufacture of radiopharmaceuticals) 127

Principle 127
Introduction 127
Quality assurance 128
Personnel 129
Documentation 130
Production 130
Quality control 131
Reference and retention samples 133
Distribution 133
Glossary 133
Annex 4
(Manufacture of veterinary medicinal products other than immunologicals) 134
Manufacture of premixes for medicated feeding stuffs 134
The manufacture of ectoparasiticides 135
The manufacture of veterinary medicinal products containing penicillins 135
Retention of samples 135
Sterile veterinary medicinal products 135
Annex 5 (Manufacture of immunological veterinary medical products) 136

Principle 136
Personnel 136
Premises 137
Equipment 140
Animals and animal houses 141
Disinfection Waste disposal 141
Production 142
PE 009-17 (Annexes) -ii- 25 August 2023

Table of contents
Starting materials 142

Quality control 145
Annex 6 (Manufacture of medicinal gases) 146

Principle 146
Manufacture of active substance gases 146
Manufacture of medicinal gases 147
Personnel 147
Documentation 149
Production 150
Quality control 153
Transportation of packaged gases 154
Glossary 155
Annex 7 (Manufacture of herbal medicinal products) 157

Principle 157
Premises 159
Storage areas 159
Production area 159
Equipment 159
Documentation 159
Specifications for starting materials 159
Processing instructions 161
Quality Control 161
Annex 8 (Sampling of starting and packaging materials) 162

Principle 162
Personnel 162
Starting materials 162
Packaging material 163
Annex 9 (Manufacture of liquids, creams and ointments) 164

Principle 164
Production 164
Annex 10
(Manufacture of pressurised metered dose aerosol preparations for inhalation) 166
Principle 166
General 166
Production and quality control 167
Annex 11 (Computerised systems) 168

Principle 168
General 168
Risk management 168
Personnel 168
Suppliers and service providers 168
Project phase 169
Validation 169
Operational phase 170
PE 009-17 (Annexes) -iii- 25 August 2023

Table of contents
Data 170
Accuracy checks 170
Data storage 170
Printouts 170
Audit trails 170
Change and configuration management 170
Periodic evaluation 170
Security 171
Incident management 171
Electronic signature 171
Batch release 171
Business continuity 171
Archiving 172
Glossary 172
Annex 12 (Use of ionising radiation in the manufacture of medicinal products) 173

Introduction 173
Responsibilities 173
Dosimetry 174
Validation of the process 174
Commissioning of the plant 175
General 175
Gamma irradiators 175
Electron beam irradiators 176
Premises 177
Processing 177
Gamma irradiators 178
Electron beam irradiators 178
Documentation 179
Microbiological monitoring 179
Annex 13 (Manufacture of investigational medicinal products) 180

Introduction 180
Scope 181
Pharmaceutical Quality System 182
Personnel 183
Documentation 184
Production 186
Quality control 190
Release of batches 191
Outsourced operations 193
Complaints 193
Recalls and returns 193
Glossary 194
Annex 14
(Manufacture of medicinal products derived from human blood or plasma) 197
Glossary 197
Scope 199
Principles 199
Quality management 201
Traceability and post collection measures 202
PE 009-17 (Annexes) -iv- 25 August 2023

Table of contents

Manufacturing 204
Quality control 206
Release of intermediate and finished products 207
Retention of plasma pool samples 207
Disposal of waste 207
Addendum 207
Annex 15 (Qualification and validation) 211

Principle 211
General 211
Organising and Planning for Qualification and Validation 211
Documentation, including VMP 212
Qualification Stages for Equipment, Facilities and Systems 213
Re-qualification 215
Process Validation 215
Verification of Transportation 219
Validation of Packaging 220
Qualification of Utilities 220
Validation of Test Methods 220
Cleaning Validation 221
Change Control 222
Glossary 223
Annex 16 (Authorised person and batch release) 226

Scope 226
General Principles 226
The Process of Certification 227
Relying on GMP Assessments by Third Parties, e.g. Audits 233
Handling of Unexpected Deviations 234
The Release of a Batch 234
Glossary 235
Appendix I 236
Appendix II 237
Annex 17 (Real Time Release Testing and Parametric Release) 239

Principle 239
Scope 239
Real Time Release Testing (RTRT) 239
Parametric Release and Sterilisation 240
Glossary 242
Annex 18 [GMP Guide for active pharmaceutical ingredients]** 244
Annex 19 (Reference and retention samples) 245

Scope 245
Principle 245
Duration of storage 246
Size of reference and retention samples 246
** The EU first adopted the ICH GMP Guide on APIs as Annex 18 to the EU GMP
Guide while PIC/S adopted it as a stand-alone GMP Guide (PE 007). The Guide has
now been adopted as Part II of the PIC/S GMP Guide (see PE 009 (Part II)).
PE 009-17 (Annexes) -v- 25 August 2023

Table of contents
Storage conditions 247

Written agreements 247
Reference samples – General points 247
Retention samples – General points 248
Reference and retention samples for parallel imported
/ parallel distributed products 248
Reference and retention samples in the case of closedown of a
manufacturer 248
Annex 20 (Quality risk management)*** 250

Foreword and scope of application 250
Introduction 250
Scope 252
Principles of quality risk management 252
General quality risk management process 252
Responsibilities 253
Initiating a quality risk management process 254
Risk assessment 254
Risk control 255
Risk communication 256
Risk review 256
Risk management methodology 256
Integration of quality risk management into industry and regulatory operations 257
Definitions 258
References 260
Appendix I: Risk Management Methods and Tools 261

Basic Risk Management Facilitation Methods 261
Failure Mode Effects Analysis (FMEA) 261
Potential Areas of Use(s) 261
Failure Mode, Effects and Criticality Analysis (FMECA) 261
Fault Tree Analysis (FTA) 262
Hazard Analysis and Critical Control Points (HACCP) 262
Hazard Operability Analysis (HAZOP) 263
Preliminary Hazard Analysis (PHA) 263
Risk Ranking and Filtering 264
Supporting Statistical Tools 264
Appendix II: Potential Applications For Quality Risk Management 265

Quality Risk Management as Part of Integrated Quality Management 265
Quality Risk Management as Part of Regulatory Operations 266
Quality Risk Management as Part of Development 267
Quality Risk Management for Facilities, Equipment and Utilities 267
Quality Risk Management as Part of Materials Management 268
Quality Risk Management as Part of Production 269
Quality Risk Management as Part of Laboratory Control and Stability Studies 270
Quality Risk Management as Part of Packaging and Labelling 270
GLOSSARY 271
*** This Annex is voluntary.
PE 009-17 (Annexes) -vi- 25 August 2023

Annex 1 Manufacture of sterile medicinal products
ANNEX 1
MANUFACTURE OF STERILE MEDICINAL PRODUCTS
Document map
Section Number General overview
1. Scope Includes additional areas (other than sterile products) where

the general principles of the annex can be applied.
2. Principle General principles as applied to the manufacture of sterile

products.
3. Pharmaceutical Quality Highlights the specific requirements of the PQS when applied
System (PQS) to sterile products.
4. Premises General guidance regarding the specific needs for premises

design and also guidance on the qualification of premises
including the use of Barrier Technology.
5. Equipment General guidance on the design and operation of equipment.
6. Utilities Guidance regarding the special requirements of utilities such

as water, gas and vacuum.
7. Personnel Guidance on the requirements for specific training, knowledge

and skills. Also gives guidance regarding the qualification of
personnel.
8. Production and specific Guidance on the approaches to be taken regarding aseptic

technologies and terminal sterilization processes. Guidance on the
approaches to sterilization of products, equipment and
packaging components. Also guidance on different
technologies such as lyophilization and Form-Fill-Seal where
specific requirements apply.
9. Environmental and This section differs from guidance given in section 4 in that the
process monitoring guidance here applies to ongoing routine monitoring regarding
the design of systems and setting of action limits alert levels
and reviewing trend data.
The section also gives guidance on the requirements of
Aseptic Process Simulations (APS).
10. Quality control (QC) Guidance on some of the specific Quality Control requirements
relating to sterile products.
11. Glossary Explanation of specific terminology.
PE 009-17 (Annexes) -1- 25 August 2023

1 Scope
The manufacture of sterile products covers a wide range of sterile product types
(active substance, excipient, primary packaging material and finished dosage
form), packed sizes (single unit to multiple units), processes (from highly
automated systems to manual processes) and technologies (e.g. biotechnology,
classical small molecule manufacturing systems and closed systems). This
Annex provides general guidance that should be used in the design and control
of facilities, equipment, systems and procedures used for the manufacture of all
sterile products applying the principles of Quality Risk Management (QRM), to
ensure that microbial, particulate and endotoxin/pyrogen contamination is
prevented in the final product.
QRM applies to this document in its entirety and will not, normally, be referred to
in specific paragraphs. Where specific limits or frequencies or ranges are
specified, these should be considered as a minimum requirement. They are
stated due to historical regulatory experience of issues that have been identified
and have impacted the safety of patients.
The intent of the Annex is to provide guidance for the manufacture of sterile
products. However, some of the principles and guidance, such as contamination
control strategy, design of premises, cleanroom classification, qualification,
validation, monitoring and personnel gowning, may be used to support the
manufacture of other products that are not intended to be sterile such as certain
liquids, creams, ointments and low bioburden biological intermediates, but where
the control and reduction of microbial, particulate and endotoxin/pyrogen
contamination is considered important. Where a manufacturer elects to apply
guidance herein to non-sterile products, the manufacturer should clearly
document which principles have been applied and acknowledge that compliance
with those principles should be demonstrated.
2 Principle
2.1 The manufacture of sterile products is subject to special requirements in order to
minimize risks of microbial, particulate and endotoxin/pyrogen contamination.
The following key areas should be considered:
i. Facility, equipment and process should be appropriately designed, qualified

and/or validated and where applicable, subjected to ongoing verification
according to the relevant sections of the Good Manufacturing Practices
(GMP) guide. The use of appropriate technologies (e.g. Restricted Access
Barriers Systems (RABS), isolators, robotic systems, rapid/alternative
methods and continuous monitoring systems) should be considered to
increase the protection of the product from potential extraneous sources of
endotoxin/pyrogen, particulate and microbial contamination such as
personnel, materials and the surrounding environment, and assist in the
rapid detection of potential contaminants in the environment and the product.
ii. Personnel should have adequate qualifications and experience, training and
behaviour with a specific focus on the principles involved in the protection of

sterile product during the manufacturing, packaging and distribution

processes.
iii. Processes and monitoring systems for sterile product manufacture should be
designed, commissioned, qualified, monitored and regularly reviewed by
personnel with appropriate process, engineering and microbiological
knowledge.
iv. Raw materials and packaging materials should be adequately controlled and
tested to ensure that level of bioburden and endotoxin/pyrogen are suitable
for use.
2.2 Processes, equipment, facilities and manufacturing activities should be managed

in accordance with QRM principles to provide a proactive means of identifying,
scientifically evaluating and controlling potential risks to quality. Where alternative
approaches are used, these should be supported by appropriate rationale, risk
assessment and mitigation, and should meet the intent of this Annex.
In the first instance, QRM priorities should include appropriate design of the
facility, equipment and processes, followed by the implementation of well-
designed procedures, and finally application of monitoring systems as the
element that demonstrates that the design and procedures have been correctly
implemented and continue to perform in line with expectations. Monitoring or
testing alone does not give assurance of sterility.
2.3 A Contamination Control Strategy (CCS) should be implemented across the

facility in order to define all critical control points and assess the effectiveness of
all the controls (design, procedural, technical and organisational) and monitoring
measures employed to manage risks to medicinal product quality and safety. The
combined strategy of the CCS should establish robust assurance of
contamination prevention. The CCS should be actively reviewed and, where
appropriate, updated and should drive continual improvement of the
manufacturing and control methods. Its effectiveness should form part of the
periodic management review. Where existing control systems are in place and
are appropriately managed, these may not require replacement but should be
referenced in the CCS and the associated interactions between systems should
be understood.
2.4 Contamination control and steps taken to minimize the risk of contamination from
microbial, endotoxin/pyrogen and particle sources includes a series of
interrelated events and measures. These are typically assessed, controlled and
monitored individually but their collective effectiveness should be considered
together.
2.5 The development of the CCS requires detailed technical and process knowledge.
Potential sources of contamination are attributable to microbial and cellular debris
(e.g. pyrogen, endotoxin) as well as particulate (e.g. glass and other visible and
sub-visible particles).
Elements to be considered within a CCS should include (but are not limited to):
i. design of both the plant and processes including the associated

documentation;

ii. premises and equipment;
iii. personnel;
iv. utilities;
v. raw material controls – including in-process controls;
vi. product containers and closures;
vii. vendor approval – such as key component suppliers, sterilisation of

components and single use systems (SUS), and critical service providers;
viii. management of outsourced activities and availability/transfer of critical

information between parties, e.g. contract sterilisation services;
ix. process risk management;
x. process validation;
xi. validation of sterilisation processes;
xii. preventative maintenance – maintaining equipment, utilities and premises

(planned and unplanned maintenance) to a standard that will ensure there is
no additional risk of contamination;
xiii. cleaning and disinfection;
xiv. monitoring systems - including an assessment of the feasibility of the

introduction of scientifically sound, alternative methods that optimize the
detection of environmental contamination;
xv. prevention mechanisms – trend analysis, detailed investigation, root cause

determination, corrective and preventive actions (CAPA) and the need for
comprehensive investigational tools;
xvi. continuous improvement based on information derived from the above.
2.6 The CCS should consider all aspects of contamination control with ongoing and
periodic review resulting in updates within the pharmaceutical quality system as
appropriate. Changes to the systems in place should be assessed for any impact
on the CCS before and after implementation.
2.7 The manufacturer should take all steps and precautions necessary to assure the
sterility of the products manufactured within its facilities. Sole reliance for sterility
or other quality aspects should not be placed on any terminal process or finished
product test.

3 Pharmaceutical Quality System (PQS)

3.1 The manufacture of sterile products is a complex activity that requires specific
controls and measures to ensure the quality of products manufactured.
Accordingly, the manufacturer’s PQS should encompass and address the
specific requirements of sterile product manufacture and ensure that all activities
are effectively controlled so that the risk of microbial, particulate and
endotoxin/pyrogen contamination is minimized in sterile products. In addition to
the PQS requirements detailed in Chapter 1 of the GMP Guide (Part I – Basic
Requirements for Medicinal Products), the PQS for sterile product manufacture
should also ensure that:
i. An effective risk management system is integrated into all areas of the

product life cycle with the aim to minimize microbial contamination and to
ensure the quality of sterile products manufactured.
ii. The manufacturer has sufficient knowledge and expertise in relation to the
products manufactured and the equipment, engineering and manufacturing
methods employed that have an impact on product quality.
iii. Root cause analysis of procedural, process or equipment failure is performed

in such a way that the risk to product is correctly identified and understood
so that suitable corrective and preventive actions (CAPA) are implemented.
iv. Risk management is applied in the development and maintenance of the

CCS, to identify, assess, reduce/eliminate (where applicable) and control
contamination risks. Risk management should be documented and should
include the rationale for decisions taken in relation to risk reduction and
acceptance of residual risk.
v. Senior management should effectively oversee the state of control

throughout the facility and product lifecycle. Risk management outcome
should be reviewed regularly as part of the on-going quality management,
during change, in the event of a significant emerging problem, and during the
periodic product quality review.
vi. Processes associated with the finishing, storage and transport of sterile
products should not compromise the sterile product. Aspects that should be
considered include: container integrity, risks of contamination and avoidance
of degradation by ensuring that products are stored and maintained in
accordance with the registered storage conditions.
vii. Persons responsible for the certification/release of sterile products have

appropriate access to manufacturing and quality information and possess
adequate knowledge and experience in the manufacture of sterile products
and the associated critical quality attributes. This is in order to allow such
persons to determine if the sterile products have been manufactured in
accordance with the registered specifications and approved process and are
of the required quality.
3.2 All non-conformities, such as sterility test failures, environmental monitoring

excursions or deviations from established procedures should be adequately

investigated before certification/release of the batch. The investigation should

determine the potential impact upon process and product quality and whether
any other processes or batches are potentially impacted. The reason for including
or excluding a product or batch from the scope of the investigation should be
clearly justified and recorded.
4 Premises
4.1 The manufacture of sterile products should be carried out in appropriate
cleanrooms, entry to which should be through change rooms that act as airlocks
for personnel and airlocks for equipment and materials. Cleanrooms and change
rooms should be maintained to an appropriate cleanliness standard and supplied
with air which has passed through filters of an appropriate efficiency. Controls
and monitoring should be scientifically justified and should effectively evaluate
the state of environmental conditions of cleanrooms, airlocks and pass-through
hatches.
4.2 The various operations of component preparation, product preparation and filling
should be carried out with appropriate technical and operational separation
measures within the cleanroom or facility to prevent mix up and contamination.
4.3 Restricted Access Barrier Systems (RABS) or isolators are beneficial in assuring
required conditions and minimizing microbial contamination associated with
direct human interventions in the critical zone. Their use should be considered in
the CCS. Any alternative approaches to the use of RABS or isolators should be
justified.
4.4 For the manufacture of sterile products there are four grades of cleanroom/zone.
Grade A: The critical zone for high-risk operations (e.g. aseptic processing line,
filling zone, stopper bowl, open primary packaging or for making aseptic
connections under the protection of first air). Normally, such conditions are
provided by a localised airflow protection, such as unidirectional airflow
workstations within RABS or isolators. The maintenance of unidirectional airflow
should be demonstrated and qualified across the whole of the grade A area.
Direct intervention (e.g. without the protection of barrier and glove port
technology) into the grade A area by operators should be minimized by premises,
equipment, process and procedural design.
Grade B: For aseptic preparation and filling, this is the background cleanroom for
grade A (where it is not an isolator). Air pressure differences should be
continuously monitored. Cleanrooms of lower grade than grade B can be
considered where isolator technology is used (see paragraph 4.20).
Grade C and D: These are cleanrooms used for carrying out less critical
stages in the manufacture of aseptically filled sterile products or as a
background for isolators. They can also be used for the preparation/filling of
terminally sterilised products. (See section 8 for the specific details on terminal
sterilisation activities).
4.5 In cleanrooms and critical zones, all exposed surfaces should be smooth,
impervious and unbroken in order to minimize the shedding or accumulation of
particles or micro-organisms.

4.6 To reduce accumulation of dust and to facilitate cleaning there should be no

recesses that are difficult to clean effectively, therefore projecting ledges,
shelves, cupboards and equipment should be kept to a minimum. Doors should
be designed to avoid recesses that cannot be cleaned. Sliding doors may be
undesirable for this reason.
4.7 Materials used in cleanrooms, both in the construction of the room and for items
used within the room, should be selected to minimize generation of particles and
to permit the repeated application of cleaning, disinfectant and sporicidal agents
where used.
4.8 Ceilings should be designed and sealed to prevent contamination from the space
above them.
4.9 Sinks and drains should be prohibited in the grade A and grade B areas. In other
cleanrooms, air breaks should be fitted between the machine or sink and the
drains. Floor drains in lower grade cleanrooms should be fitted with traps or water
seals designed to prevent back flow and should be regularly cleaned, disinfected
and maintained.
4.10 The transfer of equipment and materials into and out of the cleanrooms and
critical zones is one of the greatest potential sources of contamination. Any
activities with the potential to compromise the cleanliness of cleanrooms or the
critical zone should be assessed and if they cannot be eliminated, appropriate
controls should be implemented.
4.11 The transfer of materials, equipment, and components into the grade A or B areas
should be carried out via a unidirectional process. Where possible, items should
be sterilised and passed into these areas through double-ended sterilisers (e.g.
through a double-door autoclave or depyrogenation oven/tunnel) sealed into the
wall. Where sterilisation upon transfer of the items is not possible, a procedure
which achieves the same objective of not introducing contamination should be
validated and implemented, (e.g. using an effective transfer disinfection process,
rapid transfer systems for isolators or, for gaseous or liquid materials, a bacteria-
retentive filter). The removal of items from the grade A and B areas (e.g.
materials, waste, environmental samples) should be carried out via a separate
unidirectional process. If this is not possible, time-based separation of movement
(incoming/exiting material) by procedure should be considered and controls
applied to avoid potential contamination of incoming items.
4.12 Airlocks should be designed and used to provide physical separation and to
minimize microbial and particle contamination of the different areas and should
be present for material and personnel moving between different grades.
Wherever possible, airlocks used for personnel movement should be separated
from those used for material movement. Where this is not practical, time-based
separation of movement (personnel/material) by procedure should be
considered. Airlocks should be flushed effectively with filtered air to ensure that
the grade of the cleanroom is maintained. The final stage of the airlock should, in
the “at rest” state, be of the same cleanliness grade (viable and total particle) as
the cleanroom into which it leads. The use of separate change rooms for entering
and leaving the grade B area is desirable. Where this is not practical, time-based
separation of activities (ingress/egress) by procedure should be considered.

Where the CCS indicates that the risk of contamination is high, separate change
rooms for entering and leaving production areas should be used. Airlocks should
be designed as follows:
i. Personnel airlocks: Areas of increasing cleanliness used for entry of

personnel (e.g. from the grade D area to the grade C area to the grade B
area). In general hand washing facilities should be provided only in the first
stage of the changing room and not be present in changing rooms directly
accessing the grade B area.
ii. Material airlocks: used for materials and equipment transfer.
 Only materials and equipment that have been included on an approved list
and assessed during validation of the transfer process, should be transferred
into the grade A or grade B areas via an airlock or pass-through hatches.
Equipment and materials (intended for use in the grade A area) should be
protected when transiting through the grade B area. Any unapproved items
that require transfer should be pre-approved as an exception. Appropriate
risk assessment and mitigation measures should be applied and recorded as
per the manufacturer's CCS and should include a specific disinfection and
monitoring programme approved by quality assurance.
 Pass-through hatches should be designed to protect the higher-grade

environment, for example by effective flushing with an active filtered air
supply.
 The movement of material or equipment from lower grade or unclassified

area to higher grade clean areas should be subject to cleaning and
disinfection commensurate with the risk and in line with the CCS.
4.13 For pass-through hatches and airlocks (for material and personnel), the entry and
exit doors should not be opened simultaneously. For airlocks leading to the
grade A and grade B areas, an interlocking system should be used. For airlocks
leading to grade C and D areas, a visual and/or audible warning system should
be operated as a minimum. Where required to maintain area segregation, a time
delay between the closing and opening of interlocked doors should be
established.
4.14 Cleanrooms should be supplied with a filtered air supply that maintains a positive
pressure and/or an airflow relative to the background environment of a lower
grade under all operational conditions and should flush the area effectively.
Adjacent rooms of different grades should have an air pressure difference of a
minimum of 10 Pascals (guidance value). Particular attention should be paid to
the protection of the critical zone. The recommendations regarding air supplies
and pressures may need to be modified where it is necessary to contain certain
materials (e.g. pathogenic, highly toxic or radioactive products or live viral or
bacterial materials). The modification may include positively or negatively
pressurized airlocks that prevent the hazardous material from contaminating
surrounding areas. Decontamination of facilities (e.g. the cleanrooms and the
heating, ventilation, and air conditioning (HVAC) systems) and the treatment of
air leaving a clean area, may be necessary for some operations. Where
containment requires air to flow into a critical zone, the source of the air should

be from an area of the same or higher grade.
4.15 Airflow patterns within cleanrooms and zones should be visualised to

demonstrate that there is no ingress from lower grade to higher grade areas and
that air does not travel from less clean areas (such as the floor) or over operators
or equipment that may transfer contamination to the higher-grade areas. Where
unidirectional airflow is required, visualisation studies should be performed to
determine compliance, (see paragraphs 4.4 & 4.19). When filled, closed products
are transferred to an adjacent cleanroom of a lower grade via a small egress
point, airflow visualization studies should demonstrate that air does not ingress
from the lower grade cleanrooms to the grade B area. Where air movement is
shown to be a contamination risk to the clean area or critical zone, corrective
actions, such as design improvement, should be implemented. Airflow pattern
studies should be performed both at rest and in operation (e.g. simulating
operator interventions). Video recordings of the airflow patterns should be
retained. The outcome of the air visualisation studies should be documented and
considered when establishing the facility's environmental monitoring programme.
4.16 Indicators of air pressure differences should be fitted between cleanrooms and/or
between isolators and their background. Set-points and the criticality of air
pressure differences should be considered within the CCS. Air pressure
differences identified as critical should be continuously monitored and recorded.
A warning system should be in place to instantly indicate and warn operators of
any failure in the air supply or reduction of air pressure differences (below set
limits for those identified as critical). The warning signal should not be overridden
without assessment and a procedure should be available to outline the steps to
be taken when a warning signal is given. Where alarm delays are set, these
should be assessed and justified within the CCS. Other air pressure differences
should be monitored and recorded at regular intervals.
4.17 Facilities should be designed to permit observation of production activities from

outside the grade A and B areas (e.g. through the provision of windows or remote
cameras with a full view of the area and processes to allow observation and
supervision without entry). This requirement should be considered when
designing new facilities or during refurbishment of existing facilities.
BARRIER TECHNOLOGIES
4.18 Isolators or RABS, which are different technologies, and the associated
processes, should be designed to provide protection through separation of the
grade A environment from the environment of the surrounding room. The hazards
introduced from entry or removal of items during processing should be minimized
and supported by high capability transfer technologies or validated systems that
robustly prevent contamination and are appropriate for the respective technology.
4.19 The design of the technology and processes used should ensure appropriate
conditions are maintained in the critical zone to protect the exposed product
during operations.
i. Isolators:
a. The design of open isolators should ensure grade A conditions with first air

protection in the critical zone and unidirectional airflow that sweeps over and
away from exposed products during processing.
b. The design of closed isolators should ensure grade A conditions with
adequate protection for exposed products during processing. Airflow may not
be fully unidirectional in closed isolators where simple operations are
conducted. However, any turbulent airflow should not increase risk of
contamination of the exposed product. Where processing lines are included
in closed isolators, grade A conditions should be ensured with first air
protection in the critical zone and unidirectional airflow that sweeps over and
away from exposed products during processing.
c. Negative pressure isolators should only be used when containment of the
product is considered essential (e.g. radiopharmaceutical products) and
specialized risk control measures should be applied to ensure the critical
zone is not compromised.
ii. RABS:
The design of RABS should ensure grade A conditions with unidirectional

airflow and first air protection in the critical zone. A positive airflow from the
critical zone to the supporting background environment should be
maintained.
4.20 The background environment for isolators or RABS should ensure the risk of
transfer of contamination is minimized.
i. Isolators:
a. The background environment for open isolators should generally correspond

to a minimum of grade C. The background for closed isolators should
correspond to a minimum of grade D. The decision on the background
classification should be based on risk assessment and justified in the CCS.
b. Key considerations when performing the risk assessment for the CCS of an
isolator should include (but are not limited to); the bio-decontamination
programme, the extent of automation, the impact of glove manipulations that
may potentially compromise ‘first air’ protection of critical process points, the
impact of potential loss of barrier/glove integrity, transfer mechanisms used
and activities such as set-up or maintenance that may require the doors to
be opened prior to the final bio-decontamination of the isolator. Where
additional process risks are identified, a higher grade of background should
be considered unless appropriately justified in the CCS.
c. Airflow pattern studies should be performed at the interfaces of open
isolators to demonstrate the absence of air ingress.
ii. RABS:
The background environment for RABS used for aseptic processing, should
correspond to a minimum of grade B and airflow pattern studies should be
performed to demonstrate the absence of air ingress during interventions,
including door openings if applicable.

4.21 The materials used for glove systems (for both isolators and RABS) should be
demonstrated to have appropriate mechanical and chemical resistance. The
frequency of glove replacement should be defined within the CCS.
i. Isolators:
a. For isolators, leak testing of the glove system should be performed using a
methodology demonstrated to be suitable for the task and criticality. The
testing should be performed at defined intervals. Generally glove integrity
testing should be performed at a minimum frequency of the beginning and
end of each batch or campaign. Additional glove integrity testing may be
necessary depending on the validated campaign length.
Glove integrity monitoring should include a visual inspection associated with
each use and following any manipulation that may affect the integrity of the
system.
For manual aseptic processing activities where single unit or small batch
sizes are produced, the frequency of integrity verification may be based on
other criteria, such as the beginning and end of each manufacturing session.
b. Integrity / leak testing of isolator systems should be performed at defined
intervals.
ii. RABS:
For RABS, gloves used in the grade A area should be sterilised before
installation and sterilised or effectively bio-decontaminated by a validated
method prior to each manufacturing campaign. If exposed to the background
environment during operation, disinfection using an approved methodology
following each exposure should be completed. Gloves should be visually
examined with each use, and integrity testing should be performed at
periodic intervals.
4.22 Decontamination methods (cleaning and bio-decontamination, and where

applicable inactivation for biological materials) should be appropriately defined
and controlled. The cleaning process prior to the bio-decontamination step is
essential; any residues that remain may inhibit the effectiveness of the
decontamination process. Evidence should also be available to demonstrate that
the cleaning and bio-decontamination agents used do not have adverse impact
on the product produced within the RABS or isolator.
i. For isolators
The bio-decontamination process of the interior should be automated,

validated and controlled within defined cycle parameters and should include
a sporicidal agent in a suitable form (e.g. gaseous or vaporized form). Gloves
should be appropriately extended with fingers separated to ensure contact
with the agent. Methods used (cleaning and sporicidal bio-decontamination)
should render the interior surfaces and critical zone of the isolator free from
viable microorganisms.

ii. For RABS
The sporicidal disinfection should include the routine application of a sporicidal

agent using a method that has been validated and demonstrated to robustly
include all areas of the interior surfaces and ensure a suitable environment for
aseptic processing.
CLEANROOM AND CLEAN AIR EQUIPMENT QUALIFICATION
4.23 Cleanrooms and clean air equipment such as unidirectional airflow units (UDAFs),
RABS and isolators, used for the manufacture of sterile products, should be
qualified according to the required characteristics of the environment. Each
manufacturing operation requires an appropriate environmental cleanliness level
in the operational state in order to minimize the risk of contamination of the product
or materials being handled. Appropriate cleanliness levels in the “at rest” and
“operational” states should be maintained.
4.24 Cleanrooms and clean air equipment should be qualified using methodology in
accordance with the requirements of Annex 15. Cleanroom qualification (including
classification) should be clearly differentiated from operational environmental
monitoring.
4.25 Cleanroom and clean air equipment qualification is the overall process of
assessing the level of compliance of a classified cleanroom or clean air
equipment with its intended use. As part of the qualification requirements of
Annex 15, the qualification of cleanrooms and clean air equipment should include
(where relevant to the design/operation of the installation):
i. installed filter system leakage and integrity testing,
ii. airflow tests - volume and velocity,
iii. air pressure difference test,
iv. airflow direction test and visualisation,
v. microbial airborne and surface contamination,
vi. temperature measurement test,
vii. relative humidity test,
viii. recovery test,
ix. containment leak test.
Reference for the qualification of the cleanrooms and clean air equipment can be
found in the ISO 14644 series of standards.
4.26 Cleanroom classification is part of the cleanroom qualification and is a method of

assessing the level of air cleanliness against a specification for a cleanroom or
clean air equipment by measuring the total particle concentration. Classification

activities should be scheduled and performed in order to avoid any impact on

process or product quality. For example, initial classification should be performed
during simulated operations and reclassification performed during simulated
operations or during aseptic process simulation (APS).
4.27 For cleanroom classification, the total of particles equal to or greater than 0.5 and
5 µm should be measured. This measurement should be performed both at rest
and in simulated operations in accordance with the limits specified in Table 1.
Table 1: Maximum permitted total particle concentration for classification
Maximum limits for total particle Maximum limits for total particle
Grade ≥ 0.5 µm/m3 ≥ 5 µm/m3
at rest in operation at rest in operation

A 3 520 3 520 Not specified (a) Not specified (a)
B 3 520 352 000 Not specified (a) 2 930
C 352 000 3 520 000 2 930 29 300
3 520 000 Not 29 300 Not
D
predetermined (b) predetermined (b)
(a)
Classification including 5µm particles may be considered where indicated by the
CCS or historical trends.
(b)
For grade D, in operation limits are not predetermined. The manufacturer should
establish in operation limits based on a risk assessment and routine data where
applicable.
4.28 For classification of the cleanroom, the minimum number of sampling locations
and their positioning can be found in ISO 14644 Part 1. For the aseptic processing
area and the background environment (the grade A and grade B areas,
respectively), additional sample locations should be considered and all critical
processing areas such as the point of fill and container closure feeder bowls
should be evaluated. Critical processing locations should be determined by
documented risk assessment and knowledge of the process and operations to
be performed in the area.
4.29 Cleanroom classification should be carried out in the “at rest” and “in operation”
states.
i. The definition of “at rest” state is the condition whereby the installation of all
the utilities is complete including any functioning HVAC, with the main
manufacturing equipment installed as specified but not operating and without
personnel present in the room.
ii. The definition of “in operation” state is the condition where the installation of
the cleanroom is complete, the HVAC system fully operational, equipment
installed and functioning in the manufacturer’s defined operating mode with
the maximum number of personnel present performing or simulating routine
operational work.
iii. The total particle limits given in Table 1 above for the “at rest” state should
be achieved after a “clean up” period on completion of operations and line
clearance/cleaning activities. The "clean up" period (guidance value of less

than 20 minutes) should be determined during the qualification of the rooms,

documented and adhered to in procedures to reinstate a qualified state of
cleanliness if disrupted during operation.
4.30 The speed of air supplied by unidirectional airflow systems should be clearly
justified in the qualification protocol including the location for air speed
measurement. Air speed should be designed, measured and maintained to
ensure that appropriate unidirectional air movement provides protection of the
product and open components at the working position (e.g. where high-risk
operations occur and where product and/or components are exposed).
Unidirectional airflow systems should provide a homogeneous air speed in a
range of 0.36 – 0.54 m/s (guidance value) at the working position, unless
otherwise scientifically justified in the CCS. Airflow visualization studies should
correlate with the air speed measurement.
4.31 The microbial contamination level of the cleanrooms should be determined as

part of the cleanroom qualification. The number of sampling locations should be
based on a documented risk assessment and the results obtained from room
classification, air visualization studies and knowledge of the process and
operations to be performed in the area. The maximum limits for microbial
contamination during qualification for each grade are given in Table 2.
Qualification should include both “at rest” and “in operation” states.
Table 2: Maximum permitted microbial contamination level during qualification
Settle plates Contact plates

Grade Air sample (diameter 90 mm) (diameter 55
CFU/m3 CFU/4 hours (a) mm) CFU/plate
A No growth
B 10 5 5
C 100 50 25
D 200 100 50
a) Settle plates should be exposed for the duration of operations and changed as required
after a maximum of 4 hours. Exposure time should be based on recovery studies and
should not allow desiccation of the media used.
Note 1: All methods indicated for a specific grade in the table should be used for qualifying
the area of that specific grade. If one of the methods tabulated is not used, or
alternative methods are used, the approach taken should be appropriately
justified.
Note 2: Limits are applied using CFU throughout the document. If different or new
technologies are used that present results in a manner different from CFU, the
manufacturer should scientifically justify the limits applied and where possible
correlate them to CFU.
Note 3: For the qualification of personnel gowning, the limits given for contact plates and
glove prints in Table 6 should apply.
Note 4: Sampling methods should not pose a risk of contamination to the manufacturing
operations.

4.32 The requalification of cleanrooms and clean air equipment should be carried out
periodically following defined procedures. The requalification should include at a
minimum the following:
i. cleanroom classification (total particle concentration),

ii. integrity test of final filters,
iii. airflow volume measurement,
iv. verification of air pressure difference between rooms, and
v. air velocity test
(Note: For grade B, C and D the air velocity test should be performed according
to a risk assessment documented as part of the CCS. However, it is required for
filling zones supplied with unidirectional airflow (e.g. when filling terminally
sterilised products or background to grade A and RABS). For grades with non-
unidirectional airflow, a measurement of recovery testing should replace velocity
testing).
The maximum time interval for requalification of grade A & B areas, is 6 months.
The maximum time interval for requalification of grade C & D areas, is 12 months.
Appropriate requalification consisting of at least the above tests should also be

carried out following completion of remedial action implemented to rectify an out
of compliance equipment or facility condition or after changes to equipment,
facility or processes as appropriate. The significance of a change should be
determined through the change management process. Examples of changes to
be considered include but are not limited to the following:
i. interruption of air movement which affects the operation of the installation,

ii. change in the design of the cleanroom or of the operational setting
parameters of the HVAC system,
iii. special maintenance which affects the operation of the installation (e.g.
change of final filters).
DISINFECTION
4.33 The disinfection of cleanrooms is particularly important. They should be cleaned

and disinfected thoroughly in accordance with a written programme. For
disinfection to be effective, prior cleaning to remove surface contamination should
be performed. Cleaning programmes should effectively remove disinfectant
residues. More than one type of disinfecting agent should be employed to ensure
that where they have different modes of action, their combined usage is effective
against bacteria and fungi. Disinfection should include the periodic use of a
sporicidal agent. Monitoring should be undertaken regularly in order to assess
the effectiveness of the disinfection programme and to detect changes in types
of microbial flora (e.g. organisms resistant to the disinfection regime currently in
use).
4.34 The disinfection process should be validated. Validation studies should

demonstrate the suitability and effectiveness of disinfectants in the specific

manner in which they are used and on the type of surface material, or
representative material if justified, and should support the in-use expiry periods
of prepared solutions.
4.35 Disinfectants and detergents used in grade A and grade B areas should be sterile
prior to use. Disinfectants used in grade C and D may also be required to be
sterile where determined in the CCS. Where the disinfectants and detergents are
diluted / prepared by the sterile product manufacturer, this should be done in a
manner to prevent contamination and they should be monitored for microbial
contamination. Dilutions should be kept in previously cleaned containers (and
sterilized where applicable) and should only be stored for the defined period. If
the disinfectants and detergents are supplied “ready-made” then results from
certificates of analysis or conformance can be accepted subject to successful
completion of the appropriate vendor qualification.
4.36 Where fumigation or vapour disinfection (e.g. Vapour-phase Hydrogen Peroxide)

of cleanrooms and associated surfaces are used, the effectiveness of any
fumigation agent and dispersion system should be understood and validated.
5 Equipment
5.1 A written, detailed description of the equipment design should be available
(including process and instrumentation diagrams as appropriate). This should
form part of the initial qualification package and be kept up to date.
5.2 Equipment monitoring requirements should be defined in “user requirements

specifications” during early stages of development, and confirmed during
qualification. Process and equipment alarm events should be acknowledged and
evaluated for trends. The frequency at which alarms are assessed should be
based on their criticality (with critical alarms reviewed immediately).
5.3 As far as practicable, equipment, fittings and services should be designed and
installed so that operations, maintenance, and repairs can be performed outside
the cleanroom. If maintenance has to be performed in the cleanroom, and the
required standards of cleanliness and/or asepsis cannot be maintained, then
precautions such as restricting access to the work area to specified personnel,
generation of clearly defined work protocols and maintenance procedures should
be considered. Additional cleaning, disinfection and environmental monitoring
should also be considered. If sterilisation of equipment is required, it should be
carried out, wherever possible, after complete reassembly.
5.4 The cleaning process should be validated to be able to:
i. remove any residue or debris that would detrimentally impact the

effectiveness of the disinfecting agent used,
ii. minimize chemical, microbial and particulate contamination of the product
during the process and prior to disinfection.
5.5 For aseptic processes, direct and indirect product contact parts should be
sterilised. Direct product contact parts are those that the product passes through,
such as filling needles or pumps. Indirect product contact parts are equipment

parts that do not contact the product, but may come into contact with other
sterilised surfaces, the sterility of which is critical to the overall product sterility
(e.g. sterilised items such as stopper bowls and guides, and sterilised
components).
5.6 All equipment such as sterilisers, air handling systems (including air filtration) and
water systems should be subject to qualification, monitoring and planned
maintenance. Upon completion of maintenance, their return to use should be
approved.
5.7 Where unplanned maintenance of equipment critical to the sterility of the product
is to be carried out, an assessment of the potential impact to the sterility of the
product should be performed and recorded.
5.8 A conveyor belt should not pass through a partition between a grade A or B
area and a processing area of lower air cleanliness, unless the belt itself is
continually sterilised (e.g. in a sterilising tunnel).
5.9 Particle counters, including sampling tubing, should be qualified. The

manufacturer’s recommended specifications should be considered for tube
diameter and bend radii. Tube length should typically be no longer than 1m unless
justified and the number of bends should be minimized. Portable particle counters
with a short length of sample tubing should be used for classification purposes.
Isokinetic sampling heads should be used in unidirectional airflow systems. They
should be oriented appropriately and positioned as close as possible to the critical
location to ensure that samples are representative.
6 Utilities
6.1 The nature and extent of controls applied to utility systems should be
commensurate with the risk to product quality associated with the utility. The
impact should be determined via a risk assessment and documented as part of
the CCS.
6.2 In general, higher risk utilities are those that:
i. directly contact product e.g. water for washing and rinsing, gases and steam
for sterilisation,
ii. contact materials that will ultimately become part of the product,
iii. contact surfaces that come into contact with the product,
iv. otherwise directly impact the product.
6.3 Utilities should be designed, installed, qualified, operated, maintained and

monitored in a manner to ensure that the utility system functions as expected.
6.4 Results for critical parameters and critical quality attributes of high risk utilities
should be subject to regular trend analysis to ensure that system capabilities
remain appropriate.

6.5 Records of utility system installation should be maintained throughout the

system’s life-cycle. Such records should include current drawings and schematic
diagrams, construction material lists and system specifications. Typically,
important information includes attributes such as:
i. pipeline flow direction, slopes, diameter and length,
ii. tank and vessel details,
iii. valves, filters, drains, sampling and user points,
6.6 Pipes, ducts and other utilities should not be present in cleanrooms. If
unavoidable, then they should be installed so that they do not create recesses,
unsealed openings and surfaces which are difficult to clean. Installation should
allow cleaning and disinfection of outer surface of the pipes.
WATER SYSTEMS
6.7 Water treatment plant and distribution systems should be designed, constructed,
installed, commissioned, qualified, monitored and maintained to prevent
microbiological contamination and to ensure a reliable source of water of an
appropriate quality. Measures should be taken to minimize the risk of presence
of particulates, microbial contamination/proliferation and endotoxin/pyrogen (e.g.
sloping of piping to provide complete drainage and the avoidance of dead legs).
Where filters are included in the system, special attention should be given to their
monitoring and maintenance. Water produced should comply with the current
monograph of the relevant Pharmacopeia.
6.8 Water systems should be qualified and validated to maintain the appropriate
levels of physical, chemical and microbial control, taking the effect of seasonal
variation into account.
6.9 Water flow should remain turbulent through the pipes in water distribution
systems to minimize the risk of microbial adhesion, and subsequent biofilm
formation. The flow rate should be established during qualification and be
routinely monitored.
6.10 Water for injections (WFI) should be produced from water meeting specifications
that have been defined during the qualification process, stored and distributed in
a manner which minimizes the risk of microbial growth (e.g. by constant
circulation at a temperature above 70°C). WFI should be produced by distillation
or by a purification process that is equivalent to distillation. This may include
reverse osmosis coupled with other appropriate techniques such as
electrodeionization (EDI), ultrafiltration or nanofiltration.
6.11 Where WFI storage tanks are equipped with hydrophobic bacteria retentive vent
filters, the filters should not be a source of contamination and the integrity of the
filter tested before installation and after use. Controls should be in place to
prevent condensation formation on the filter (e.g. by heating).
6.12 To minimize the risk of biofilm formation, sterilisation, disinfection or regeneration

of water systems should be carried out according to a predetermined schedule

and as a remedial action following out-of-limit or specification results. Disinfection
of a water system with chemicals should be followed by a validated
rinsing/flushing procedure. Water should be tested after
disinfection/regeneration. Chemical testing results should be approved before the
water system is returned to use and microbiological/endotoxin results verified to
be within specification and approved before batches manufactured using water
from the system are considered for certification/release.
6.13 Regular ongoing chemical and microbial monitoring of water systems should be
performed to ensure that the water continues to meet compendial expectations.
Alert levels should be based on the initial qualification data and thereafter
periodically reassessed on data obtained during subsequent re-qualifications,
routine monitoring, and investigations. Review of ongoing monitoring data should
be carried out to identify any adverse trend in system performance. Sampling
programmes should reflect the requirements of the CCS and should include all
outlets and points of use, at a specified interval, to ensure that representative
water samples are obtained for analysis on a regular basis. Sample plans should
be based on the qualification data, should consider the potential worst case
sampling locations and should ensure that at least one representative sample is
included every day of the water that is used for manufacturing processes.
6.14 Alert level excursions should be documented and reviewed, and include an
investigation to determine whether the excursion is a single (isolated) event or if
results are indicative of an adverse trend or system deterioration. Each action
limit excursion should be investigated to determine the probable root causes and
any potential impact on the quality of products and manufacturing processes as
a result of the use of the water.
6.15 WFI systems should include continuous monitoring systems such as Total
Organic Carbon (TOC) and conductivity, as these may give a better indication of
overall system performance than discrete sampling. Sensor locations should be
based on risk.
STEAM USED AS A DIRECT STERILISING AGENT
6.16 Feed water to a pure steam (clean steam) generator should be appropriately
purified. Pure steam generators should be designed, qualified and operated in a
manner to ensure that the quality of steam produced meets defined chemical and
endotoxin levels.
6.17 Steam used as a direct sterilising agent should be of suitable quality and should
not contain additives at a level which could cause contamination of product or
equipment. For a generator supplying pure steam used for the direct sterilisation
of materials or product-contact surfaces (e.g. porous / hard-good autoclave
loads), steam condensate should meet the current monograph for WFI of the
relevant Pharmacopeia (microbial testing is not mandatory for steam
condensate). A suitable sampling schedule should be in place to ensure that
representative pure steam is obtained for analysis on a regular basis. Other
aspects of the quality of pure steam used for sterilisation should be assessed
periodically against validated parameters. These parameters should include the
following (unless otherwise justified): non-condensable gases, dryness value

(dryness fraction) and superheat.
GASES AND VACUUM SYSTEMS
6.18 Gases that come in direct contact with the product/primary container surfaces
should be of appropriate chemical, particulate and microbial quality. All relevant
parameters, including oil and water content, should be specified, taking into
account the use and type of the gas, the design of the gas generation system
and, where applicable, comply with the current monograph of the relevant
Pharmacopeia or the product quality requirement.
6.19 Gases used in aseptic processes should be filtered through a sterilising grade
filter (with a nominal pore size of a maximum of 0.22 µm) at the point of use.
Where the filter is used on a batch basis (e.g. for filtration of gas used for overlay
of aseptically filled products) or as product vessel vent filter, then the filter should
be integrity tested and the results reviewed as part of the batch
certification/release process. Any transfer pipework or tubing that is located after
the final sterilising grade filter should be sterilised. When gases are used in the
process, microbial monitoring of the gas should be performed periodically at the
point of use.
6.20 Where backflow from vacuum or pressure systems poses a potential risk to the
product, there should be mechanism(s) to prevent backflow when the vacuum or
pressure system is shut off.
HEATING AND COOLING AND HYDRAULIC SYSTEMS
6.21 Major items of equipment associated with hydraulic, heating and cooling systems
should, where possible, be located outside the filling room. There should be
appropriate controls to contain any spillage and/or cross contamination
associated with the system fluids.
6.22 Any leaks from these systems that would present a risk to the product should be
detectable (e.g. an indication system for leakage).
7 Personnel
7.1 The manufacturer should ensure that there are sufficient appropriate personnel,
suitably qualified, trained and experienced in the manufacture and testing of
sterile products, and any of the specific manufacturing technologies used in the
site’s manufacturing operations, to ensure compliance with GMP applicable to
the manufacture and handling of sterile products.
7.2 Only the minimum number of personnel required should be present in

cleanrooms. The maximum number of operators in cleanrooms should be
determined, documented and considered during activities such as initial
qualification and APS, so as not to compromise sterility assurance.
7.3 All personnel including those performing cleaning, maintenance, monitoring and

those that access cleanrooms should receive regular training, gowning

qualification and assessment in disciplines relevant to the correct manufacture of
sterile products. This training should include the basic elements of microbiology
and hygiene, with a specific focus on cleanroom practices, contamination control,
aseptic techniques and the protection of sterile products (for those operators
entering the grade B cleanrooms and/or intervening into grade A) and the
potential safety implications to the patient if the product is not sterile. The level of
training should be based on the criticality of the function and area in which the
personnel are working.
7.4 The personnel accessing grade A and B areas should be trained for aseptic
gowning and aseptic behaviours. Compliance with aseptic gowning procedures
should be confirmed by assessment and periodic reassessment at least annually,
and should involve both visual and microbial assessment (using monitoring
locations such as gloved fingers, forearms, chest and hood (facemask /
forehead). See paragraph 9.30 for the expected limits). The unsupervised access
to the grade A and grade B areas where aseptic operations are or will be
conducted should be restricted to appropriately qualified personnel, who have
passed the gowning assessment and have participated in a successful APS.
7.5 Unqualified personnel should not enter grade B cleanrooms or grade A in

operation. If needed in exceptional cases, manufacturers should establish written
procedures outlining the process by which unqualified personnel are brought into
the grade B and A areas. An authorized person from the manufacturer should
supervise the unqualified personnel during their activities and should assess the
impact of these activities on the cleanliness of the area. Access by these persons
should be assessed and recorded in accordance with the PQS.
7.6 There should be systems in place for the disqualification of personnel from
working in or given unsupervised entry into cleanrooms that is based on aspects
including ongoing assessment and/or identification of an adverse trend from the
personnel monitoring programme and/or after being implicated in a failed APS.
Once disqualified, retraining and requalification should be completed before
permitting the operator to have any further involvement in aseptic practices. For
operators entering grade B cleanrooms or performing intervention into grade A,
this requalification should include consideration of participation in a successful
APS.
7.7 High standards of personal hygiene and cleanliness are essential to prevent
excessive shedding or increased risk of introduction of microbial contamination.
Personnel involved in the manufacture of sterile products should be instructed to
report any specific health conditions or ailments which may cause the shedding
of abnormal numbers or types of contaminants and therefore preclude cleanroom
access. Health conditions and actions to be taken with regard to personnel who
could be introducing an undue microbial hazard should be provided by the
designated competent person and described in procedures.
7.8 Personnel who have been engaged in the processing of human or animal tissue
materials or of cultures of micro-organisms, other than those used in the current
manufacturing process, or any activities that may have a negative impact to
quality (e.g. microbial contamination), should not enter clean areas unless clearly
defined and effective decontamination and entry procedures have been followed
and documented.

7.9 Wristwatches, make-up, jewellery, other personal items such as mobile phones
and any other non-essential items should not be allowed in clean areas.
Electronic devices used in cleanrooms, e.g. mobile phones and tablets, that are
supplied by the manufacturer solely for use in the cleanrooms, may be acceptable
if suitably designed to permit cleaning and disinfection commensurate with the
grade in which they are used. The use and disinfection of such equipment should
be included in the CCS.
7.10 Cleanroom gowning and hand washing should follow a written procedure
designed to minimize contamination of cleanroom clothing and/or the transfer of
contaminants to the clean areas.
7.11 The clothing and its quality should be appropriate for the process and the
grade of the working area. It should be worn in such a way as to protect the
product from contamination. When the type of clothing chosen needs to provide
the operator protection from the product, it should not compromise the protection
of the product from contamination. Garments should be visually checked for
cleanliness and integrity immediately prior to and after gowning. Gown integrity
should also be checked upon exit. For sterilised garments and eye coverings,
particular attention should be taken to ensure they have been subject to the
sterilisation process, are within their specified hold time and that the packaging
is visually inspected to ensure it is integral before use. Reusable garments
(including eye coverings) should be replaced if damage is identified, or at a set
frequency that is determined during qualification studies. The qualification of
garments should consider any necessary garment testing requirements,
including damage to garments that may not be identified by visual inspection
alone.
7.12 Clothing should be chosen to limit shedding due to operators’ movement.
7.13 A description of typical clothing required for each cleanliness grade is given
below:
i. Grade B (including access / interventions into grade A): appropriate garments

that are dedicated for use under a sterilised suit should be worn before gowning
(see paragraph 7.14). Appropriately sterilised, non-powdered, rubber or plastic
gloves should be worn while donning the sterilised garments. Sterile headgear
should enclose all hair (including facial hair) and where separate from the rest
of the gown, it should be tucked into the neck of the sterile suit. A sterile
facemask and sterile eye coverings (e.g. goggles) should be worn to cover and
enclose all facial skin and prevent the shedding of droplets and particles.
Appropriate sterilised footwear (e.g. over-boots) should be worn. Trouser legs
should be tucked inside the footwear. Garment sleeves should be tucked into a
second pair of sterile gloves worn over the pair worn while donning the gown.
The protective clothing should minimize shedding of fibres or particles and
retain particles shed by the body. The particle shedding and the particle
retention efficiencies of the garments should be assessed during the garment
qualification. Garments should be packed and folded in such a way as to allow
operators to don the gown without contacting the outer surface of the garment
and to prevent the garment from touching the floor.
ii. Grade C: Hair, beards and moustaches should be covered. A single or two-

piece trouser suit gathered at the wrists and with high neck and appropriately
disinfected shoes or overshoes should be worn. They should minimize the
shedding of fibres and particles.
iii. Grade D: Hair, beards and moustaches should be covered. A general protective
suit and appropriately disinfected shoes or overshoes should be worn.
Appropriate measures should be taken to avoid any ingress of contaminants
from outside the clean area.
iv. Additional gowning including gloves and facemask may be required in grade C
and D areas when performing activities considered to be a contamination risk
as defined by the CCS.
7.14 Cleanroom gowning should be performed in change rooms of an appropriate

cleanliness grade to ensure gown cleanliness is maintained. Outdoor clothing
including socks (other than personal underwear) should not be brought into
changing rooms leading directly to grade B and C areas. Single or two-piece
facility trouser suits, covering the full length of the arms and the legs, and facility
socks covering the feet, should be worn before entry to change rooms for grades
B and C. Facility suits and socks should not present a risk of contamination to the
gowning area or processes.
7.15 Every operator entering grade B or A areas should gown into clean, sterilised
protective garments (including eye coverings and masks) of an appropriate size
at each entry. The maximum period for which the sterilised gown may be worn
before replacement during a shift should be defined as part of the garment
qualification.
7.16 Gloves should be regularly disinfected during operations. Garments and gloves
should be changed immediately if they become damaged and present any risk of
product contamination.
7.17 Reusable clean area clothing should be cleaned in a laundry facility adequately
segregated from production operations, using a qualified process ensuring that
the clothing is not damaged and/or contaminated by fibres or particles during the
repeated laundry process. Laundry facilities used should not introduce risk of
contamination or cross-contamination. Inappropriate handling and use of clothing
may damage fibres and increase the risk of shedding of particles. After washing
and before packing, garments should be visually inspected for damage and visual
cleanliness. The garment management processes should be evaluated and
determined as part of the garment qualification programme and should include a
maximum number of laundry and sterilisation cycles.
7.18 Activities in clean areas that are not critical to the production processes should
be kept to a minimum, especially when aseptic operations are in progress.
Movement of personnel should be slow, controlled and methodical to avoid
excessive shedding of particles and organisms due to over-vigorous activity.
Operators performing aseptic operations should adhere to aseptic technique at
all times to prevent changes in air currents that may introduce air of lower quality
into the critical zone. Movement adjacent to the critical zone should be restricted
and the obstruction of the path of the unidirectional (first air) airflow should be
avoided. A review of airflow visualisation studies should be considered as part of
the training programme.

8 Production and Specific Technologies

TERMINALLY STERILISED PRODUCTS
8.1 Preparation of components and materials should be performed in at least a

grade D cleanroom in order to limit the risk of microbial, endotoxin/pyrogen and
particle contamination, so that the product is suitable for sterilisation. Where the
product is at a high or unusual risk of microbial contamination (e.g. the product
actively supports microbial growth, the product must be held for long periods
before filling or the product is not processed mostly in closed vessels), then
preparation should be carried out in at least a grade C environment. Preparation
of ointments, creams, suspensions and emulsions should be carried out in at
least a grade C environment before terminal sterilisation. Specific guidance
regarding terminally sterilised veterinary medicinal products can be found within
Annex 4 of the GMP Guide.
8.2 Primary packaging containers and components should be cleaned using

validated processes to ensure that particle, endotoxin/pyrogen and bioburden
contamination is appropriately controlled.
8.3 Filling of products for terminal sterilisation should be carried out in at least a
grade C environment.
8.4 Where the CCS identifies that the product is at an unusual risk of contamination
from the environment because, for example, the filling operation is slow, the
containers are wide necked or are necessarily exposed for more than a few seconds
before closing, then the product should be filled in grade A with at least a grade C
background.
8.5 Processing of the bulk solution should include a filtration step with a
microorganism retaining filter, where possible, to reduce bioburden levels and
particles prior to filling into the final product containers and there should be a
maximum permissible time between preparation and filling.
8.6 Examples of operations to be carried out in the various grades are given in
Table 3.
Table 3: Examples of operations and grades for terminally sterilised preparation and
processing operations
Grade A - Filling of products, when unusually at risk.

Grade C - Preparation of solutions, when unusually at risk.
- Filling of products.
Grade D - Preparation of solutions and components for subsequent filling.
ASEPTIC PREPARATION AND PROCESSING
8.7 The aseptic process should be clearly defined. The risks associated with the
aseptic process, and any associated requirements, should be identified,
assessed and appropriately controlled. The site’s CCS should clearly define the

acceptance criteria for these controls, requirements for monitoring and the review
of their effectiveness. Methods and procedures to control these risks should be
described and implemented. Accepted residual risks should be formally
documented.
8.8 Precautions to minimize microbial, endotoxin/pyrogenic and particle

contamination should be taken, as per the site’s CCS, during the preparation
of the aseptic environment, during all processing stages (including the stages
before and after bulk product sterilisation), and until the product is sealed in its final
container. The presence of materials liable to generate particles and fibres should
be minimized in cleanrooms.
8.9 Where possible, the use of equipment such as RABS, isolators or other systems,
should be considered in order to reduce the need for critical interventions into
grade A and to minimize the risk of contamination. Robotics and automation of
processes can also be considered to eliminate direct human critical interventions
(e.g. dry heat tunnel, automated lyophilizer loading, sterilisation in place).
8.10 Examples of operations to be carried out in the various environmental grades are
given in Table 4.
Table 4: Examples of operations and grades for aseptic preparation and processing
operations
- Aseptic assembly of filling equipment.

- Connections made under aseptic conditions (where sterilised product contact
surfaces are exposed) that are post the final sterilising grade filter. These
connections should be sterilised by steam-in-place whenever possible.
- Aseptic compounding and mixing.
- Replenishment of sterile bulk product, containers and closures.
Grade A - Removal and cooling of unprotected (e.g. with no packaging) items from
sterilisers.
- Staging and conveying of sterile primary packaging components in the aseptic
filling line while not wrapped.
- Aseptic filling, sealing of containers such as ampoules, vial closure, transfer of
open or partially stoppered vials.
- Loading of a lyophilizer.
- Background support for grade A (when not in an isolator).

Grade B - Conveying or staging, while protected from the surrounding environment, of
equipment, components and ancillary items for introduction into grade A.
Grade C - Preparation of solutions to be filtered including sampling and dispensing.
- Cleaning of equipment.
- Handling of components, equipment and accessories after cleaning.
Grade D - Assembly under HEPA filtered airflow of cleaned components, equipment and
accessories prior to sterilisation.
- Assembly of closed and sterilised SUS using intrinsic sterile connection
devices.

8.11 For sterile products where the final formulation cannot be filtered, the following
should be considered:
i. all product and component contact equipment should be sterilised prior to use,
ii. all raw materials or intermediates should be sterilised and aseptically added,
iii. bulk solutions or intermediates should be sterilised.
8.12 The unwrapping, assembly and preparation of sterilised equipment, components

and ancillary items with direct or indirect product contact should be treated as an
aseptic process and performed in grade A with a grade B background. The filling
line set-up and filling of the sterile product should be treated as an aseptic process
and performed in grade A with a grade B background. Where an isolator is used,
the background should be in accordance with paragraph 4.20.
8.13 Preparation and filling of sterile products such as ointments, creams,

suspensions and emulsions should be performed in grade A with a grade B
background when the product and components are exposed to the environment
and the product is not subsequently filtered (via a sterilising grade filter) or
terminally sterilised. Where an isolator or RABS is used, the background should
be in accordance with paragraph 4.20.
8.14 Aseptic connections should be performed in grade A with a grade B background

unless subsequently sterilised in place or conducted with intrinsic sterile
connection devices that minimize any potential contamination from the immediate
environment. Intrinsic sterile connection devices should be designed to mitigate
risk of contamination.
Where an isolator is used, the background should be in accordance with

paragraph 4.20. Aseptic connections should be appropriately assessed and their
effectiveness verified. For requirements regarding intrinsic sterile connection
devices, see paragraphs 8.129 and 8.130.
8.15 Aseptic manipulations (including non-intrinsic sterile connection devices) should

be minimized through the use of engineering design solutions such as
preassembled and sterilised equipment. Whenever feasible, product contact
piping and equipment should be pre-assembled, and sterilised in place.
8.16 There should be an authorized list of allowed and qualified interventions, both
inherent and corrective, that may occur during production (see paragraph 9.34).
Interventions should be carefully designed to ensure that the risk of
contamination of the environment, process and product is effectively minimized.
The process of designing interventions should include the consideration of any
impact on air-flows and critical surfaces and products. Engineering solutions
should be used whenever possible to minimize incursion by operators during the
intervention. Aseptic technique should be observed at all times, including the
appropriate use of sterile tools for manipulations. The procedures listing the types
of inherent and corrective interventions, and how to perform them, should be first
evaluated via risk management and APS and be kept up to date. Non-qualified
interventions should only be used in exceptional circumstances, with due
consideration of the risks associated with the intervention and with the
authorisation of the quality unit. The details of the intervention conducted should

be subject to risk assessment, recorded and fully investigated under the

manufacturer's PQS. Any non-qualified interventions should be thoroughly
assessed by the quality department and considered during batch disposition.
8.17 Interventions and stoppages should be recorded in the batch record. Each line
stoppage or intervention should be sufficiently documented in batch records with
the associated time, duration of the event, and operators involved (ref to
paragraph 9.34).
8.18 The duration of each aspect of aseptic preparation and processing should be
minimized and limited to a defined and validated maximum time, including:
i. the holding time between equipment, component, and container cleaning,

drying and sterilisation;
ii. the holding time for sterilised equipment, components, and containers before
use and during filling/assembly;
iii. the holding time for a decontaminated environment, such as the RABS or
isolator before use;
iv. the time between the start of the preparation of a product and its sterilisation or
filtration through a microorganism-retaining filter (if applicable), through to the
end of the aseptic filling process There should be a maximum permissible time
for each product that takes into account its composition and the prescribed
method of storage;
v. the holding time for sterilised product prior to filling;
vi. the aseptic processing time;
vii. the filling time.
8.19 Aseptic operations (including APS) should be observed on a regular basis by

personnel with specific expertise in aseptic processing to verify the correct
performance of operations including operator behaviour in the cleanroom and
address inappropriate practices if detected.
FINISHING OF STERILE PRODUCTS
8.20 Open primary packaging containers should be maintained under grade A

conditions with the appropriate background for the technology as described in
paragraph 4.20. For partially stoppered vials or prefilled syringes (see paragraph
8.126).
8.21 Final containers should be closed by appropriately validated methods.
8.22 Where final containers are closed by fusion, e.g. Blow-Fill-Seal (BFS), Form-Fill-
Seal (FFS), Small and Large Volume Parenteral (SVP & LVP) bags, glass or
plastic ampoules, the critical parameters and variables that affect seal integrity
should be evaluated, determined, effectively controlled and monitored during
operations. Glass ampoules, BFS units and small volume containers (≤100 ml)

closed by fusion should be subject to 100% integrity testing using validated

methods. For large volume containers (>100 ml) closed by fusion, reduced
sampling may be acceptable where scientifically justified and based on data
demonstrating the consistency of the existing process, and a high level of process
control. It should be noted that visual inspection is not considered as an
acceptable integrity test method.
8.23 Samples of products using systems other than fusion should be taken and
checked for integrity using validated methods. The frequency of testing should
be based on the knowledge and experience of the container and closure systems
being used. A scientifically justified sampling plan should be used. The sample
size should be based on information such as supplier management, packaging
component specifications and process knowledge.
8.24 Containers sealed under vacuum should be tested for maintenance of vacuum
after an appropriate pre-determined period prior to certification/release and during
shelf life.
8.25 The container closure integrity validation should take into consideration any
transportation or shipping requirements that may negatively impact the integrity
of the container (e.g. by decompression or extreme temperatures).
8.26 Where the equipment used to crimp vial caps can generate large quantities of
non-viable particle, measures to prevent particle contamination such as locating
the equipment at a physically separate station equipped with adequate air
extraction should be taken.
8.27 Vial capping of aseptically filled products can be undertaken as an aseptic

process using sterilised caps or as a clean process outside the aseptic
processing area. Where the latter approach is adopted, vials should be
protected by grade A conditions up to the point of leaving the aseptic processing
area, and thereafter stoppered vials should be protected with a grade A air supply
until the cap has been crimped. The supporting background environment of grade
A air supply should meet at least grade D requirements. Where capping is a
manual process, it should be performed under grade A conditions either in an
appropriately designed isolator or in grade A with a grade B background.
8.28 Where capping of aseptically filled sterile product is conducted as a clean process
with grade A air supply protection, vials with missing or displaced stoppers
should be rejected prior to capping. Appropriately qualified, automated methods
for stopper height detection should be in place.
8.29 Where human intervention is required at the capping station, appropriate

technological and organizational measures should be used to prevent direct
contact with the vials and to minimize contamination. RABS and isolators may be
beneficial in assuring the required conditions.
8.30 All filled containers of parenteral products should be inspected individually for
extraneous contamination or other defects. Defect classification and criticality
should be determined during qualification and based on risk and historical
knowledge. Factors to consider include, but are not limited to, the potential impact
of the defect to the patient and the route of administration. Different defect types
should be categorized and batch performance analysed. Batches with unusual

levels of defects, when compared with routine defect numbers for the process
(based on routine and trend data), should be investigated. A defect library should
be generated and maintained which captures all known classes of defects. The
defect library should be used for the training of production and quality assurance
personnel. Critical defects should not be identified during any subsequent
sampling and inspection of acceptable containers. Any critical defect identified
subsequently should trigger an investigation as it indicates a possible failure of
the original inspection process.
8.31 When inspection is performed manually, it should be conducted under suitable

and controlled conditions of illumination and background. Inspection rates should
be appropriately controlled and qualified. Operators performing the inspection
should undergo visual inspection qualification (whilst wearing corrective lenses, if
these are normally worn) at least annually. The qualification should be
undertaken using appropriate samples from the manufacturer's defect library sets
and taking into consideration worst case scenarios (e.g. inspection time, line
speed where the product is transferred to the operator by a conveyor system,
container size or fatigue) and should include consideration of eyesight checks.
Operator distractions should be minimized and frequent breaks, of an appropriate
duration, should be taken from inspection.
8.32 Where automated methods of inspection are used, the process should be
validated to detect known defects (which may impact product quality or safety)
and be equal to, or better than, manual inspection methods. The performance of
the equipment should be challenged using representative defects prior to start up
and at regular intervals throughout the batch.
8.33 Results of the inspection should be recorded and defect types and numbers
trended. Reject levels for the various defect types should also be trended based
on statistical principles. Impact to product on the market should be assessed as
part of the investigation when adverse trends are observed.
STERILISATION
8.34 Where possible, finished product should be terminally sterilised, using a validated
and controlled sterilisation process, as this provides a greater assurance of
sterility than a validated and controlled sterile filtration process and/or aseptic
processing. Where it is not possible for a product to undergo terminal sterilisation,
consideration should be given to using post-aseptic processing terminal heat
treatment, combined with aseptic process to give improved sterility assurance.
8.35 The selection, design and location of the equipment and cycle/programme used
for sterilisation should be based on scientific principles and data which
demonstrate repeatability and reliability of the sterilisation process. All
parameters should be defined, and where critical, these should be controlled,
monitored and recorded.
8.36 All sterilisation processes should be validated. Validation studies should take into
account the product composition, storage conditions and maximum time between
the start of the preparation of a product or material to be sterilised and its
sterilisation. Before any sterilisation process is adopted, its suitability for the
product and equipment, and its efficacy in consistently achieving the desired

sterilising conditions in all parts of each type of load to be processed should be

validated notably by physical measurements and where appropriate by Biological
Indicators (BI). For effective sterilisation, the whole of the product, and surfaces
of equipment and components should be subject to the required treatment and
the process should be designed to ensure that this is achieved.
8.37 Particular attention should be given when the adopted product sterilisation
method is not described in the current edition of the Pharmacopoeia, or when it
is used for a product which is not a simple aqueous solution. Where possible,
heat sterilisation is the method of choice.
8.38 Validated loading patterns should be established for all sterilisation processes
and load patterns should be subject to periodic revalidation. Maximum and
minimum loads should also be considered as part of the overall load validation
strategy.
8.39 The validity of the sterilizing process should be reviewed and verified at
scheduled intervals based on risk. Heat sterilization cycles should be revalidated
with a minimum frequency of at least annually for load patterns that are
considered worst case. Other load patterns should be validated at a frequency
justified in the CCS.
8.40 Routine operating parameters should be established and adhered to for all
sterilisation processes, e.g. physical parameters and loading patterns.
8.41 There should be mechanisms in place to detect a sterilisation cycle that does not
conform to the validated parameters. Any failed sterilisation or sterilisation that
deviated from the validated process (e.g. have longer or shorter phases such as
heating cycles) should be investigated.
8.42 Suitable BIs placed at appropriate locations should be considered as an

additional method to support the validation of the sterilisation process. BIs should
be stored and used according to the manufacturer’s instructions. Where BIs are
used to support validation and/or to monitor a sterilisation process (e.g. with
ethylene oxide), positive controls should be tested for each sterilisation cycle. If
BIs are used, strict precautions should be taken to avoid transferring microbial
contamination to the manufacturing or other testing processes. BI results in
isolation should not be used to override other critical parameters and process
design elements.
8.43 The reliability of BIs is important. Suppliers should be qualified and transportation
and storage conditions should be controlled in order that BI quality is not
compromised. Prior to use of a new batch/lot of BIs, the population, purity and
identity of the indicator organism of the batch/lot should be verified. For other
critical parameters, e.g. D-value, Z-value, the batch certificate provided by the
qualified supplier can normally be used.
8.44 There should be a clear means of differentiating products, equipment and

components, which have not been subjected to the sterilisation process from
those which have. Equipment such as baskets or trays used to carry products,
other items of equipment and/or components should be clearly labelled (or
electronically tracked) with the product name and batch number and an indication
of whether or not it has been sterilised. Indicators such as autoclave tape, or

irradiation indicators may be used, where appropriate, to indicate whether or not

a batch (or sub-batch material, component, equipment) has passed through a
sterilisation process. However, these indicators show only that the sterilisation
process has occurred; they do not indicate product sterility or achievement of the
required sterility assurance level.
8.45 Sterilisation records should be available for each sterilisation run. Each cycle
should have a unique identifier. Their conformity should be reviewed and
approved as part of the batch certification/release procedure.
8.46 Where required, materials, equipment and components should be sterilised by

validated methods appropriate to the specific material. Suitable protection after
sterilisation should be provided to prevent recontamination. If sterilised items are
not used immediately after sterilisation, these should be stored using
appropriately sealed packaging and a maximum hold time should be established.
Where justified, components that have been packaged with multiple sterile
packaging layers need not be stored in a cleanroom if the integrity and
configuration of the sterile pack allows the items to be readily disinfected during
transfer by operators into grade A (e.g. by the use of multiple sterile coverings
that can be removed at each transfer from lower to higher grade). Where
protection is achieved by containment in sealed packaging, this packaging
process should be undertaken prior to sterilisation.
8.47 Where materials, equipment, components and ancillary items are sterilised in
sealed packaging and then transferred into grade A, this should be done using
appropriate validated methods (for example, airlocks or pass-through hatches)
with accompanying disinfection of the exterior of the sealed packaging. The use
of rapid transfer port technology should also be considered. These methods
should be demonstrated to effectively control the potential risk of contamination
of the grade A and grade B areas and, likewise, the disinfection procedure should
be demonstrated to be effective in reducing any contamination on the packaging
to acceptable levels for entry of the item into the grade B and grade A areas.
8.48 Where materials, equipment, components and ancillary items are sterilised in
sealed packaging or containers, the packaging should be qualified for minimizing
the risk of particulate, microbial, endotoxin/pyrogen or chemical contamination,
and for compatibility with the selected sterilisation method. The packaging sealing
process should be validated. The validation should consider the integrity of the
sterile protective barrier system, the maximum hold time before sterilisation and
the maximum shelf life assigned to the sterilised items. The integrity of the sterile
protective barrier system for each of the sterilised items should be checked prior
to use.
8.49 For materials, equipment, components and ancillary items that are not a direct or
indirect product contact part and are necessary for aseptic processing but cannot
be sterilised, an effective and validated disinfection and transfer process should
be in place. These items, once disinfected, should be protected to prevent
recontamination. These items, and others representing potential routes of
contamination, should be included in the environmental monitoring programme.

STERILISATION BY HEAT
8.50 Each heat sterilisation cycle should be recorded either electronically or by

hardcopy, using equipment with suitable accuracy and precision. The system
should have safeguards and/or redundancy in its control and monitoring
instrumentation to detect a cycle not conforming to the validated cycle parameter
requirements and abort or fail this cycle (e.g. by the use of duplex/double probes
connected to independent control and monitoring systems).
8.51 The position of the temperature probes used for controlling and/or recording
should be determined during the validation and selected based on system design
and in order to correctly record and represent routine cycle conditions. Validation
studies should be designed to demonstrate the suitability of system control and
recording probe locations, and should include the verification of the function and
location of these probes by the use of an independent monitoring probe located
at the same position during validation.
8.52 The whole of the load should reach the required temperature before
measurement of the sterilising time-period starts. For sterilisation cycles
controlled by using a reference probe within the load, specific consideration
should be given to ensuring the load probe temperature is controlled within
defined temperature range prior to cycle commencement.
8.53 After completion of the high temperature phase of a heat sterilisation cycle,
precautions should be taken against contamination of a sterilised load during
cooling. Any cooling liquid or gas that comes into contact with the product or
sterilised material should be sterilised.
8.54 In those cases where parametric release has been authorized, a robust system
should be applied to the product lifecycle validation and the routine monitoring of
the manufacturing process. This system should be periodically reviewed. Further
guidance regarding parametric release is provided in Annex 17.
MOIST HEAT STERILISATION
8.55 Moist heat sterilisation can be achieved using steam, (direct or indirect contact),
but also includes other systems such as superheated water systems (cascade or
immersion cycles) that could be used for containers that may be damaged by
other cycle designs (e.g. Blow-Fill-Seal containers, plastic bags).
8.56 The items to be sterilised, other than products in sealed containers, should be dry,
packaged in a protective barrier system which allows removal of air and
penetration of steam and prevents recontamination after sterilisation. All loaded
items should be dry upon removal from the steriliser. Load dryness should be
confirmed by visual inspection as a part of the sterilisation process acceptance.
8.57 For porous cycles (hard goods), time, temperature and pressure should be used
to monitor the process and be recorded. Each sterilised item should be inspected
for damage, packaging material integrity and moisture on removal from the
autoclave. Any item found not to be fit for purpose should be removed from the
manufacturing area and an investigation performed.

8.58 For autoclaves capable of performing prevacuum sterilisation cycles, the

temperature should be recorded at the chamber drain throughout the sterilisation
period. Load probes may also be used where appropriate but the controlling
system should remain related to the load validation. For steam in place systems,
the temperature should be recorded at appropriate condensate drain locations
throughout the sterilisation period.
8.59 Validation of porous cycles should include a calculation of equilibration time,

exposure time, correlation of pressure and temperature and the
minimum/maximum temperature range during exposure. Validation of fluid cycles
should include temperature, time and/or F0. Critical processing parameters
should be subject to defined limits (including appropriate tolerances) and be
confirmed as part of the sterilisation validation and routine cycle acceptance
criteria.
8.60 Leak tests on the steriliser should be carried out periodically (normally weekly)
when a vacuum phase is part of the cycle or the system is returned, post-
sterilisation, to a pressure lower than the environment surrounding the steriliser.
8.61 There should be adequate assurance of air removal prior to and during
sterilisation when the sterilisation process includes air purging (e.g. porous
autoclave loads, lyophilizer chambers). For autoclaves, this should include an air
removal test cycle (normally performed on a daily basis) or the use of an air
detector system. Loads to be sterilised should be designed to support effective
air removal and be free draining to prevent the build-up of condensate.
8.62 Distortion and damage of non-rigid containers that are terminally sterilised, such
as containers produced by Blow-Fill-Seal or Form-Fill-Seal technologies, should
be prevented by appropriate cycle design and control (for instance setting correct
pressure, heating and cooling rates and loading patterns).
8.63 Where steam in place systems are used for sterilisation (e.g. for fixed pipework,
vessels and lyophilizer chambers), the system should be appropriately designed
and validated to assure all parts of the system are subjected to the required
treatment. The system should be monitored for temperature, pressure and time
at appropriate locations during routine use to ensure all areas are effectively and
reproducibly sterilised. These locations should be demonstrated as being
representative of, and correlated with, the slowest to heat locations during initial
and routine validation. Once a system has been sterilised by steam in place, it
should remain integral and where operations require, maintained under positive
pressure or otherwise equipped with a sterilising vent filter prior to use.
8.64 In fluids load cycles where superheated water is used as the heat transfer
medium, the heated water should consistently reach all of the required contact
points. Initial qualification studies should include temperature mapping of the
entire load. There should be routine checks on the equipment to ensure that
nozzles (where the water is introduced) are not blocked and drains remain free
from debris.
8.65 Validation of the sterilisation of fluids loads in a superheated water autoclave

should include temperature mapping of the entire load and heat penetration and
reproducibility studies. All parts of the load should heat up uniformly and achieve
the desired temperature for the specified time. Routine temperature monitoring

probes should be correlated to the worst case positions identified during the
qualification process.
DRY HEAT STERILISATION
8.66 Dry heat sterilisation utilizes high temperatures of air or gas to sterilise a product
or article. Dry heat sterilisation is of particular use in the thermal removal of
difficult-to-eliminate thermally robust contaminants such as endotoxin/pyrogen
and is often used in the preparation of components for aseptic filling. The
combination of time and temperature to which product, components or equipment
are exposed should produce an adequate and reproducible level of lethality
and/or endotoxin/pyrogen inactivation/removal when operated routinely within
the established limits. The process may be operated in an oven or in a continuous
tunnel process, e.g. for sterilisation and depyrogenation of glass containers.
8.67 Dry heat sterilisation/depyrogenation tunnels should be configured to ensure that

airflow protects the integrity and performance of the grade A sterilising zone by
maintaining appropriate pressure differentials and airflow through the tunnel. Air
pressure difference profiles should be assessed. The impact of any airflow
change should be assessed to ensure the heating profile is maintained. All air
supplied to the tunnel should pass through at least a HEPA filter and periodic
tests (at least biannually) should be performed to demonstrate air filter integrity.
Any tunnel parts that come into contact with sterilised components should be
appropriately sterilised or disinfected. Critical process parameters that should be
considered during validation and/or routine processing should include, but are
not limited to:
i. belt speed or dwell time within the sterilising zone,
ii. temperature – minimum and maximum temperatures,
iii. heat penetration of the material/article,
iv. heat distribution/uniformity,
v. airflows determined by air pressure difference profiles correlated with the heat
distribution and penetration studies.
8.68 When a thermal process is used as part of the depyrogenation process for any
component or product contact equipment/material, validation studies should be
performed to demonstrate that the process provides a suitable Fh value and
results in a minimum 3 log10 reduction in endotoxin concentration. When this is
attained, there is no additional requirement to demonstrate sterilisation in these
cases.
8.69 Containers spiked with endotoxin should be used during validation and should be
carefully managed with a full reconciliation performed. Containers should be
representative of the materials normally processed (in respect to composition of
the packaging materials, porosity, dimensions, nominal volume). Endotoxin
quantification and recovery efficiency should also be demonstrated.

8.70 Dry heat ovens are typically employed to sterilise or depyrogenate primary
packaging components, starting materials or active substances but may be used
for other processes. They should be maintained at a positive pressure relative to
lower grade clean areas throughout the sterilisation and post sterilisation hold
process unless the integrity of the packaging is maintained. All air entering the
oven should pass through a HEPA filter. Critical process parameters that should
be considered in qualification and/or routine processing should include, but are
not limited to:
i. temperature,
ii. exposure period/time,
iii. chamber pressure (for maintenance of over pressure),
iv. air speed,
v. air quality within the oven,
vi. heat penetration of material/article (slow to heat spots),
vii. heat distribution/uniformity,
viii. load pattern and configuration of articles to be sterilised/depyrogenated

including minimum and maximum loads.
STERILISATION BY RADIATION
8.71 Sterilisation by radiation is used mainly for the sterilisation of heat sensitive
materials and products. Ultraviolet irradiation is not an acceptable method of
sterilisation. Guidance regarding ionising radiation sterilisation can be found
within Annex 12.
8.72 Validation procedures should ensure that the effects of variation in density of the
product and packages are considered.
STERILISATION WITH ETHYLENE OXIDE
8.73 This method should only be used when no other method is practicable. During
process validation, it should be shown that there is no damaging effect on the
product and that the conditions and time allowed for degassing result in the
reduction of any residual ethylene oxide (EO) gas and reaction products to
defined acceptable limits for the given product or material.
8.74 Direct contact between gas and microbial cells is essential, precautions should
be taken to avoid the presence of organisms likely to be enclosed in material
such as crystals or dried protein. The nature, porosity and quantity of packaging
materials can significantly affect the process.
8.75 Before exposure to the gas, materials should be brought into equilibrium
with the humidity and temperature required by the process. Where steam is

used to condition the load for sterilisation, it should be of an appropriate quality.

The time required for this should be balanced against the opposing need to
minimize the time before sterilisation.
8.76 Each sterilisation cycle should be monitored with suitable BIs, using the
appropriate number of test units distributed throughout the load at defined
locations that have been shown to be worst case locations during validation.
8.77 Critical process parameters that could be considered as part of the sterilisation
process validation and routine monitoring include, but are not limited to:
i. EO gas concentration,
ii. pressure,
iii. amount of EO gas used,
iv. relative humidity,
v. temperature,
vi. exposure time.
8.78 After sterilisation, the load should be aerated to allow EO gas and/or its reaction
products to desorb from the packaged product to predetermined levels. Aeration
can occur within a steriliser chamber and/or in a separate aeration chamber or
aeration room. The aeration phase should be validated as part of the overall EO
sterilisation process validation.
FILTER STERILISATION OF PRODUCTS WHICH CANNOT BE STERILISED IN

THEIR FINAL CONTAINER
8.79 If the product cannot be sterilised in its final container, solutions or liquids should
be sterilised by filtration through a sterile sterilising grade filter (with a nominal
pore size of a maximum of 0.22 µm that has been appropriately validated to
obtain a sterile filtrate) and subsequently aseptically filled into a previously
sterilised container. The selection of the filter used should ensure that it is
compatible with the product and as described in the marketing authorization (see
paragraph 8.135).
8.80 Suitable bioburden reduction prefilters and/or sterilising grade filters may be used
at multiple points during the manufacturing process to ensure a low and
controlled bioburden of the liquid prior to the final sterilising filter. Due to the
potential additional risks of a sterile filtration process, as compared with other
sterilisation processes, an additional filtration through a sterile sterilising grade
filter, as close to the point of fill as possible, should be considered as part of an
overall CCS.
8.81 The selection of components for the filtration system and their interconnection
and arrangement within the filtration system, including pre-filters, should be
based on the critical quality attributes of the product, justified and documented.

The filtration system should minimize the generation of fibres and particles, not
cause or contribute to unacceptable levels of impurities, or possess
characteristics that otherwise alter the quality and efficacy of the product.
Similarly, the filter characteristics should be compatible with the fluid and not be
adversely affected by the product to be filtered. Adsorption of product
components and extraction/leaching of filter components should be evaluated
(see paragraph 8.135).
8.82 The filtration system should be designed to:
i. allow operation within validated process parameters;
ii. maintain the sterility of the filtrate;
iii. minimize the number of aseptic connections required between the final
sterilising grade filter and the final filling of the product;
iv. allow cleaning procedures to be conducted as necessary;
v. allow sterilisation procedures, including sterilisation in place, to be conducted

as necessary;
vi. permit in-place integrity testing, of the 0.22 µm final sterilising grade filter,
preferably as a closed system, both prior to, and following filtration as
necessary. In-place integrity testing methods should be selected to avoid any
adverse impact on the quality of the product.
8.83 Sterile filtration of liquids should be validated in accordance with relevant

Pharmacopeia requirements. Validation can be grouped by different strengths or
variations of a product but should be done under worst case conditions. The
rationale for grouping should be justified and documented.
8.84 During filter validation, wherever possible, the product to be filtered should be
used for bacterial retention testing of the sterilising grade filter. Where the product
to be filtered is not suitable for use in bacterial retention testing, a suitable
surrogate product should be justified for use in the test. The challenge organism
used in the bacterial retention test should be justified.
8.85 Filtration parameters that should be considered and established during validation
should include, but are not limited to:
i. The wetting fluid used for filter integrity testing:
 It should be based on the filter manufacturer’s recommendation or the fluid

to be filtered. The appropriate integrity test value specification should be
established.
 If the system is flushed or integrity tested in-situ with a fluid other than the
product, appropriate actions are taken to avoid any deleterious effect on
product quality.

ii. Filtration process conditions including:
 fluid pre-filtration holding time and effect on bioburden,
 filter conditioning, with fluid if necessary,
 maximum filtration time/total time filter is in contact with the fluid,
 maximum operating pressure,
 flow rate,
 maximum filtration volume,
 temperature,
 the time taken to filter a known volume of bulk solution and the pressure
difference to be used across the filter.
8.86 Routine process controls should be implemented to ensure adherence to

validated filtration parameters. Results of critical process parameters should be
included in the batch record, including but not limited to the minimum time taken
to filter a known volume of bulk solution and pressure difference across the filter.
Any significant difference from critical parameters during manufacturing should
be documented and investigated.
8.87 The integrity of the sterilised filter assembly should be verified by integrity testing
before use (pre-use post sterilisation integrity test or PUPSIT), to check for
damage and loss of integrity caused by the filter preparation prior to use. A
sterilising grade filter that is used to sterilise a fluid should be subject to a non-
destructive integrity test post-use prior to removal of the filter from its housing.
The integrity test process should be validated and test results should correlate to
the microbial retention capability of the filter established during validation.
Examples of tests that are used include bubble point, diffusive flow, water
intrusion or pressure hold test. It is recognized that PUPSIT may not always be
possible after sterilisation due to process constraints (e.g. the filtration of very
small volumes of solution). In these cases, an alternative approach may be taken
providing that a thorough risk assessment has been performed and compliance
is achieved by the implementation of appropriate controls to mitigate any risk of
a non-integral filtration system. Points to consider in such a risk assessment
should include but are not limited to:
i. in depth knowledge and control of the filter sterilisation process to ensure

that the potential for damage to the filter is minimized,
ii. in depth knowledge and control of the supply chain to include:
 contract sterilisation facilities,

 defined transport mechanisms,
 packaging of the sterilised filter, to prevent damage to the filter during
transportation and storage.

iii. in depth process knowledge such as:
 the specific product type, including particle burden and whether there
exists any risk of impact on filter integrity values, such as the potential to
alter integrity-testing values and therefore prevent the detection of a non-
integral filter during a post-use filter integrity test; and
 pre-filtration and processing steps, prior to the final sterilising grade filter,
which would remove particle burden and clarify the product prior to the
sterile filtration.
8.88 The integrity of critical sterile gas and air vent filters (that are directly linked to the
sterility of the product) should be verified by testing after use, with the filter
remaining in the filter assembly or housing.
8.89 The integrity of non-critical air or gas vent filters should be confirmed and
recorded at appropriate intervals. Where gas filters are in place for extended
periods, integrity testing should be carried out at installation and prior to
replacement. The maximum duration of use should be specified and monitored
based on risk (e.g. considering the maximum number of uses and heat treatment/
sterilisation cycles permitted as applicable).
8.90 For gas filtration, unintended moistening or wetting of the filter or filter equipment
should be avoided.
8.91 If the sterilising filtration process has been validated as a system consisting of
multiple filters to achieve the sterility for a given fluid, the filtration system is
considered to be a single sterilising unit and all filters within the system should
satisfactorily pass integrity testing after use.
8.92 In a redundant filtration system (where a second redundant sterilising grade filter
is present as a backup but the sterilising process is validated as only requiring
one filter), post-use integrity test of the primary sterilising grade filter should be
performed and if demonstrated to be integral, then a post-use integrity test of the
redundant (backup) filter is not necessary. However, in the event of a failure of
the post-use integrity test on the primary filter, post-use integrity test on the
secondary (redundant) filter should be performed, in conjunction with an
investigation and risk assessment to determine the reason for the primary filter
test failure.
8.93 Bioburden samples should be taken from the bulk product and immediately prior
to the final sterile filtration. In case where a redundant filtration set-up is used, it
should be taken prior to the first filter. Systems for taking samples should be
designed so as not to introduce contamination.
8.94 Liquid sterilising grade filters should be discarded after the processing of a single
batch and the same filter should not be used continuously for more than one
working day unless such use has been validated.
8.95 Where campaign manufacture of a product has been appropriately justified in the
CCS and validated, the filter user should:

i. assess and document the risks associated with the duration of filter use for
the sterile filtration process for a given fluid;
ii. conduct and document effective validation and qualification studies to
demonstrate that the duration of filter use for a given sterile filtration process
and for a given fluid does not compromise performance of the final sterilising
grade filter or filtrate quality;
iii. document the maximum validated duration of use for the filter and implement
controls to ensure that filters are not used beyond the validated maximum
duration. Records of these controls should be maintained;
iv. implement controls to ensure that filters contaminated with fluid or cleaning
agent residues, or considered defective in any other way, are removed from
use.
FORM-FILL-SEAL (FFS)
8.96 The conditions for FFS machines used for terminally sterilised products should
comply with the environmental requirements of paragraphs 8.3 and 8.4 of this
Annex. The conditions for FFS machines used in aseptic manufacture should
comply with the environmental requirements of paragraph 8.10 of this Annex.
8.97 Contamination of the packaging films used in the FFS process should be
minimized by appropriate controls during component fabrication, supply and
handling. Due to the criticality of packaging films, procedures should be
implemented to ensure that the films supplied meet defined specifications and
are of the appropriate quality, including material thickness and strength, microbial
and particulate contamination, integrity and artwork, as relevant. The sampling
frequency, the bioburden and, where applicable, endotoxin/pyrogen levels of
packaging films and associated components should be defined and controlled
within the PQS and considered in the CCS.
8.98 Particular attention should be given to understanding and assessing the

operation of the equipment, including set-up, filling, sealing and cutting
processes, so that critical process parameters are understood, validated,
controlled and monitored appropriately.
8.99 Any product contact gases, e.g. those used to inflate the container or used as a
product overlay, should be appropriately filtered, as close to the point of use as
possible. The quality of gases used and the effectiveness of gas filtration systems
should be verified periodically in accordance with paragraphs 6.18 and 6.19.
8.100 The controls identified during qualification of FFS should be in alignment with the
CCS. Aspects to be considered include but are not limited to:
i. determination of the boundaries of the critical zone,
ii. environmental control and monitoring, both of the machine and the
background in which it is placed,
iii. personnel gowning requirements,

iv. integrity testing of the product filling lines and filtration systems (as relevant),
v. duration of the batch or filling campaign,
vi. control of packaging films, including any requirements for film

decontamination or sterilisation,
vii. cleaning-in-place and sterilisation-in-place of equipment as necessary,
viii. machine operation, settings and alarm management (as relevant).
8.101 Critical process parameters for FFS should be determined during equipment
qualification and should include, but are not limited to:
i. settings for uniform package dimensions and cutting in accordance with

validated parameters;
ii. setting, maintenance and monitoring of validated forming temperatures

(including pre-heating and cooling), forming times and pressures as relevant;
iii. setting, maintenance and monitoring of validated sealing temperatures,

sealing temperature uniformity across the seal, sealing times and pressures
as relevant;
iv. environmental and product temperature;
v. batch-specific testing of package seal strength and uniformity;
vi. settings for correct filling volumes, speeds and uniformity;
vii. settings for any additional printing (batch coding), embossing or debossing
to ensure that unit integrity is not compromised;
viii. methods and parameters for integrity testing of filled containers (see
paragraph 8.22).
8.102 Appropriate procedures for the verification, monitoring and recording of FFS
critical process parameters and equipment operation should be applied during
production.
8.103 Operational procedures should describe how forming and sealing issues are
detected and rectified. Rejected units or sealing issues should be recorded and
investigated.
8.104 Appropriate maintenance procedures should be established based on risk, and

include maintenance and inspection plans for tooling critical to the effectiveness
of unit sealing. Any issues identified that indicate a potential product quality
concern should be documented and investigated.

BLOW-FILL-SEAL
8.105 Blow-Fill-Seal equipment used for the manufacture of products which are
terminally sterilised should be installed in at least a grade D environment. The
conditions at the point of fill should comply with the environmental requirements
of paragraphs 8.3 and 8.4.
8.106 BFS used for aseptic processing:
i. For shuttle type equipment used for aseptic filling, the parison is open to the
environment and therefore the areas where parison extrusion, blow-
moulding and sealing take place should meet grade A conditions at the
critical zones. The filling environment should be designed and maintained to
meet grade A conditions for viable and total particle limits both at rest and
when in operation.
ii. For rotary-type equipment used for aseptic filling, the parison is generally
closed to the environment once formed, the filling environment within the
parison should be designed and maintained to meet grade A conditions for
viable and total particle limits both at rest and when in operation.
iii. The equipment should be installed in at least a grade C environment,

provided that grade A/B clothing is used. The microbiological monitoring of
operators wearing grade A/B clothing in a grade C area, should be performed
in accordance with risk management principles, and the limits and monitoring
frequencies applied with consideration of the activities performed by these
operators.
8.107 Due to the generation of particles from polymer extrusion and cutting during
operation, and the restrictive size of critical filling zones of BFS equipment, in
operation monitoring of total particle for BFS equipment is not expected.
However, data should be available to demonstrate that the design of the
equipment ensures that critical zones of the filling process environment would
meet grade A conditions in operation.
8.108 Viable environmental monitoring of BFS processes should be risk-based, and

designed in accordance with section 9 of this Annex. In operation viable
monitoring should be undertaken for the full duration of critical processing,
including equipment assembly. For rotary-type BFS equipment, it is
acknowledged that monitoring of the critical filling zone may not be possible.
8.109 The environmental control and monitoring programme should take into
consideration the moving parts and complex airflow paths generated by the BFS
process and the effect of the high heat outputs of the process, (e.g. through the
use of airflow visualization studies and/or other equivalent studies).
Environmental monitoring programmes should also consider factors such as air-
filter configuration, air-filter integrity, cooling systems integrity (see paragraph
6.21), equipment design and qualification.
8.110 Air or other gases that make contact with critical surfaces of the container during
extrusion, formation or sealing of the moulded container should undergo
appropriate filtration. The quality of gas used and the effectiveness of gas

filtration systems should be verified periodically in accordance with paragraphs

6.18 and 6.19.
8.111 Particulate and microbial contamination of the polymer granulate should be

prevented by appropriate design, control, and maintenance of the polymer
granulate storage, sampling and distribution systems.
8.112 The capability of the extrusion system to provide appropriate sterility assurance
for the moulded container should be understood and validated. The sampling
frequency, the bioburden and, where applicable, endotoxin/pyrogen levels of the
raw polymer should be defined and controlled within the PQS and considered in
the CCS.
8.113 Interventions requiring cessation of filling and/or extrusion, moulding and sealing
and, where required, re-sterilisation of the filling machine should be clearly
defined and described in the filling procedure, and included in the APS as relevant
(see paragraphs 9.34, 9.35 and 9.36).
8.114 The controls identified during qualification of BFS should be in alignment with the
site’s CCS. Aspects to be considered include but are not limited to:
i. determination of the boundaries of the critical zone,
ii. environmental control and monitoring, both of the machine and the
background in which it is placed,
iii. personnel gowning requirements,
iv. integrity testing of the product filling lines and filtration systems (as relevant),
v. duration of the batch or filling campaign,
vi. control of polymer granulate, including distribution systems and critical

extrusion temperatures,
vii. cleaning-in-place and sterilisation-in-place of equipment as necessary,
viii. machine operation, settings and alarm management (as relevant).
8.115 Critical process parameters for BFS should be determined during equipment
qualification and should include, but are not limited to:
i. clean-in-place and sterilisation-in-place of product pipelines and filling

needles (mandrels);
ii. setting, maintenance and monitoring of extrusion parameters, including

temperature, speed and extruder throat settings for parison thickness;
iii. setting, maintenance and monitoring of mould temperatures, including rate

of cooling where necessary for product stability;
iv. preparation and sterilisation of ancillary components added to the moulded

unit, e.g. bottle caps;

v. environmental control, cleaning, sterilisation and monitoring of the critical

extrusion, transfer and filling areas as relevant;
vi. batch-specific testing of package wall-thickness at critical points of the

container;
vii. settings for correct filling volumes, speeds and uniformity;
viii. settings for any additional printing (batch coding), embossing or debossing
to ensure that unit integrity and quality is not compromised;
ix. methods and parameters for integrity testing of 100% of all filled containers
(see paragraph 8.22);
x. settings for cutters or punches used to remove waste plastic surrounding

filled units (flash removal).
8.116 Appropriate procedures for the verification, monitoring and recording of BFS
critical process parameters and equipment operation should be applied during
production.
8.117 Operational procedures should describe how blowing, forming and sealing issues
are detected and rectified. Rejected units or sealing issues should be recorded
and investigated.
8.118 Where the BFS process includes the addition of components to moulded
containers (e.g. addition of caps to LVP bottles), these components should be
appropriately decontaminated and added to the process using a clean, controlled
process.
i. For aseptic processes, the addition of components should be performed

under grade A conditions, to ensure the sterility of critical surfaces, using pre-
sterilised components.
ii. For terminally sterilised products, the validation of terminal sterilisation

processes should ensure the sterility of all critical product pathways between
the component and moulded container, including areas that are not wetted
during sterilisation.
iii. Testing procedures should be established and validated to ensure the

effective sealing of components and moulded containers.
8.119 Appropriate maintenance procedures should be established based on risk, and

include maintenance and inspection plans for items critical to unit sealing,
integrity and sterility.
8.120 The moulds used to form containers are considered critical equipment and any
changes or modification to moulds should result in an assessment of finished
product container integrity, and where the assessment indicates, should be
supported by validation. Any issues identified that indicate a potential product
quality concern should be documented and investigated.

LYOPHILIZATION
8.121 Lyophilization is a critical process step and all activities that can affect the sterility
of the product or material need to be regarded as extensions of the aseptic
processing of the sterilised product. The lyophilization equipment and its
processes should be designed to ensure that product or material sterility is
maintained during lyophilization by preventing microbial and particle
contamination between the filling of products for lyophilization, and completion of
lyophilization process. All control measures in place should be determined by the
site’s CCS.
8.122 The sterilisation of the lyophilizer and associated equipment (e.g. trays, vial
support rings) should be validated and the holding time between the sterilisation
cycle and use appropriately challenged during APS (see paragraph 9.33). The
lyophilizer should be sterilised regularly, based on system design. Re-sterilisation
should be performed following maintenance or cleaning. Sterilised lyophilizers
and associated equipment should be protected from contamination after
sterilisation.
8.123 Lyophilizers and associated product transfer and loading/unloading areas should
be designed to minimize operator intervention as far as possible. The frequency
of lyophilizer sterilisation should be determined based on the design and risks
related to system contamination during use. Lyophilizers that are manually
loaded or unloaded with no barrier technology separation should be sterilised
before each load. For lyophilizers loaded and unloaded by automated systems or
protected by closed barrier systems, the frequency of sterilisation should be
justified and documented as part of the CCS.1
8.124 The integrity of the lyophilizer should be maintained following sterilisation and
during lyophilization. The filter used to maintain lyophilizer integrity should be
sterilised before each use of the system and its integrity testing results should be
part of the batch certification/release. The frequency of vacuum/leak integrity
testing of the chamber should be documented and the maximum permitted
leakage of air into the lyophilizer should be specified and checked at the start of
every cycle.
8.125 Lyophilization trays should be checked regularly to ensure that they are not
misshapen or damaged.
8.126 Points to consider for the design of loading (and unloading, where the lyophilized
material is still unsealed and exposed), include but are not limited to:
i. The loading pattern within the lyophilizer should be specified and

documented.
ii. The transfer of partially closed containers to a lyophilizer should be

undertaken under grade A conditions at all times and handled in a manner
designed to minimize direct operator intervention. Technologies such as
conveyor systems or portable transfer systems (e.g. clean air transfer carts,
1 This provision enters into force on 25 August 2024.

portable unidirectional airflow workstations) should be used to ensure that

the cleanliness of the system used to transfer the partially closed containers
is maintained. Alternatively, where supported by validation, trays closed in
grade A and not reopened whilst in the grade B area may be used to protect
partially stoppered vials (e.g. appropriately closed boxes).
iii. Airflow patterns should not be adversely affected by transport devices and
venting of the loading zone.
iv. Unsealed containers (such as partially stoppered vials) should be maintained

under grade A conditions and should normally be separated from operators
by physical barrier technology or any other appropriate measures.
v. Where seating of the stoppers is not completed prior to opening the

lyophilizer chamber, product removed from the lyophilizer should remain
under grade A conditions during subsequent handling.
vi. Utensils used during loading and unloading of the lyophilizer (e.g. trays,
bags, placing devices, tweezers) should be sterile.
CLOSED SYSTEMS
8.127 The use of closed systems can reduce the risk of microbial, particle and chemical
contamination from the adjacent environment. Closed systems should always be
designed to reduce the need for manual manipulations and the associated risks.
8.128 It is critical to ensure the sterility of all product contact surfaces of closed systems
used for aseptic processing. The design and selection of any closed system used
for aseptic processing should ensure maintenance of sterility. Connection of
sterile equipment (e.g. tubing/pipework) to the sterilised product pathway after
the final sterilising grade filter should be designed to be connected aseptically
(e.g. by intrinsic sterile connection devices).
8.129 Appropriate measures should be in place to ensure the integrity of components

used in aseptic connections. The means by which this is achieved should be
determined and captured in the CCS. Appropriate system integrity tests should
be considered when there is a risk of compromising product sterility. Supplier
assessment should include the collation of data in relation to potential failure
modes that may lead to a loss of system sterility.
8.130 The background environment in which closed systems are located should be
based on their design and the processes undertaken. For aseptic processing and
where there are any risks that system integrity may be compromised, the system
should be located in grade A. If the system can be shown to remain integral at
every usage (e.g. via pressure testing and/or monitoring) then a lower classified
area may be used. Any transfer between classified areas should be thoroughly
assessed (see paragraph 4.10). If the closed system is opened (e.g. for
maintenance of a bulk manufacturing line) then this should be performed in a
classified area appropriate to the materials (e.g. grade C for terminal sterilisation
processes, or grade A for aseptic processing) or be subject to further cleaning
and disinfection (and sterilisation in case of aseptic processes).

SINGLE USE SYSTEMS (SUS)
8.131 SUS are those technologies used in manufacture of sterile products which are
used as an alternative to reusable equipment. SUS can be individual components
or made up of multiple components such as bags, filters, tubing, connectors,
valves, storage bottles and sensors. Single use systems should be designed to
reduce the need for manipulations and complexity of manual interventions.
8.132 There are some specific risks associated with SUS which should be assessed as
part of the CCS. These risks include but are not limited to:
i. the interaction between the product and product contact surface (such as
adsorption, or leachables and extractables),
ii. the fragile nature of the system compared with fixed reusable systems,
iii. the increase in the number and complexity of manual operations (including
inspection and handling of the system) and connections made,
iv. the complexity of the assembly,
v. the performance of the pre- and post-use integrity testing for sterilising grade
filters (see paragraph 8.87),
vi. the risk of holes and leakage,
vii. the potential for compromising the system at the point of opening the outer
packaging,
viii. the risk of particle contamination.
8.133 Sterilisation processes for SUS should be validated and shown to have no
adverse impact on system performance.
8.134 Assessment of suppliers of disposable systems including sterilisation is critical to

the selection and use of these systems. For sterile SUS, verification of sterility
assurance should be performed as part of the supplier qualification and evidence
of sterilisation of each unit should be checked on receipt.
8.135 The adsorption and reactivity of the product with product contact surfaces should
be evaluated under process conditions.
8.136 The extractable and leachable profiles of the SUS and any impact on the quality
of the product especially where the system is made from polymer-based
materials should be evaluated. An assessment should be carried out for each
component to evaluate the applicability of the extractable profile data. For
components considered to be at high risk from leachables, including those that
may absorb processed materials or those with extended material contact times,
an assessment of leachable profile studies, including safety concerns, should be
taken into consideration. If applying simulated processing conditions, these
should accurately reflect the actual processing conditions and be based on a
scientific rationale.

8.137 SUS should be designed to maintain integrity throughout processing under the
intended operational conditions. Attention to the structural integrity of the single
use components is necessary where these may be exposed to more extreme
conditions (e.g. freezing and thawing processes) either during routine processing
or transportation. This should include verification that intrinsic sterile connection
devices (both heat sealed and mechanically sealed) remain integral under these
conditions.
8.138 Acceptance criteria should be established and implemented for SUS

corresponding to the risks or criticality of the products and its processes. On
receipt, each piece of SUS should be checked to ensure that they have been
manufactured, supplied and delivered in accordance with the approved
specification. A visual inspection of the outer packaging (e.g. appearance of
exterior carton, product pouches), label printing, and review of attached
documents (e.g. certificate of conformance and proof of sterilisation) should be
carried out and documented prior to use.
8.139 Critical manual handling operations of SUS such as assembly and connections
should be subject to appropriate controls and verified during APS.
9 Environmental & process monitoring

GENERAL
9.1 The site’s environmental and process monitoring programme forms part of the
overall CCS and is used to monitor the controls designed to minimize the risk of
microbial and particle contamination. It should be noted that the reliability of each
of the elements of the monitoring system (viable, non-viable and APS) when
taken in isolation is limited and should not be considered individually to be an
indicator of asepsis. When considered together, the results help confirm the
reliability of the design, validation and operation of the system that they are
monitoring.
9.2 This programme is typically comprised of the following elements:
i. environmental monitoring – total particle;

ii. environmental and personnel monitoring – viable particle;
iii. temperature, relative humidity and other specific characteristics;
iv. APS (aseptically manufactured product only).
9.3 The information from these systems should be used for routine batch
certification/release and for periodic assessment during process review or
investigation. This applies for both terminal sterilisation and aseptic processes,
however, the criticality of the impact may differ depending upon the product and
process type.

ENVIRONMENTAL AND PROCESS MONITORING
9.4 An environmental monitoring programme should be established and

documented. The purpose of the environmental monitoring programme, is to:
i. Provide assurance that cleanrooms and clean air equipment continue to
provide an environment of appropriate air cleanliness, in accordance with
design and regulatory requirements.
ii. Effectively detect excursions from environmental limits triggering
investigation and assessment of risk to product quality.
Risk assessments should be performed in order to establish this comprehensive
environmental monitoring programme, i.e. sampling locations, frequency of
monitoring, monitoring methods and incubation conditions (e.g. time,
temperature(s), aerobic and/or anaerobic conditions).
These risk assessments should be conducted based on detailed knowledge of;

the process inputs and final product, the facility, equipment, the criticality of
specific processes and steps, the operations involved, routine monitoring data,
monitoring data obtained during qualification and knowledge of typical microbial
flora isolated from the environment.
The risk assessment should include the determination of critical monitoring

locations, those locations where the presence of microorganisms during
processing may have an impact upon product quality, (e.g. grade A, aseptic
processing areas and the grade B areas that directly interface with the grade A
area). Consideration of other information such as air visualisation studies should
also be included. These risk assessments should be reviewed regularly in order
to confirm the effectiveness of the site’s environmental monitoring programme.
The monitoring programme should be considered in the overall context of the
trend analysis and the CCS for the site.
9.5 Routine monitoring of cleanrooms, clean air equipment and personnel should be
performed in operation throughout all critical stages of processing, including
equipment set-up.
9.6 Other characteristics, such as temperature and relative humidity, should be

controlled within ranges that align with product/processing/personnel
requirements and support maintenance of defined cleanliness standards (e.g.
grade A or B).
9.7 The monitoring of grade A should demonstrate the maintenance of aseptic

processing conditions during critical operations. Monitoring should be performed
at locations posing the highest risk of contamination to the sterile equipment
surfaces, containers, closures and product. The selection of monitoring locations
and the orientation and positioning of sampling devices should be justified and
appropriate to obtain reliable data from the critical zones.
9.8 Sampling methods should not pose a risk of contamination to the manufacturing
operations.
9.9 Appropriate alert levels and action limits should be set for the results of viable
and total particle monitoring. The maximum total particle action limits are

described in Table 5 and the maximum viable particle action limits are described
in Table 6. However, more stringent action limits may be applied based on data
trending, the nature of the process or as determined within the CCS. Both viable
and total particle alert levels should be established based on results of cleanroom
qualification tests and periodically reviewed based on ongoing trend data.
9.10 Alert levels for grade A (total particle only) grade B, grade C and grade D should
be set such that adverse trends (e.g. a numbers of events or individual events
that indicate a deterioration of environmental control) are detected and
addressed.
9.11 Monitoring procedures should define the approach to trending. Trends should
include, but are not limited to:
i. increasing numbers of excursions from action limits or alert levels;

ii. consecutive excursions from alert levels;
iii. regular but isolated excursion from action limits that may have a common
cause, (e.g. single excursions that always follow planned preventative
maintenance);
iv. changes in microbial flora type and numbers and predominance of specific
organisms. Particular attention should be given to organisms recovered that
may indicate a loss of control, deterioration in cleanliness or organisms that
may be difficult to control such as spore-forming microorganisms and
moulds.
9.12 The monitoring of grade C and D cleanrooms in operation should be performed

based on data collected during qualification and routine data to allow effective
trend analysis. The requirements of alert levels and action limits will depend on
the nature of the operations carried out. Action limits may be more stringent than
those listed in Table 5 and Table 6.
9.13 If action limits are exceeded, operating procedures should prescribe a root cause
investigation, an assessment of the potential impact to product (including batches
produced between the monitoring and reporting) and requirements for corrective
and preventive actions. If alert levels are exceeded, operating procedures should
prescribe assessment and follow-up, which should include consideration of an
investigation and/or corrective actions to avoid any further deterioration of the
environment.
ENVIRONMENTAL MONITORING – TOTAL PARTICLE
9.14 A total particle monitoring program should be established to obtain data for
assessing potential contamination risks and to ensure the maintenance of the
environment for sterile operations in a qualified state.
9.15 The limits for environmental monitoring of airborne particle concentration for each
graded area are given in Table 5.

Table 5: Maximum permitted total particle concentration for monitoring.
Maximum limits for total particle Maximum limits for total particle
Grade ≥ 0.5 μm/m3 ≥ 5 μm/m3
at rest in operation at rest in operation
A 3 520 3 520 29 29
B 3 520 352 000 29 2 930
C 352 000 3 520 000 2 930 29 300
3 520 000 Not 29 300 Not
D
predetermined (a) predetermined (a)
(a) For grade D, in operation limits are not predetermined. The manufacturer should
establish in operation limits based on a risk assessment and on routine data, where
applicable.
Note 1: The particle limits given in the table for the “at rest” state should be achieved after
a short “clean up” period defined during qualification (guidance value of less than
20 minutes) in an unmanned state, after the completion of operations (see
paragraph 4.29).
Note 2: The occasional indication of macro particle counts, especially ≥ 5 µm, within
grade A may be considered to be false counts due to electronic noise, stray light,
coincidence loss etc. However, consecutive or regular counting of low levels may
be indicative of a possible contamination event and should be investigated. Such
events may indicate early failure of the room air supply filtration system,
equipment failure, or may also be diagnostic of poor practices during machine
set-up and routine operation.
9.16 For grade A, particle monitoring should be undertaken for the full duration of
critical processing, including equipment assembly.
9.17 The grade A area should be monitored continuously (for particles ≥0.5 and
≥5 µm) and with a suitable sample flow rate (at least 28 litres (1ft 3) per minute)
so that all interventions, transient events and any system deterioration is
captured. The system should frequently correlate each individual sample result
with alert levels and action limits at such a frequency that any potential excursion
can be identified and responded to in a timely manner. Alarms should be triggered
if alert levels are exceeded. Procedures should define the actions to be taken in
response to alarms including the consideration of additional microbial monitoring.
9.18 It is recommended that a similar system be used for the grade B area although
the sample frequency may be decreased. The grade B area should be monitored
at such a frequency and with suitable sample size that the programme captures
any increase in levels of contamination and system deterioration. If alert levels
are exceeded, alarms should be triggered.
9.19 The selection of the monitoring system should take into account any risk
presented by the materials used in the manufacturing operation (e.g. those
involving live organisms, powdery products or radiopharmaceuticals) that may
give rise to biological, chemical or radiation hazards.
9.20 In the case where contaminants are present due to the processes involved and
would potentially damage the particle counter or present a hazard (e.g. live
organisms, powdery products and radiation hazards), the frequency and strategy

employed should be such as to assure the environmental classification both prior

to and post exposure to the risk. An increase in viable particle monitoring should
be considered to ensure comprehensive monitoring of the process. Additionally,
monitoring should be performed during simulated operations. Such operations
should be performed at appropriate intervals. The approach should be defined in
the CCS.
9.21 The size of monitoring samples taken using automated systems will usually be a
function of the sampling rate of the system used. It is not necessary for the
sample volume to be the same as that used for formal classification of cleanrooms
and clean air equipment. Monitoring sample volumes should be justified.
ENVIRONMENTAL AND PERSONNEL MONITORING – VIABLE PARTICLE
9.22 Where aseptic operations are performed, microbial monitoring should be frequent
using a combination of methods such as settle plates, volumetric air sampling,
glove, gown and surface sampling (e.g. swabs and contact plates). The method
of sampling used should be justified within the CCS and should be demonstrated
not to have a detrimental impact on grade A and B airflow patterns. Cleanroom
and equipment surfaces should be monitored at the end of an operation.
9.23 Viable particle monitoring should also be performed within the cleanrooms when
normal manufacturing operations are not occurring (e.g. post disinfection, prior to
start of manufacturing, on completion of the batch and after a shutdown period),
and in associated rooms that have not been used, in order to detect potential
incidents of contamination which may affect the controls within the cleanrooms.
In case of an incident, additional sample locations may be used as a verification
of the effectiveness of a corrective action (e.g. cleaning and disinfection).
9.24 Continuous viable air monitoring in grade A (e.g. air sampling or settle plates)
should be undertaken for the full duration of critical processing, including
equipment (aseptic set-up) assembly and critical processing. A similar approach
should be considered for grade B cleanrooms based on the risk of impact on the
aseptic processing. The monitoring should be performed in such a way that all
interventions, transient events and any system deterioration would be captured
and any risk caused by interventions of the monitoring operations is avoided.
9.25 A risk assessment should evaluate the locations, type and frequency of personnel
monitoring based on the activities performed and the proximity to critical zones.
Monitoring should include sampling of personnel at periodic intervals during the
process. Sampling of personnel should be performed in such a way that it will not
compromise the process. Particular consideration should be given to monitoring
personnel following involvement in critical interventions (at a minimum gloves,
but may require monitoring of areas of gown as applicable to the process) and
on each exit from the grade B cleanroom (gloves and gown). Where monitoring
of gloves is performed after critical interventions, the outer gloves should be
replaced prior to continuation of activity. Where monitoring of gowns is required
after critical interventions, the gown should be replaced before further activity in
the cleanroom.
9.26 Microbial monitoring of personnel in the grade A and grade B areas should be
performed. Where operations are manual in nature (e.g. aseptic compounding or

filling), the increased risk should lead to enhanced emphasis placed on microbial
monitoring of gowns and justified within the CCS.
9.27 Where monitoring is routinely performed by manufacturing personnel, this should

be subject to regular oversight by the quality unit (refer also to paragraph 8.19).
9.28 The adoption of suitable alternative monitoring systems such as rapid methods
should be considered by manufacturers in order to expedite the detection of
microbiological contamination issues and to reduce the risk to product. These
rapid and automated microbial monitoring methods may be adopted after
validation has demonstrated their equivalency or superiority to the established
methods.
9.29 Sampling methods and equipment used should be fully understood and
procedures should be in place for the correct operation and interpretation of
results obtained. Supporting data for the recovery efficiency of the sampling
methods chosen should be available.
9.30 Action limits for viable particle contamination are shown in Table 6.
Table 6: Maximum action limits for viable particle contamination
Settle plates Contact plates Glove print,

Grade Air sample (diam. 90 mm) (diam. 55mm), Including 5 fingers on
CFU /m3 CFU /4 hours(a) CFU / plate(b) both hands
CFU / glove
A No growth(c)
B 10 5 5 5
C 100 50 25 -
D 200 100 50 -
(a) - Settle plates should be exposed in grade A and B areas for the duration of operations
(including equipment set-up) and changed as required after a maximum of 4 hours
(exposure time should be based on validation including recovery studies and it
should not have any negative effect on the suitability of the media used).
- For grade C and D areas, exposure time (with a maximum of 4 hours) and frequency
should be based on QRM.
- Individual settle plates may be exposed for less than 4 hours.
(b) Contact plate limits apply to equipment, room and gown surfaces within the grade A and
grade B areas. Routine gown monitoring is not normally required for grade C and D
areas, depending on their function.
(c) It should be noted that for grade A, any growth should result in an investigation.
Note 1: It should be noted that the types of monitoring methods listed in the table above
are examples and other methods can be used provided they meet the intent of
providing information across the whole of the critical process where product may
be contaminated (e.g. aseptic line set-up, aseptic processing, filling and
lyophilizer loading).
Note 2: Limits are applied using CFU throughout the document. If different or new
technologies are used that present results in a manner different from CFU, the
manufacturer should scientifically justify the limits applied and where possible
correlate them to CFU.

9.31 Microorganisms detected in the grade A and grade B areas should be identified
to species level and the potential impact of such microorganisms on product
quality (for each batch implicated) and overall state of control should be
evaluated. Consideration should also be given to the identification of
microorganisms detected in grade C and D areas (for example where action limits
or alert levels are exceeded) or following the isolation of organisms that may
indicate a loss of control, deterioration in cleanliness or that may be difficult to
control such as spore-forming microorganisms and moulds and at a sufficient
frequency to maintain a current understanding of the typical flora of these areas.
ASEPTIC PROCESS SIMULATION (APS) (ALSO KNOWN AS MEDIA FILL)
9.32 Periodic verification of the effectiveness of the controls in place for aseptic
processing should include an APS using a sterile nutrient media and/or surrogate
in place of the product. The APS should not be considered as the primary means
to validate the aseptic process or aspects of the aseptic process. The
effectiveness of the aseptic process should be determined through process
design, adherence to the pharmaceutical quality system and process controls,
training, and evaluation of monitoring data. Selection of an appropriate nutrient
media and/or surrogate should be made based on the ability of the media and/or
surrogate to imitate physical product characteristics assessed to pose a risk to
product sterility during the aseptic process. Where processing stages may
indirectly impact the viability of any introduced microbial contamination, (e.g.
aseptically produced semi-solids, powders, solid materials, microspheres,
liposomes and other formulations where product is cooled or heated or
lyophilized), alternative procedures that represent the operations as closely as
possible should be developed. Where surrogate materials, such as buffers, are
used in parts of the APS, the surrogate material should not inhibit the growth of
any potential contamination.
9.33 The APS should imitate as closely as possible the routine aseptic manufacturing
process and include all the critical manufacturing steps, specifically:
i. The APS should assess all aseptic operations performed subsequent to the
sterilisation and decontamination cycles of materials utilised in the process
to the point where the container is sealed.
ii. For non-filterable formulations, any additional aseptic steps should be

assessed.
iii. Where aseptic manufacturing is performed under an inert atmosphere, the

inert gas should be substituted with air in the process simulation unless
anaerobic simulation is intended.
iv. Processes requiring the addition of sterile powders should use an acceptable
surrogate material in the same containers as those used in the process under
evaluation.
v. Separate simulations of individual unit operations (e.g. processes involving

drying, blending, milling and subdivision of a sterile powder) should be
avoided. Any use of individual simulations should be supported by a
documented justification and ensure that the sum total of the individual

simulations continues to fully cover the whole process.
vi. The process simulation procedure for lyophilized products should represent
the entire aseptic processing chain including filling, transport, loading, a
representative duration of the chamber dwell, unloading and sealing under
specified, documented and justified conditions representing worst case
operating parameters.
vii. The lyophilization process simulation should mimic all aspects of the
process, except those that may affect the viability or recovery of
contaminants. For instance, boiling-over or actual freezing of the solution
should be avoided. Factors to consider in determining APS design include,
where applicable:
 the use of air to break vacuum instead of nitrogen or other process

gases,
 replicating the maximum interval between sterilisation of the

lyophilizer and its use,
 replicating the maximum period of time between filtration and

lyophilization, and
 quantitative aspects of worst-case situations, e.g. loading the largest

number of trays, replicating the longest duration of loading where the
chamber is open to the environment.
9.34 The APS should take into account various aseptic manipulations and
interventions known to occur during normal production as well as worst-case
situations, and take into account the following:
i. Inherent and corrective interventions representative of the routine process

should be performed in a manner and frequency similar to that during the
routine aseptic process.
ii. The inclusion and frequency of interventions in the APS should be based on
assessed risks posed to product sterility.
9.35 APS should not be used to justify practices that pose unnecessary contamination
risks.
9.36 In developing the APS plan, consideration should be given to the following:
i. Identification of worst case conditions covering the relevant variables, such

as container size and line speed, and their impact on the process. The
outcome of the assessment should justify the variables selected.
ii. Determining the representative sizes of container/closure combinations to be

used for validation. Bracketing or matrix approach may be considered for
validation of the same container/closure configuration for different products
where process equivalence is scientifically justified.
iii. Maximum permitted holding times for sterile product and equipment exposed

during the aseptic process.
iv. The volume filled per container, which should be sufficient to ensure that the
media contacts all equipment and component surfaces that may directly
contaminate the sterile product. The volume used should provide sufficient
headspace to support potential microbial growth and ensure that turbidity can
be detected during inspection.
v. The requirement for substitution of any inert gas used in the routine aseptic
manufacturing process by air unless anaerobic simulation is intended. In
these situations, inclusion of occasional anaerobic simulations as part of the
overall validation strategy should be considered (see paragraph 9.33 point
iii).
vi. The selected nutrient media should be capable of growing a designated

group of reference microorganisms as described by the relevant
pharmacopeia and suitably representative local isolates.
vii. The method of detection of microbial contamination should be scientifically

justified to ensure that contamination is reliably detected.
viii. The process simulation should be of sufficient duration to challenge the

process, the operators that perform interventions, shift changes and the
capability of the processing environment to provide appropriate conditions
for the manufacture of a sterile product.
ix. Where the manufacturer operates different or extended shifts, the APS
should be designed to capture factors specific to those shifts that are
assessed to pose a risk to product sterility, for example the maximum
duration for which an operator may be present in the cleanroom.
x. Simulating normal aseptic manufacturing interruptions where the process is

idle (e.g. shift changeovers, recharging dispensing vessels, introduction of
additional equipment).
xi. Ensuring that environmental monitoring is conducted as required for routine

production, and throughout the entire duration of the process simulation.
xii. Where campaign manufacturing occurs, such as in the use of Barrier

Technologies or manufacture of sterile active substances, consideration
should be given to designing and performing the process simulation so that
it simulates the risks associated with both the beginning and the end of the
campaign and demonstrating that the campaign duration does not pose any
risk.
xiii. The performance of "end of production or campaign APS" may be used as

additional assurance or investigative purposes; however, their use should be
justified in the CCS and should not replace routine APS. If used, it should be
demonstrated that any residual product does not negatively impact the
recovery of any potential microbial contamination.
9.37 For sterile active substances, batch size should be large enough to represent
routine operation, simulate intervention operation at the worst case, and cover all

surfaces that may come into contact with the sterile product. In addition, all the
simulated materials (surrogates or growth medium) should be subjected to
microbial evaluation. The simulation materials should be sufficient to satisfy the
evaluation of the process being simulated and should not compromise the
recovery of micro-organisms.
9.38 APS should be performed as part of the initial validation, with at least three
consecutive satisfactory simulation tests that cover all working shifts that the
aseptic process may occur in, and after any significant modification to operational
practices, facilities, services or equipment which are assessed to have an impact
on the sterility assurance of the product (e.g. modification to the HVAC system,
equipment, changes to process, number of shifts and numbers of personnel,
major facility shut down). Normally, APS (periodic revalidation) should be
repeated twice a year (approximately every six months) for each aseptic process,
each filling line and each shift. Each operator should participate in at least one
successful APS annually. Consideration should be given to performing an APS
after the last batch prior to shut down, before long periods of inactivity or before
decommissioning or relocation of a line.
9.39 Where manual operation (e.g. aseptic compounding or filling) occurs, each type
of container, container closure and equipment train should be initially validated
with each operator participating in at least 3 consecutive successful APS and
revalidated with one APS approximately every 6 months for each operator. The
APS batch size should mimic that used in the routine aseptic manufacturing
process.
9.40 The number of units processed (filled) for APS should be sufficient to effectively
simulate all activities that are representative of the aseptic manufacturing
process. Justification for the number of units to be filled should be clearly
captured in the CCS. Typically, a minimum of 5000 to 10000 units are filled. For
small batches (e.g. those under 5000 units), the number of containers for APS
should at least equal the size of the production batch.
9.41 Filled APS units should be agitated, swirled or inverted before incubation to
ensure contact of the media with all interior surfaces in the container. All integral
units from the APS should be incubated and evaluated, including units with
cosmetic defects or those which have gone through non-destructive in-process
control checks. If units are discarded during the process simulation and not
incubated, these should be comparable with units discarded during a routine fill,
and only if production SOPs clearly specify that units must be removed under the
same circumstances (i.e. type of intervention; line location; specific number of
units removed). In no case should more units be removed during a media fill
intervention than would be cleared during a production run. Examples may
include those that must be discarded during routine production after the set-up
process or following a specific type of intervention. To fully understand the
process and assess contamination risks during aseptic setup or mandatory line
clearances, these units would typically be incubated separately, and would not
necessarily be included in the acceptance criteria for the APS.
9.42 Where processes include materials that contact the product contact surfaces but
are then discarded (e.g. product flushes), the discarded material should be
simulated with nutrient media and be incubated as part of the APS, unless it can
be clearly demonstrated that this waste process would not impact the sterility of
the product.

9.43 Filled APS units should be incubated in a clear container to ensure visual
detection of microbial growth. Where the product container is not clear (e.g.
amber glass, opaque plastic), clear containers of identical configuration may be
substituted to aid in the detection of contamination. When a clear container of
identical configuration cannot be substituted, a suitable method for the detection
of microbial growth should be developed and validated. Microorganisms isolated
from contaminated units should be identified to the species level when practical,
to assist in the determination of the likely source of the contaminant.
9.44 Filled APS units should be incubated without unnecessary delay to achieve the
best possible recovery of potential contamination. The selection of the incubation
conditions and duration should be scientifically justified and validated to provide
an appropriate level of sensitivity of detection of microbial contamination.
9.45 On completion of incubation:
i. Filled APS units should be inspected by personnel who have been

appropriately trained and qualified for the detection of microbiological
contamination. Inspection should be conducted under conditions that
facilitate the identification of any microbial contamination.
ii. Samples of the filled units should undergo positive control by inoculation
with a suitable range of reference organisms and suitably representative
local isolates.
9.46 The target should be zero growth. Any contaminated unit should result in a failed
APS and the following actions should be taken:
i. an investigation to determine the most probable root cause(s);
ii. determination and implementation of appropriate corrective measures;
iii. a sufficient number of successful, consecutive repeat APS (normally a

minimum of 3) should be conducted in order to demonstrate that the process
has been returned to a state of control;
iv. a prompt review of all appropriate records relating to aseptic production since
the last successful APS;
a) The outcome of the review should include a risk assessment of potential

sterile breaches in batches manufactured since the last successful APS.
b) All other batches not released to the market should be included in the
scope of the investigation. Any decision regarding their release status
should consider the investigation outcome.
v. all products that have been manufactured on a line subsequent to a process

simulation failure should be quarantined until a successful resolution of the
process simulation failure has occurred;
vi. where the root cause investigation indicates that the failure was related to
operator activity, actions to limit the operator’s activities, until retrained and

requalified, should be taken;
vii. production should resume only after completion of successful revalidation.
9.47 All APS runs should be fully documented and include a reconciliation of units
processed (e.g. units filled, incubated and not incubated). Justification for filled
and non-incubated units should be included in the documentation. All
interventions performed during the APS should be recorded, including the start
and end time of each intervention and the involved person. All microbial
monitoring data as well as other testing data should be recorded in the APS batch
record.
9.48 An APS run should be aborted only under circumstances in which written
procedures require commercial lots to be equally handled. An investigation
should be documented in such cases.
9.49 An aseptic process should be subject to a repeat of the initial validation when:
i. the specific aseptic process has not been in operation for an extended period
of time; or
ii. there is a change to the process, equipment, procedures or environment that

has the potential to affect the aseptic process or an addition of new product
containers or container-closure combinations.
10 Quality Control (QC)

10.1 There should be personnel available with appropriate training and experience in
microbiology, sterility assurance and knowledge of the processes to support the
design of the manufacturing activities, environmental monitoring regime and any
investigation assessing the impact of microbiologically linked events to the safety
of the sterile product.
10.2 Specifications for raw materials, components and products should include
requirements for microbial, particulate and endotoxin/pyrogen limits when the
need for this has been indicated by monitoring and/or by the CCS.
10.3 The bioburden assay should be performed on each batch for both aseptically
filled product and terminally sterilised products and the results considered as part
of the final batch review. There should be defined limits for bioburden immediately
before the final sterilising grade filter or the terminal sterilisation process, which
are related to the efficiency of the method to be used. Samples should be taken
to be representative of the worst case scenario (e.g. at the end of hold time).
Where overkill sterilisation parameters are set for terminally sterilised products,
bioburden should be monitored at suitable scheduled intervals.
10.4 For products authorised for parametric release, a supporting pre-sterilisation

bioburden monitoring programme for the filled product prior to initiating the
sterilisation cycle should be developed and the bioburden assay should be
performed for each batch. The sampling locations of filled units before
sterilisation should be based on a worst case scenario and be representative of

the batch. Any organisms found during bioburden testing should be identified and
their impact on the effectiveness of the sterilising process determined. Where
appropriate, the level of endotoxin/pyrogen should be monitored.
10.5 The sterility test applied to the finished product should only be regarded as the
last in a series of critical control measures by which sterility is assured. It cannot
be used to assure sterility of a product that does not meet its design, procedural
or validation parameters. The test should be validated for the product concerned.
10.6 The sterility test should be performed under aseptic conditions. Samples taken
for sterility testing should be representative of the whole of the batch but should
in particular include samples taken from parts of the batch considered to be most
at risk of contamination, for example:
i. For products which have been filled aseptically, samples should include
containers filled at the beginning and end of the batch. Additional samples,
e.g. taken after critical interventions should be considered based on risk.
ii. For products which have been heat sterilised in their final containers,
samples taken should be representative of the worst case locations (e.g. the
potentially coolest or slowest to heat part of each load).
iii. For products which have been lyophilized, samples taken from different
lyophilization loads.
Note: Where the manufacturing process results in sub-batches (e.g. for

terminally sterilised products) then sterility samples from each sub-batch should
be taken and a sterility test for each sub-batch performed. Consideration should
also be given to performing separate testing for other finished product tests.
10.7 For some products it may not be possible to obtain a sterility test result prior to
release because the shelf life of the product is too short to allow completion of a
sterility test. In these cases, the additional considerations of design of the process
and additional monitoring and/or alternative test methods required to mitigate the
identified risks should be assessed and documented.
10.8 Any process (e.g. Vaporized Hydrogen Peroxide, Ultra Violet) used to
decontaminate the external surfaces of sterility samples prior to testing should
not negatively impact the sensitivity of the test method or the reliability of the
sample.
10.9 Media used for product testing should be quality control tested according to the
related Pharmacopeia before use. Media used for environmental monitoring and
APS should be tested for growth promotion before use, using a scientifically
justified and designated group of reference microorganisms and including
suitably representative local isolates. Media quality control testing should
normally be performed by the end user. Any reliance on outsourced testing or
supplier testing of media should be justified and transportation and shipping
conditions should be thoroughly considered in this case.
10.10 Environmental monitoring data and trend data generated for classified areas
should be reviewed as part of product batch certification/release. A written
procedure should be available that describes the actions to be taken when data

from environmental monitoring are found out of trend or exceeding the

established limits. For products with short shelf life, the environmental data for
the time of manufacture may not be available; in these cases, the compliance
should include a review of the most recent available data. Manufacturers of these
products should consider the use of rapid/alternative methods.
10.11 Where rapid and automated microbial methods are used for general
manufacturing purposes, these methods should be validated for the product(s) or
processes concerned.
Glossary
Airlock – An enclosed space with interlocked doors, constructed to maintain air pressure
control between adjoining rooms (generally with different air cleanliness standards). The
intent of an airlock is to preclude ingress of particle matter and microorganism
contamination from a lesser controlled area.
Action limit – An established relevant measure (e.g. microbial, or airborne particle limits)
that, when exceeded, should trigger appropriate investigation and corrective action
based on the investigation.
Alert level – An established relevant measure (e.g. microbial, or airborne particle levels)
giving early warning of potential drift from normal operating conditions and validated
state, which does not necessarily give grounds for corrective action but triggers
appropriate scrutiny and follow-up to address the potential problem. Alert levels are
established based on routine and qualification trend data and are periodically reviewed.
The alert level can be based on a number of parameters including adverse trends,
individual excursions above a set limit and repeat events.
Aseptic preparation/processing – The handling of sterile product, containers and/or

devices in a controlled environment in which the air supply, materials and personnel are
regulated to prevent microbial, endotoxin/pyrogen and particle contamination.
Aseptic Process Simulation (APS) – A simulation of the entire aseptic manufacturing

process in order to verify the capability of the process to assure product sterility. Includes
all aseptic operations associated with routine manufacturing, e.g. equipment assembly,
formulation, filling, lyophilization and sealing processes as necessary.
Asepsis – A state of control attained by using an aseptic work area and performing
activities in a manner that precludes microbial contamination of the exposed sterile
product.
Bacterial retention testing – This test is performed to validate that a filter can remove
bacteria from a gas or liquid. The test is usually performed using a standard organism,
such as Brevundimonas diminuta at a minimum concentration of 107 Colony Forming
Units/cm2.
Barrier – A physical partition that affords aseptic processing area (usually grade A)
protection by separating it from the background environment. Such systems frequently
use in part or totally the Barrier Technologies known as RABS or isolators.

Bioburden – The total number of microorganisms associated with a specific item such as
personnel, manufacturing environments (air and surfaces), equipment, product
packaging, raw materials (including water), in-process materials, or finished products.
Bio-decontamination - A process that eliminates viable bioburden via use of sporicidal

chemical agents.
Biological Indicators (BI) – A population of microorganisms inoculated onto a suitable

medium (e.g. solution, container or closure) and placed within a steriliser or load or room
locations to determine the sterilisation or disinfection cycle efficacy of a physical or
chemical process. The challenge microorganism is selected and validated based upon
its resistance to the given process. Incoming lot D-value, microbiological count and purity
define the quality of the BI.
Blow-Fill-Seal (BFS) – A technology in which containers are formed from a thermoplastic

granulate, filled with product, and then sealed in a continuous, integrated, automatic
operation. The two most common types of BFS machines are the Shuttle type (with
Parison cut) and the Rotary type (Closed Parison).
Campaign manufacture – A manufacture of a series of batches of the same product in

sequence in a given period of time with strict adherence to established and validated
control measures.
Classified area – An area that contains a number of cleanrooms (see cleanroom

definition).
Cleaning – A process for removing contamination e.g. product residues or disinfectant

residues.
Clean area – An area with defined particle and microbiological cleanliness standards
usually containing a number of joined cleanrooms.
Cleanroom – A room designed, maintained, and controlled to prevent particle and

microbial contamination of drug products. Such a room is assigned and reproducibly
meets an appropriate air cleanliness level.
Cleanroom classification – A method of assessing the level of air cleanliness against a

specification for a cleanroom or clean air equipment by measuring the total particle
concentration.
Cleanroom qualification – A method of assessing the level of compliance of a classified

cleanroom or clean air equipment with its intended use.
Closed system – A system in which the product is not exposed to the surrounding
environment. For example, this can be achieved by the use of bulk product holders (such
as tanks or bags) that are connected to each other by pipes or tubes as a system, and
where used for sterile products, the full system is sterilised after the connections are
made. Examples of these can be (but are not limited to) large scale reusable systems,
such as those seen in active substance manufacturing, or disposable bag and manifold
systems, such as those seen in the manufacture of biological products. Closed systems
are not opened until the conclusion of an operation. The use of the term “closed systems”
in this Annex does not refer to systems such as RABS or isolator systems.

Colony Forming Unit (CFU) – A microbiological term that describes a single detectable
colony that originates from one or more microorganisms. Colony forming units are
typically expressed as CFU per ml for liquid samples, CFU per m3 for air sample and
CFU per sample for samples captured on solid medium such as settle or contact plates.
Contamination – The undesired introduction of impurities of a microbiological nature

(quantity and type of microorganisms, pyrogen), or of foreign particle matter, into or onto
a raw material, intermediate, active substance or drug product during production,
sampling, packaging or repackaging, storage or transport with the potential to adversely
impact product quality.
Contamination Control Strategy (CCS) – A planned set of controls for microorganisms,

endotoxin/pyrogen and particles, derived from current product and process
understanding that assures process performance and product quality. The controls can
include parameters and attributes related to active substance, excipient and drug product
materials and components, facility and equipment operating conditions, in-process
controls, finished product specifications, and the associated methods and frequency of
monitoring and control.
Corrective intervention – An intervention that is performed to correct or adjust an aseptic

process during its execution. These may not occur at a set frequency in the routine
aseptic process. Examples include such as clearing component jams, stopping leaks,
adjusting sensors, and replacing equipment components.
Critical surfaces – Surfaces that may come directly into contact with, or directly affect, a
sterile product or its containers or closures. Critical surfaces are rendered sterile prior to
the start of the manufacturing operation, and sterility is maintained throughout
processing.
Critical zone – A location within the aseptic processing area in which product and critical
surfaces are exposed to the environment.
Critical intervention – An intervention (corrective or inherent) into the critical zone.
D-value – The value of a parameter of sterilisation (duration or absorbed dose) required

to reduce the number of viable organisms to 10 per cent of the original number.
Dead leg – Length of non-circulating pipe (where fluid may remain static) that is greater
than 3 internal pipe diameters.
Decommission – When a process, equipment or cleanroom are closed and they will not
be used again.
Decontamination – The overall process of removal or reduction of any contaminants

(chemical, waste, residue or microorganisms) from an area, object, or person. The
method of decontamination used (e.g. cleaning, disinfection, sterilisation) should be
chosen and validated to achieve a level of cleanliness appropriate to the intended use of
the item decontaminated. See also Bio-decontamination.
Depyrogenation – A process designed to remove or inactivate pyrogenic material (e.g.

endotoxin) to a specified minimum quantity.

Disinfection – The process by which the reduction of the number of microorganisms is

achieved by the irreversible action of a product on their structure or metabolism, to a
level deemed to be appropriate for a defined purpose.
Endotoxin – A pyrogenic product (i.e. lipopolysaccharide) present in the Gram negative

bacterial cell wall. Endotoxin can lead to reactions in patients receiving injections ranging
from fever to death.
Equilibration time – Period which elapses between the attainment of the sterilisation
temperature at the reference measurement point and the attainment of the sterilisation
temperature at all points within the load.
Extractables - Chemical entities that migrate from the surface of the process equipment,
exposed to an appropriate solvent at extreme conditions, into the product or material
being processed.
First Air – Refers to filtered air that has not been interrupted prior to contacting exposed
product and product contact surfaces with the potential to add contamination to the air
prior to reaching the critical zone.
Filter Integrity test - A test to confirm that a filter (product, gas or HVAC filter) retain their
retentive properties and have not been damaged during handling, installation or
processing.
Form-Fill-Seal (FFS) –An automated filling process, typically used for terminally sterilised
products, which constructs the primary container out of a continuous flat roll of packaging
film while simultaneously filling the formed container with product and sealing the filled
containers in a continuous process. FFS processes may utilize a single web system
(where a single flat roll of film is wrapped around itself to form a cavity), or a dual web
system (where two flat rolls of film are brought together to form a cavity), often with the
aid of vacuum moulds or pressurised gases. The formed cavity is filled, sealed and cut
into sections. Films typically consist of a polymeric material, polymeric coated foil or other
suitable material.
Gowning qualification – A programme that establishes, both initially and on a periodic

basis, the capability of an individual to don the complete gown.
Grade A air supply – Air which is passed through a filter qualified as capable of producing
grade A total particle quality air, but where there is no requirement to perform continuous
total particle monitoring or meet grade A viable monitoring limits. Specifically used for
the protection of fully stoppered vials where the cap has not yet been crimped.
HEPA filter – High efficiency particulate air filter specified in accordance with a relevant
international standard.
Inherent interventions – An intervention that is an integral part of the aseptic process and
is required for either set-up, routine operation and/or monitoring (e.g. aseptic assembly,
container replenishment, environmental sampling). Inherent interventions are required
by procedure or work instruction for the execution of the aseptic process.
Intrinsic sterile connection device – A device that reduces the risk of contamination during
the connection process; these can be mechanical or fusion sealing.

Isokinetic sampling head – A sampling head designed to disturb the air as little as
possible so that the same particles go into the nozzle as would have passed the area if
the nozzle had not been there (i.e. the sampling condition in which the mean velocity of
the air entering the sample probe inlet is nearly the same (± 20 percent) as the mean
velocity of the airflow at that location).
Isolator – An enclosure capable of being subject to reproducible interior bio-

decontamination, with an internal work zone meeting grade A conditions that provides
uncompromised, continuous isolation of its interior from the external environment (e.g.
surrounding cleanroom air and personnel). There are two major types of isolators:
i. Closed isolator systems exclude external contamination of the isolator’s

interior by accomplishing material transfer via aseptic connection to auxiliary
equipment, rather than use of openings to the surrounding environment.
Closed systems remain sealed throughout operations.
ii. Open isolator systems are designed to allow for the continuous or semi-
continuous ingress and/or egress of materials during operations through one
or more openings. Openings are engineered (e.g. using continuous
overpressure) to exclude the entry of external contaminant into the isolator.
Leachables – Chemical entities that migrate into products from the product contact
surface of the process equipment or containers under normal condition of use and/or
storage.
Local isolates – Suitably representative microorganisms of the site that are frequently
recovered through environmental monitoring within the classified zone/areas especially
grade A and B areas, personnel monitoring or positive sterility test results.
Lyophilization – A physical-chemical drying process designed to remove solvents, by

way of sublimation, from both aqueous and non-aqueous systems, primarily to achieve
product or material stability. Lyophilization is synonymous to the term freeze-drying.
Manual aseptic processing– An aseptic process where the operator manually

compounds, fills, places and /or seals an open container with sterile product.
Operator - Any individual participating in the processing operation, including line set-up,
filling, maintenance, or other personnel associated with manufacturing activities.
Overkill sterilisation – A process that is sufficient to provide at least a 12 log 10 reduction

of microorganisms having a minimum D-value of 1 minute.
Parison – The "tube" of polymer extruded by the BFS machine from which containers
are formed.
Pass-through hatch – Synonymous with airlock (see airlock definition) but typically
smaller in size.
Patient – Human or animal including participants in a clinical trial.
Post-aseptic processing terminal heat treatment– A terminal moist heat process

employed after aseptic processing which has been demonstrated to provide a sterility
assurance level (SAL) ≤10-6 but where the requirements of steam sterilisation (for

example, F0≥8 min) are not fulfilled. This may also be beneficial in the destruction of
viruses that may not be removed through filtration.
Pyrogen – A substance that induces a febrile reaction in patients receiving injections;
Rapid Transfer System/Port (RTP) – A System used for the transfer of items into RABS
or isolators that minimizes the risk to the critical zone. An example would be a rapid
transfer container with an alpha/beta port.
Raw material – Any ingredient intended for use in the manufacture of a sterile product,
including those that may not appear in the final drug product.
Restricted Access Barrier System (RABS) – System that provides an enclosed, but not
fully sealed, environment meeting defined air quality conditions (for aseptic processing
grade A), and using a rigid-wall enclosure and integrated gloves to separate its interior
from the surrounding cleanroom environment. The inner surfaces of the RABS are
disinfected and decontaminated with a sporicidal agent. Operators use gloves, half suits,
RTPs and other integrated transfer ports to perform manipulations or convey materials
to the interior of the RABS. Depending on the design, doors are rarely opened, and only
under strictly pre-defined conditions.
Single Use Systems (SUS) – Systems in which product contact components are used
only once to replace reusable equipment such as stainless steel transfer lines or bulk
containers. SUS covered in this document are those that are used in manufacturing
processes of sterile products and are typically made up of disposable components such
as bags, filters, tubing, connectors, storage bottles and sensors.
Sporicidal agent – An agent that destroys bacterial and fungal spores when used in
sufficient concentration for specified contact time. It is expected to kill all vegetative
microorganisms.
Sterile Product – For purpose of this guidance, sterile product refers to one or more of
the sterilised elements exposed to aseptic conditions and ultimately making up the sterile
active substance or finished sterile product. These elements include the containers,
closures, and components of the finished drug product. Or, a product that is rendered
sterile by a terminal sterilisation process.
Sterilising grade filter – A filter that, when appropriately validated, will remove a defined
microbial challenge from a fluid or gas producing a sterile effluent. Usually such filters
have a pore size equal or less than 0.22 µm.
Terminal Sterilisation – The application of a lethal sterilising agent or conditions to a

product in its final container to achieve a predetermined sterility assurance level (SAL)
of 10⁻⁶ or better (e.g. the theoretical probability of there being a single viable
microorganism present on or in a sterilised unit is equal to or less than 1 x 10-6 (one in a
million)).

Annex 2A Manufacture of advanced therapy medicinal products for human use
ANNEX 2A
MANUFACTURE OF ADVANCED THERAPY MEDICINAL

PRODUCTS FOR HUMAN USE
SCOPE
The methods employed in the manufacture of Advanced Therapy Medicinal
Products (ATMPs) are a critical factor in shaping the appropriate regulatory
control. ATMPs can be defined therefore largely by reference to their method of
manufacture. For example, for gene therapy ATMPs, genetic modifications can
be obtained through a variety of methods (e.g. viral & non-viral vectors, mRNA,
ex vivo and in vivo genome-editing tools). The genetically modified cells can be
of human origin (autologous or allogeneic) or of animal origin (xenogeneic cells),
either primary or established cell lines. In a medicinal product, the genetically
modified cells or gene therapy products can be presented alone or combined with
medical devices.
This annex provides additional and specific guidance on the full range of ATMPs
(as defined in the glossary) and the active substances that are used in their
manufacture. This annex applies both to investigational ATMPs and market-
authorised ATMPs. It can also be applied to ATMP manufacturing in hospital
settings and for compassionate use programs, where authorised by national law.
Although one of the objectives of this present annex was to prepare a document
that would stand for several years, the field is quickly changing. It is recognised
that amendments may be necessary to accommodate technological change, to
clarify uncertainty or to specifically recognise important alternatives. Comments
are therefore invited at any stage of the life of this edition.
This annex is divided into two main parts:
1. Part A contains supplementary guidance and alternative provisions on the

manufacture of ATMPs, from control over seed lots and cell banks through
to finishing activities and testing.
2. Part B contains further guidance on selected types of ATMPs and its

substances.
APPLICATION OF THIS ANNEX
This annex, along with several other annexes of the Guide to GMP, provides
guidance, which supplements that in Part I: Basic Requirements for Medicinal
Products and in Part II: Basic Requirements for active pharmaceutical ingredients
of the PIC/S GMP Guide. This annex is not a stand-alone document and should
be applied in conjunction with PIC/S GMP guidelines and annexes. It has

however been written in a manner that it could enable development of a

standalone guide if integrated with PIC/S GMP Part I, Part II, and related
annexes.
Where due to the nature of the product or technical necessities, specific guidance
is provided in this annex, compliance with this annex is expected and takes
precedence over other sections in the PIC/S GMP Guide unless there are good
reasons for not doing so with documented sound scientific rationale applied using
QRM principles.
In certain cases, other national laws may be applicable to the starting materials
for ATMPs. For example:
(a) Tissues and cells used as starting materials of ATMPs may be subject to
other national legislation that cover donation, procurement, testing,
processing, preservation, storage and distribution.
(b) For blood or blood components used as starting materials for ATMPs,
national legislation may provide the technical requirements for the selection
of donors and the collection and testing of blood and blood components.
The manufacturing process for ATMPs is product-specific and different design

approaches are possible. The appropriate application of GMP should be
described, justified in the Clinical Trial Application (CTA) or Marketing
Authorisation (MA), and in accordance with national law. Consideration may be
given to defining which manufacturing process steps are required to manufacture
starting materials, ATMP active substance, or the finished ATMP. In some cases,
the manufacturing process between the ATMP active substance and the final
product can be defined as continuous.
The manufacture and control of genetically modified organisms also needs to

comply with other local, national or regional requirements. Appropriate
containment should be established and maintained in facilities where any
genetically modified organism is handled. Advice should be obtained according
to national law in order to establish and maintain the appropriate Biological Safety
Level. GMP should be adhered alongside these requirements.
Table 1 gives examples of where this annex applies. It should be noted that this
table is illustrative only and is not meant to describe the precise scope. It should
also be understood that adherence to the GMP or GMP principles for the
manufacturing steps indicated in the corresponding table is dependent on
applicable national legislation. The level of GMP requirements increases from
early to later steps in the manufacture of ATMP active substances. The inclusion
of some early steps of manufacture within the scope of this annex does not imply
that those steps will be routinely subject to inspection by the authorities.
According to national legislation more or less stringent approaches on the
application of GMP on those early stages may apply.

Table 1. Illustrative guide to manufacturing activities within the scope of Annex 2A
Example
Application of this Annex (see note 1)
Products
Linear DNA
Gene therapy: In vitro cell free Formulation,
template mRNA purification
mRNA transcription filling
preparation
Gene therapy:
Plasmid Establishment of MCB, Vector manufacturing and Formulation,
in vivo viral
manufacturing WCB2 purification filling
vectors
Gene therapy:
in vivo non-
viral vectors
Plasmid Establishment of Formulation,
(naked DNA, Fermentation and purification
manufacturing bacterial bank2 filling
lipoplexes,
polyplexes,
etc.)
Gene therapy: Donation, Plasmid manufacturing

ex-vivo procurement and Ex-vivo genetic modification Formulation,
genetically testing of starting of cells filling
modified cells tissue / cells Vector manufacturing3
Donation,
Establishment of MCB, Cell isolation, culture Formulation,
Somatic cell procurement and
WCB or primary cell lot purification, combination with combination,
therapy testing of starting
or cell pool2 non-cellular components filling
tissue / cells
Donation, Initial processing,

Tissue Cell isolation, culture, Formulation,
procurement and isolation and
engineered purification, combination with combination,
testing of starting purification, establish
products non-cellular components filling
tissue / cells MCB, WCB, primary
cell lot or cell pool2
1 Application of this annex applies to manufacturing steps illustrated in dark grey. Application of
this annex or principles of this annex apply to steps illustrated in light grey apply depending on
the requirements of national legislation.
2 Refer to points 5.32 for establishment of cell banks and seed lots.
3 In the case of gene therapy ex-vivo genetically modified cells, this guide applies to vector
manufacturing except where otherwise authorised by national law where principles of GMP
should apply.

The following are some non-exhaustive examples in the application of GMP to the
manufacture of ATMP.
Figure 1: Example of gene therapy mRNA Figure 2: Example of in vivo viral vector gene
ATMP manufacturing therapy ATMP manufacturing
Linear DNA template ATMP Manufacturing Plasmid ATMP Manufacturing

preparation Manufacturing
Transcription Establishing MCB or
Plasmid DNA construct ↓ Plasmid DNA construct WCB
preparation Purification preparation ↓
↓ ↓ ↓ Thawing
Transfer of Plasmid Harvest Transfer of Plasmid ↓
DNA to starter colony ↓ DNA to starter colony Transfection
(e.g. E. coli) Formulation (e.g. E. coli) ↓
↓ ↓ ↓ Induction
Purification, Filling Expansion ↓
linearization and ↓ ↓ Harvest
polishing Storage Dispensing ↓
↓ ↓ ↓ Purification
Storage of linear DNA Distribution for Storage ↓
template patient access Formulation
↓
OR Sterile Filtration
↓
Plasmid DNA Filling
construct preparation ↓
↓ Storage
Polymerase Chain ↓
Reaction (PCR) Distribution for
↓ patient access
Storage of linear DNA
template
 GMP requirements  A Marketing  GMP requirements  A MAH may justify

can vary from early Authorisation Holder can vary from early these steps to be a
steps in making the (MAH) may justify steps in making the continuous process
plasmid DNA these steps to be a plasmid DNA producing both the
construct to later continuous process construct to later ATMP active
steps but should align producing both the steps but should align substance and
with Annex 2A and ATMP active with Annex 2A and medicinal product.
PIC/S GMP Guide substance and PIC/S GMP Guide  PIC/S GMP Part I and
Part II or principles of medicinal product. Part II or principles of Part II along with
these requirements as  PIC/S GMP Part I and these requirements as applicable annexes
applicable under Part II along with applicable under apply as appropriate
national legislation. applicable annexes national legislation. to the step of
 Refer to Section 5.23 apply as appropriate  Refer to Section 5.23 manufacture.
for additional to the step of for additional
information in manufacture. information in
determining the determining the
appropriate appropriate
application of GMP. application of GMP.

Figure 3: Example of autologous CAR-T therapy ATMP manufacturing
Plasmid Manufacturing Viral Vector Product ATMP Manufacturing

Manufacturing
Plasmid DNA construct Establishing MCB or WCB Donation or procurement of

preparation ↓ patient cells
↓ Thawing ↓
Transfer of Plasmid DNA to ↓ Transduction
starter colony Transfection ↓
(e.g. E. coli) ↓ Expansion
↓ Induction ↓
Expansion ↓ Harvest
↓ Harvest ↓
Dispensing ↓ Formulation
↓ Purification ↓
Storage ↓ Filling
Sterile Filtration ↓
↓ Storage
Dispensing ↓
↓ Distribution for
Storage patient access
 GMP requirements can  GMP requirements applied  The application of this

vary from early steps in to the manufacture of a guide does not include the
making the plasmid DNA viral vector should align donation or procurement of
construct to later steps but with Annex 2A and PIC/S patient cells.
should align with principles GMP Part II or principles of  A MAH may justify these
of Annex 2A and PIC/S these requirements as steps to be a continuous
GMP Guide Part II or applicable under national process producing both the
principles of these legislation. ATMP active substance
requirements as applicable  Refer to Section 5.23 for and medicinal product.
under national legislation. additional information in  PIC/S GMP Part I and
 Refer to Section 5.23 for determining the Part II along with
additional information in appropriate application of applicable annexes apply
determining the GMP. as appropriate to the step
appropriate application of of manufacture.
GMP.
PRINCIPLE
The manufacture of ATMPs involves certain specific considerations arising from
the nature of the products and the processes. The ways in which biological
medicinal products are manufactured, controlled and administered make some
particular precautions necessary.
Since materials and processing conditions used in manufacturing processes are

designed to provide conditions for the growth of specific cells and
microorganisms, this provides an opportunity for extraneous microbial
contaminants (e.g. bacteria, fungi) to grow. In addition, some products may be
limited in their ability to withstand a wide range of purification techniques,
particularly those designed to inactivate or remove adventitious viral

contaminants. The design of the processes, equipment, facilities, utilities, the

conditions of preparation and addition of buffers and reagents, sampling and
training of the operators are key considerations to minimise such contamination
events (i.e. engineering and technical controls). In addition, manufacturing
processes need to be well designed and controlled so as not to add further
variability to the product.
Product specifications such as those in pharmacopoeial monographs, CTA, and

MA will dictate whether and to what manufacturing stage substances and
materials can have a defined level of bioburden or need to be sterile. Similarly,
manufacturing must be consistent with other specifications set out in the CTA or
MA (e.g. number of generations (doublings, passages) between the seed lot or
cell bank).
For biological materials that cannot be sterilized (e.g. by filtration), processing

must be conducted aseptically to minimise the introduction of contaminants.
Where they exist, other guidance documents should be consulted on the
validation of specific manufacturing methods (e.g. virus removal or inactivation).
The application of appropriate environmental controls and monitoring and,
wherever feasible, in-situ cleaning and sterilisation systems together with the use
of closed systems and sterile disposable product-contact equipment can
significantly reduce the risk of accidental contamination and cross-contamination.
ATMPs require a combination of unique biological methods and standard

physico-chemical assays for their Quality Control (QC). For many cell-based
products, there is variability introduced through the starting materials that cannot
be overcome by the manufacturing process or In-Process Controls (IPCs).
Adequate control of the starting and raw materials, well defined characterisation
of the ATMP active substance and ATMP drug product release testing form the
crucial part of the QC. Controls should take into consideration the intrinsic
variability of the biological material needed for ATMP manufacturing. A robust
manufacturing process is therefore crucial and in-process controls take on a
particular importance in the manufacture of biological active substances and
medicinal products.
PART A: GENERAL GUIDANCE

Part A provides alternative or supplementary provisions to respective sections in
Part I, II and annexes of the PIC/S GMP Guide, where necessary. Where this
annex provides specific guidance for the manufacture of ATMPs (including
modification, replacement or redundancy of other sections), this will be clearly
indicated. In the absence of specific guidance for ATMPs, compliance with other
sections in the PIC/S GMP Guide is expected.
Note: Where the term Marketing Authorisation Holder (MAH) is used, unless
otherwise specified, it should be intended to signify the “Sponsor” for
investigational ATMP that is used according to a CTA or equivalent.

SUPPLIMENTARY PROVISIONS TO PIC/S GMP GUIDE PART I
CHAPTER 1 PHARMACEUTICAL QUALITY SYSTEM

Pharmaceutical Quality System
1.1 ATMPs are not sold or supplied before an Authorised Person has certified that
each production batch has been produced and controlled in accordance with the
requirements of the CTA, MA and any other regulations relevant to the
production, control and release of medicinal products as applicable. Special
provisions apply for the supply of products that have a two-step release process
(described in Section 6.14) or such that do not meet release specifications where
there is no alternative treatment available (described in Sections 6.11 to 6.13).
(Replaces PIC/S GMP Guide Part I Section 1.4, xv)
Quality Risk Management
1.2 GMP applies to the lifecycle stages from the manufacture of investigational
ATMP, technology transfer, and commercial manufacturing through to product
discontinuation. The biological processes may display inherent variability, so that
the range and nature of by-products may be variable. As a result, Quality Risk
Management (QRM) principles as detailed in Annex 20 are particularly important
for this class of medicinal products and should be used to develop their control
strategy across all stages of development and manufacturing steps to minimise
variability and to reduce the opportunity for contamination and
cross-contamination. (Replaces PIC/S GMP Guide Part I Section 1.2)
CHAPTER 2 PERSONNEL
2.1 The health status of personnel should be taken into consideration for product
safety. Personnel (including those concerned with cleaning, maintenance or
quality control) employed in areas where ATMP active substances and products
are manufactured and tested should receive training, and periodic retraining,
specific to the products manufactured and to the duties assigned to them,
including any specific safety measures to protect product, personnel and the
environment.
2.2 Any changes in the health status of personnel, which could adversely affect the
quality of the product, should prevent work in the production area. Health
monitoring of staff should be commensurate with the risk; medical advice should
be sought for personnel involved with hazardous organisms. General
consideration should be given to Occupational Health & Safety (OH&S) for
personnel involved with hazardous substances as required by national law.
2.3 Every person entering the manufacturing areas should wear clean protective
garments appropriate to the operations to be carried out.
Where required to minimise the opportunity for cross-contamination, restrictions

on the movement of all personnel (including QC, maintenance and cleaning
personnel) should be controlled based on QRM principles.

In general, personnel should not pass from areas of exposure to live

micro-organisms, genetically modified organisms, toxins or animals to areas
where other products, inactivated products or different organisms are handled. If
such route is unavoidable, a Contamination Control Strategy (CCS) based on
QRM principles should be applied (refer to Section 3.4 CCS). (Replaces PIC/S
GMP Guide Part I Section 2.18)
CHAPTER 3 PREMISES AND EQUIPMENT
PREMISES
Production Areas
3.1 Cross-contamination should be prevented for all products by appropriate design

and operation of manufacturing facilities. The measures to prevent cross-
contamination should be commensurate with the risks to product quality. QRM
principles should be used to assess and control the risks.
Depending on the level of risk presented by some ATMPs and the materials
involved in their production (for example, viruses), it may be necessary to
dedicate premises and equipment for manufacturing and/or packaging operations
to control the risk. Segregated production areas should be used for the
manufacture of ATMPs presenting a risk that cannot be adequately controlled by
operational and/or technical measures. (Replaces PIC/S GMP Guide Part I
Section 3.6)
3.2 Concurrent production of two or more different ATMPs/batches in the same area
might be permitted due to adequate operational and/or technical control where
justified under QRM principles applied across the entire sequence of
manufacturing steps. For example:
(a) The use of more than one closed isolator (or other closed systems) in the
same room at the same time is acceptable, provided that appropriate
mitigation measures are taken to avoid cross-contamination or mix-ups of
materials.
(b) When more than one isolator is used to process different viral vectors within
the same room there should be 100% air exhaustion from the room and the
facility (i.e. no recirculation). In addition, in case of concurrent production of
viral vectors, it is necessary to provide for closed, separate and unidirectional
waste handling.
(c) The possibility of using more than one biosafety cabinet (BSC) in the same
room is only acceptable if effective technical and organisational measures
are implemented to separate the activities. The simultaneous use of more
than one BSC entails additional risks and, therefore, it should be
demonstrated that the measures implemented are effective to avoid risks to
the quality of the product and any mix-ups. The rationale should be justified
based on QRM principles.
(d) The use of multiple closed systems in the same area is permitted, in the case
that their close state can be demonstrated. (refer to point 3.13.)

3.3 The measures and procedures necessary for containment (i.e. for environment
and operator safety) should not conflict with those for product quality.
3.4 Special precautions should be taken in the case of manufacturing activities

involving infectious viral vectors (e.g. oncolytic viruses, replication competent
vectors) that should be segregated based on a documented CCS and QRM
principles. The manufacturer should justify the level of segregation required
based on the CCS and through QRM principles. The outcome of the QRM
process should determine the necessity for and extent to which the premises and
equipment should be dedicated to a particular product. In some cases, dedicated
facilities, dedicated areas or dedicated equipment may be required in accordance
with the national law. Simultaneous incubation and/or storage of replication
competent vectors/products, or infected materials/products, with other
materials/products is not acceptable.
3.5 Air handling units should be designed, constructed and maintained to minimise
the risk of cross-contamination between different manufacturing areas and may
need to be specific for an area. Consideration, based on QRM principles, should
be given to the use of single pass air systems.
3.6 If materials (such as culture media and buffers) have to be measured or weighed
during the production process, small stocks may be kept in the production area
for a specified duration based on defined criteria (e.g. duration of manufacture of
the batch or of the campaign). (Replaces PIC/S GMP Guide Part I Section 3.13)
3.7 Positive pressure areas should be used to process sterile products, but negative
pressure in specific areas at the point of exposure of pathogens is acceptable for
containment reasons. Where negative pressure areas or BSCs are used for
aseptic processing of materials with particular risks (e.g. pathogens), they should
be surrounded by a positive pressure clean zone of appropriate Grade. These
pressure cascades should be clearly defined and continuously monitored with
appropriate alarm settings as defined by Annex 1. The design of such areas
should be such that measures put in place to prevent release of material into the
surrounding environment should not compromise sterility assurance level (SAL)
of the product and vice versa.
3.8 Air vent filters that are directly linked to the sterility of the product (e.g. to maintain
the integrity of a closed system) should be hydrophobic, monitored during use
(e.g. pressure differential monitoring if appropriate) and validated for their
scheduled life span with integrity testing at appropriate intervals based on
appropriate QRM principles. If pressure monitoring or integrity testing is
technically not feasible for the filter system, vendor supplied information may be
considered for approval. However, this has to be taken into account in the CCS
as an additional risk factor especially for short shelf life ATMPs, where
microbiological quality tests are not available at the time of batch release prior to
medical product administration.
3.9 Drainage systems must be designed so that effluents can be effectively

neutralised or decontaminated to minimise the risk of cross-contamination. They
must comply with national law to minimize the risk of contamination of the external
environment according to the risk associated with the biohazardous nature of
waste materials. (Replaces PIC/S GMP Guide Part I Section 3.11)

3.10 The degree of environmental control of particulate and microbial contamination

of the production premises should be adapted to the product and the production
step, bearing in mind the potential level of contamination of the starting materials
and the risks to the product. The microbiological environmental monitoring
programme should be supplemented by the inclusion of methods to detect the
presence of specific microorganisms (e.g. host organism, yeasts, moulds,
anaerobes, etc.) where indicated by the QRM principles.
3.11 Where processes are not closed and there is exposure of the product to the
immediate room environment without a subsequent microbial inactivation
process, (e.g. during additions of supplements, media, buffers, gasses,
manipulations) appropriate environmental conditions should be applied. For
aseptic manipulations parameters in line with Annex 1 (i.e. Grade A with Grade
B background) should be applied. The environmental monitoring program should
include testing and monitoring of non-viable contamination, viable contamination
and air pressure differentials. The monitoring locations should be determined
having regards to the QRM principles. The number of samples, volume, and
frequency of monitoring, alert and action limits should be appropriate taking into
account the QRM principles. Sampling methods should not pose a risk of
contamination to the manufacturing operations. Where appropriate control is
required in the process, temperature and relative humidity should be monitored.
All environmental monitoring results should be trended.
3.12 Only in exceptional circumstances when an appropriate manufacturing

environment is not available, a less stringent environment than that specified in
Section 3.11 above may be acceptable for processes that are not closed where
approved by the Competent Authority and in accordance with CTA or MA or other
national requirements. However, this option should be considered exceptional
and applicable only if the product is intended to treat a life-threatening condition
where no alternative therapeutic options exist. The environment must be
specified and justified to provide patient benefit that outweighs the significant risk
created by manufacturing under less stringent environments. If the Competent
Authority grants an approval, the manufacturer must pursue establishing the
appropriate environment as improvements in the technology occur.
3.13 For closed systems, a lower classified area than Grade A in background Grade B
might be acceptable based on the outcome of a QRM assessment. The
appropriate level of air classification and monitoring should be determined having
regard to the specific risks, considering the nature of the product, the
manufacturing process and the equipment used. QRM should be used to
determine whether the technology used supports reduced monitoring, in
particular where monitoring can be a source of contamination. This is in addition
to:
(a) The use of technologies as e.g. processing inside single use sterile
disposable kits, or processing using closed, automated manufacturing
platform or incubation in closed flasks, bags or fermenters in Grade C
may be acceptable if adequate control measures are implemented to
avoid the risk of microbial contamination and cross-contamination (e.g.
appropriate control of materials, personnel flows and cleanliness).
Particular attention should be paid if the materials are subsequently
moved to a clean area of higher Grade.

(b) If the closed system can be shown to remain integral throughout the
entire usage, a background of Grade D might be acceptable.
Requirements of Annex 1 regarding the provision of closed system should be

considered.
3.14 In exceptional circumstances, it is permissible to perform a manufacturing step in

premises that are not under direct control of the ATMP manufacturer or MAH
(including for example placing equipment used to perform manufacturing steps in
hospital wards or theatre) where approved by the Competent Authority and in
accordance with CTA or MA or other national requirements. In such cases, it
should be demonstrated that the process maintains its validated status in
accordance to principles and guidelines in Annex 15, Annex 20 and in this annex.
These arrangements should be subject to approval by the Competent Authority.
The responsibilities of each parties should be defined in written technical
agreements.
EQUIPMENT
3.15 Production equipment should not present any hazard to the products. The parts
of the production equipment that come into contact with the product must not be
reactive, additive or absorptive to such an extent that it will affect the quality of
the product and thus present any hazard.
In addition, if single use systems (i.e. disposable systems) are used, the
manufacturer should take into account and verify the impact on the product from
extractable, leachable, insoluble particulate and insoluble matter derived from
such systems. Annex 1 regarding provisions for single use systems should be
considered. (Replaces PIC/S GMP Guide Part I Section 3.39)
3.16 Where required to minimise the risk of cross-contamination, restrictions on the

movement of equipment should be applied. In general, equipment should not be
moved from high-risk areas to other areas, or between high-risk areas (e.g.
equipment used for the handling of cells from infected donors or the handling of
oncolytic viruses). Where the relocation of equipment is unavoidable, after
reviewing engineering and/ or technical modifications, the risk should be
assessed in line with QRM principles, mitigated and monitored to ensure an
effective cross-contamination control strategy (refer to Section 3.4 CCS). The
qualification status of the equipment moved should also be considered.
3.17 The design of equipment used during handling of live organisms and cells,
including those for sampling, should be considered to prevent any contamination
during processing.
3.18 Primary containment4 should be designed and periodically tested to ensure the
prevention of escape of biological agents into the immediate working
environment.
4 See Main GMP Glossary on ‘Containment’.

3.19 Electronic systems used to support manufacturing must be qualified in

accordance with Annex 11 and 15. Any analytical testing performed on materials
not used in manufacturing but that support bioinformatics informing the
manufacturing process (e.g. patient gene sequencing) should be validated. Such
analytical equipment is expected to be qualified prior to use.
CHAPTER 4 DOCUMENTATION
Specifications
4.1 Specifications for ATMP starting and raw materials may need additional
documentation on the source, origin, distribution chain, method of manufacture,
and controls applied, to assure an appropriate level of control and oversight
including their microbiological quality.
4.2 Some products may require specific definition of what materials constitute a
batch. For autologous and donor-matched situations, the manufactured product
should be viewed as a batch.
Traceability
4.3 Where human cells or tissues are used, full traceability is required from starting
and raw materials, including all substances coming into contact with the cells or
tissues through to confirmation of the receipt of the products at the point of use
whilst maintaining the privacy of individuals and confidentiality of health-related
information, according to national legislation.
4.4 For starting materials of human origin, the identification of the supplier and the
anatomical environment from which the cells/tissues/virus originates (or, as
appropriate, the identification of the cell-line, master cell bank, seed lot) should
also be described.
4.5 A system that enables the bidirectional tracking of cells/tissues contained in

ATMPs from the point of donation, through manufacturing, to the delivery of the
finished product to the recipient should be created. This system can be manual
or automated. It should be used throughout the manufacturing lifecycle to include
clinical trial and commercial batches.
4.6 Traceability records should be kept as an auditable document and unequivocally

linked to the relevant batch record. The storage system should ensure that
traceability data allow for easy access, in case of an adverse reaction from the
patient.
4.7 Traceability records for cellular and tissue-based products and for any
personalized ATMP must be retained 30 years after the expiry date of the product
unless otherwise specified in the MA/CTA or national law. Particular care should
be taken to maintain the traceability of products for special use cases, such as
donor-matched cells. National requirements applied to blood components in
regard to traceability requirements and notification of serious adverse reactions
and events apply to blood components when they are used as starting or raw
materials in the manufacturing process of medicinal products. Human cells

including haematopoietic cells must comply with the principles laid down in
national law concerning traceability.
4.8 When xenogeneic cells are used as starting materials for ATMPs, information
permitting the identification of the donor animal should be kept for 30 years unless
otherwise specified in the MA/CTA or national legislation.
CHAPTER 5 PRODUCTION
General
5.1 ATMPs must comply with the applicable national requirements on minimising the
risk of transmitting animal spongiform encephalopathy agents via human and
veterinary medicinal products.
Viral safety for gene therapy ATMPs should be ensured by having systems in
place that ensure the quality of starting (including cell banks and viral seed
stocks) and raw materials through the production process.
5.2 The conditions for sample collection, additions and transfers involving replication
competent vectors or materials from infected donors should prevent the release
of viral/infected material.
5.3 At every stage of processing, materials and products should be protected from
microbial and any other contamination. Appropriate contamination control and
monitoring strategies should be implemented (refer to Section 3.4 CCS).
Particular consideration should be given to the risk of cross-contamination
between cell preparations from different donors and, where applicable, from
donors having different positive serological markers. (Replaces PIC/S GMP
Guide Part I Section 5.10)
5.4 The use of antimicrobials may be necessary to reduce bioburden associated with
the procurement of living tissues and cells. However, the use of antimicrobials
does not replace the requirement for aseptic manufacturing. When antimicrobials
are used, their use should be recorded; they should be removed as soon as
possible, unless the presence thereof in the finished product is specifically
foreseen in the CTA or MA (e.g. antibiotics that are part of the matrix of the
finished product). Additionally, it is important to ensure that antimicrobials do not
interfere with any product microbial contamination testing or sterility testing, and
that they are not present in the finished product (unless specifically justified in the
CTA or MA).
5.5 Labels applied to containers, equipment or premises should be clear, well defined
and in the manufacturer’s agreed format.
Care should be taken in the preparation, printing, storage and application of

labels, including any specific text for patient-specific or autologous product. For
products containing cells derived from human cells or tissue, donor’s labels
should contain all relevant information that is needed to provide full traceability.
In the case of autologous products, the unique patient identifier and the statement
“for autologous use only” should be indicated on the outer packaging or, where

there is no outer packaging, on the immediate packaging or as otherwise

specified in national law.
Alternative approaches/measures are permitted as long as the risk of erroneous

administration of the product is adequately mitigated. For investigational ATMPs
that are blinded, the requirement to state “autologous use” can be substituted by
a barcode or an alternative equivalent mechanism that ensures blinding while
maintaining patient safety. (Replaces PIC/S GMP Guide Part I Section 5.13)
5.6 When setting up a programme for primary and secondary packaging operations,
particular attention should be given to minimising the risk of cross-contamination,
mix-ups or substitutions. Sterility and/or low bioburden requirements should be
adhered to and segregation strategies should be applied. (Replaces PIC/S GMP
5.7 If closed systems are used for the production of ATMPs, checks should be carried
out to ensure that all pieces of the equipment are connected in a correct manner
to assure the closed state. Special attention should be given to apply these tests
to automated systems. If feasible and based on QRM principles, for example
considering testing carried out by vendors, the integrity of single use systems
should be verified at adequate frequency prior to use and potentially post use,
possibly automatically. The integrity of reused equipment should be verified
before use after cleaning and sterilisation.
5.8 A system is no longer considered closed when materials are added or withdrawn
without aseptic techniques (e.g. without use of sterile connectors or filters
aseptically connected).
5.9 Where chromatography equipment is used, a suitable control strategy for

matrices, the housings and associated equipment (adapted to the risks) should
be implemented when used in campaign manufacture and in multi-product
environments. The re-use of the same matrix at different stages of processing is
discouraged due to risk of carryover contamination. Any such re-usage should be
supported by appropriate validation data. Acceptance criteria, operating
conditions, regeneration methods, life span, and sanitization or sterilisation
methods of chromatography columns should be defined.
5.10 Careful attention should be paid to specific requirements at any cryopreservation

stages, e.g. the rate of temperature change during freezing or thawing. The type
of storage chamber, placement and retrieval process should minimise the risk of
cross-contamination, maintain the quality of the products and facilitate their
accurate retrieval. Documented procedures should be in place for the secure
handling and storage of products with positive serological markers.
5.11 The suitability of selected packaging material should be considered. The

adhesiveness, durability and legibility of printed text of labels used for containers
that are stored at ultra-low temperatures (- 60 °C or lower) should be verified.
Additionally, apply a holistic approach to minimize the risk to container closure
integrity (CCI) that can occur during storage at ultra-low temperatures. Evidence‐
based data should be generated to support the selection of the appropriate
primary packaging components and qualification of the container/closure sealing
process.

Prevention of Cross-contamination in Production
5.12 An evidence-based QRM process should be used to assess and control the
cross-contamination risks presented by the products manufactured. Factors to
take into account include:
(a) vectors used and the risk of occurrence of replication competent virus
(including different level of risk derived from the use of replication limited,
replication defective, conditional replication and replication incompetent
vectors),
(b) facility/equipment design and use,
(c) personnel and material flow,
(d) microbiological and other adventitious agent controls,
(e) characteristics of the starting materials/active substance and raw materials,
(f) process characteristics,
(g) clean room conditions,
(h) cleaning processes, and
(i) analytical capabilities relative to the relevant limits established from the
evaluation of the products.
The outcome of the QRM process should be the basis for determining the process
workflow and necessity for and extent to which premises and equipment should
be dedicated or single use systems should be used for a particular product. This
may include dedicating specific product contact parts or dedication of the entire
manufacturing facility. It may be acceptable to confine manufacturing activities to
a segregated, self-contained production area within a multiproduct facility, where
justified. Results should be reviewed jointly with the CCS.
(Replaces PIC/S GMP Guide Part I Section 5.20)
5.13 The methods used for sterilisation, disinfection, virus removal or inactivation
should be validated. In cases where a virus inactivation or removal process is
performed during manufacture, measures to avoid the risk of recontamination
should be taken. (refer to Section 5.19(a))
5.14 An emergency plan for dealing with accidental release of viable organisms should
be in place. This should address methods and procedures for containment,
protection of operators, cleaning, decontamination and safe return to use.
Accidental spillages, especially of live organisms, must be dealt with quickly and
safely. Decontamination measures should be available for each organism or
groups of related organisms in line with the QRM process. Decontamination
measures should be validated for effectiveness.
5.15 If obviously contaminated, such as by spills or aerosols, or if a potential

hazardous organism is involved, production and control materials, including

paperwork, must be adequately disinfected, or the information transferred out by

other means. An assessment of the impact on the immediate products and any
others in the affected area should also be made.
5.16 The risks of cross-contamination should be assessed having regard to the

characteristics of the product (e.g. biological characteristics of the starting
materials, possibility to withstand purification techniques) and manufacturing
process (e.g. the use of processes that provide extraneous microbial
contaminants the opportunity to grow). For ATMPs that cannot be sterilised, any
open processing (e.g. filling) must be conducted aseptically to minimise the
introduction of contaminants.
5.17 In all manufacturing steps that may lead to unwanted formation of aerosols (e.g.
centrifugation, working under vacuum, homogenisation, and sonication)
appropriate mitigation measures should be implemented to avoid cross-
contamination. Special precautions should be taken when working with infectious
materials.
5.18 Measures to prevent cross-contamination appropriate to the risks identified

should be put in place. Measures that can be considered to prevent cross-
contamination include, among others:
(a) segregated premises,
(b) dedicating the entire manufacturing facility or a self-contained production

area on a campaign basis (separation in time) followed by a cleaning process
of validated effectiveness,
(c) adequate cleaning procedures:
i. the cleaning procedure (technique, number of sanitation steps, etc.)

should be adapted to the specific characteristics of the product and
of the manufacturing process;
ii. a risk-assessment should be used to determine the cleaning and

decontamination procedures that are necessary, including the
frequency thereof;
iii. as a minimum, there should be appropriate cleaning and

decontamination between each batch; and
iv. all cleaning and decontamination procedures should be validated.
(d) use of “closed systems” for processing and for material or product transfer
between individual processing equipment,
(e) use of air locks and pressure cascade to confine potential airborne
contaminant within a specified area,
(f) utilisation of single use systems,
(g) other suitable organisational measures, such as the:

i. dedication of certain parts of equipment (e.g. filters) to a given type

of product with a specific risk profile;
ii. keeping specific protective clothing inside areas where products with
high-risk of contamination are processed;
iii. implementing adequate measures to handling waste, contaminated

rinsing water and soiled gowning; and
iv. imposing restrictions on the movement of personnel.

Validation
5.19 During process validation potential limited availability of quantities of tissue/cells

has to be taken into account. A strategy on gaining maximum process knowledge
has to be implemented.
Validation studies should be conducted in accordance with defined procedures.

Results and conclusions should be recorded, in particular:
(a) ATMPs manufactured for exploratory, early phase clinical trials (phase I and
phase I/II), are expected to be validated proportionately with the knowledge
and the risk associated with the respective phase. All aseptic and sterilisation
processes as well as virus inactivation or removal for investigational and
authorised ATMPs are expected to be validated. The effectiveness of
disinfection methods should be proven. For all phases, the principles as
outlined in Annex 13 should be applied.
(b) For all aseptic processes, aseptic process simulations should be performed
as part of initial validation and repeated thereafter every six months in line
with Annex 1. In the case of infrequent production (i.e. if the interval between
the production of two batches is more than six months but less than a year),
it is acceptable that the process simulation test is done prior to manufacturing
of the next batch. This is provided that, the results of the process simulation
test are available prior to the starting of production. Any deviation from this
approach needs to be thoroughly justified by QRM principles considering all
aspects of product nature, product quality and patient safety.
(c) If the ATMP is not produced on a routine basis (i.e. over a year), the aseptic
process simulation should be conducted at least in triplicate prior to the start
of manufacturing, involving all relevant operators. QRM principles should be
applied in accordance with Annex 1. Any deviation from this approach needs
to be thoroughly justified by QRM principles considering all aspects of product
nature, product quality and patient safety.
(d) The use of surrogate material during process validation may be acceptable
when there is shortage of the starting materials (e.g. autologous ATMPs,
allogeneic in a matched-donor scenario, allogeneic where there is no
expansion of cells to MCB). The representativeness of surrogate starting
material should be evaluated, including – for example – donor age, use of
materials from healthy donors, anatomical source (e.g. femur vs. iliac crest)

or other different characteristics (e.g. use of representative cell-types or use

of cells at a higher passage number than that foreseen in the product
specifications).
(e) Where possible, consideration should be given to complementing the use of

surrogate materials with samples from the actual starting materials for key
aspects of the manufacturing process. For instance, in the case of an ATMP
based on modification of autologous cells to treat a genetic disorder, process
validation using the autologous cells (affected by the condition) may be
limited to those parts of the process that focus on the genetic modification
itself. Other aspects could be validated using a representative surrogate cell
type.
Control of different types of materials including ATMP Active Substances
5.20 For the approval and maintenance of suppliers of materials, the following is
required:
ATMP Active substances
The supply chain traceability should be established. Associated risks, from active
substance starting materials to the finished medicinal product, should be formally
assessed and periodically verified. Appropriate measures should be put in place
to reduce risks to the quality of the active substance.
The supply chain and traceability records for each active substance should be
available and be retained by the manufacturer of the ATMP.
Raw materials and process aids
Prior to setting up the manufacturing process and whenever a change of the

respective material is implemented, a QRM process should assess the risk of
contamination from the relevant materials as well as their influence on the entire
manufacturing process and the resulting product. Appropriate measures should
be put in place to reduce risks to the quality of the materials.
Material directly in contact with the ATMP during manufacture and storage
All materials that come in direct contact with the ATMP should be of appropriate
quality. The risk of microbiological contamination should be assessed especially
for single use systems.
5.21 Only materials that have been released by the Quality Unit and that are within
their expiration or retest date should be used. Where the results of necessary
tests are not available, it may be permissible to process materials before the
results of the tests are available, the risk of using a potentially failed material and
its potential impact on other batches should be clearly described and assessed
under the principles of QRM. In such cases, release of a finished product is

conditional on satisfactory results of these tests. (Replaces PIC/S GMP Guide

Part I Section 5.34)
5.22 A regular qualification of the vendors (e.g. manufacturers and distributors) of all
materials to confirm that they comply with the relevant GMP requirements should
be performed. Whether an on-site audit needs to be performed at a
manufacturer’s or distributor’s premises should be defined based on QRM
principles. Generally, audits need to be performed at vendors of all materials
defined as critical for the manufacturing process according to its product risk
profile (PRP). Refer to provisions detailed in Chapter 7 as modified by this annex.
5.23 Application of QRM principles to the total supply chain is a critical part of the
process to understand the risks to material quality. The principles of quality by
design (QbD) as described in ICH Q8 Guideline on Pharmaceutical Development
could be applied:
(a) The MAH should define what constitutes ATMP active substances, starting
materials, raw materials and other materials such as single use systems,
primary packaging materials and any other materials in direct contact with the
product during manufacture by means of Product Risk Profiles (PRP). The
PRP should be used to justify the levels of control that apply to individual
materials.
(b) Establish the Quality Target Product Profile (QTPP) and define the Critical
Quality Attributes (CQA) and the Critical Process Parameters (CPP) for the
ATMP to establish PRP appropriately.
(c) For each material used, identify the risks presented to the quality, safety and
function from its source through to its incorporation in the finished product
dosage form. Areas for consideration should include, but are not limited to:
i. transmissible spongiform encephalopathy;
ii. potential for viral contamination;
iii. potential for microbiological or endotoxin/pyrogen contamination;
iv. potential, in general, for any impurity originating from the raw
materials, or generated as part of the process and carried over;
v. sterility assurance for materials claimed to be sterile;
vi. potential for any impurities carried over from other processes, in
absence of dedicated equipment and/or facilities;
vii. environmental control and storage/transportation conditions

including cold chain management; if appropriate and
viii. stability.
(d) With respect to the use and function of each material, consider the following:

i. pharmaceutical form and use of the medicinal product containing the

material;
ii. function of the material in the formulation, and for gene therapy
products the impact on the gene expression of that material;
iii. degree of which the function of the final product is dependent from
the material assessed and how likely it is to be controlled further into
the manufacturing process (i.e. if the gene sequence is wrong how
easily can this be detected and corrected or if the product is
contaminated how likely can this be detected or corrected later in the
manufacturing process);
iv. time of preparation of the material in respect to the time of

administration of the final product;
v. quantity of material with particular reference to the implication of

small final product batch sizes (e.g. 5-50 mg);
vi. any known quality defects/fraudulent adulterations, both globally and

at a local company level related to the material;
vii. known or potential impact on the CQA and CPP of the ATMP; and
viii. other factors as identified or known to be relevant to assuring patient

safety.
(e) Document the risk profile as low, medium, or high based on the above
assessment and use this outcome to determine the PRP. On this basis, the
MAH should establish and document the elements of PIC/S GMP that are
needed to be in place in order to control and maintain the QTPP.
(f) Once the PRP and the appropriate GMP have been defined, ongoing risk
review should be performed through mechanisms such as:
i. number of defects connected to batches of respective material

received;
ii. type/severity of such defects;
iii. monitoring and trend analysis of material quality;
iv. observation of trends in drug product quality attributes; this will

depend on the nature and role of material; and
v. observed organisational, procedural or technical/process changes at

the material manufacturer.
(g) Incorporate the PRP into the CTA or MA as applicable.
(h) The QTPP, once approved in the production process by the Competent
Authority, should guide the manufacturer through what controls are important
and expected and which can be exempted. The manufacturer should have a

control strategy established that justifies the level of testing performed for
incoming starting materials.
5.24 Particular attention should be paid to avoiding contamination and to minimising

the variability of the materials. Specifications related to the product (such as those
in pharmacopoeial monographs, CTA, or MA), will dictate whether and to what
stage substances and materials can have a defined level of bioburden or need to
be sterile.
5.25 For products where final sterilisation is not possible and the ability to remove
microbial by-products is limited, the controls required for the quality of materials
and on the aseptic manufacturing process assume greater importance. Where a
CTA or MA provides for an allowable type and level of bioburden, for example at
the ATMP active substance stage, the control strategy should address the means
by which this is maintained within the specified limits.
5.26 The selection, qualification, approval and maintenance of suppliers of starting

materials, raw materials and materials that come in direct contact with the
products during manufacture and storage (e.g. single use systems) together with
their purchase and acceptance should be documented as part of the
pharmaceutical quality system. The level of oversight should be proportionate to
the risks posed by the individual materials taking account of their source,
manufacturing process, supply chain complexity and the final use to which the
material is put in the ATMP. The supporting evidence for each supplier / material
approval should be maintained. Personnel involved in these activities should
have a current knowledge of the suppliers, the supply chain and the associated
risks involved. Where possible, these materials should be purchased directly from
the manufacturer or a manufacturer approved supplier. (Replaces PIC/S GMP
5.27 For starting material of human origin, the agreement between the ATMP
manufacturer (or, as appropriate, the MAH) and the supplier (including blood and
tissue establishments) should contain clear provisions about the transfer of
information. In particular, this should include test results performed by the
supplier, traceability data, and transmission of health donor information that may
become available after the supply that may have an impact on the quality or
safety of the ATMPs manufactured. National laws that are required as part of the
donation and procurement of human blood and blood components,
haematopoietic progenitor cells, human tissues and cells for manufacturing
purposes need to be adhered to. (Replaces PIC/S GMP Guide Part I Section
5.28)
5.28 The quality requirements established by the manufacturer in the MA or CTA for
materials classified as critical during QRM process (according to PRP profile)
should be discussed and agreed with the suppliers during the product life cycle.
Appropriate aspects of the production, testing and control, including handling,
labelling, packaging and distribution requirements, complaints, recalls and
rejection procedures should be documented in a formal quality agreement.

Human Blood, Tissues and Cells Used as Starting Materials
5.29 The donation, procurement and testing of human blood, tissues and cells used
as starting materials for ATMPs should be in accordance with the applicable
national law.
(a) The procurement, donation and testing of blood, cells and tissues is
regulated in some countries. Such supply sites must hold appropriate
approvals from the Competent Authority(ies) which should be verified as
part of supplier management.
(b) For cell therapies, the maintenance of the aseptic processing from time of
procurement of cells through manufacturing and administration back into
the patient should be ensured.
(c) Where such human cells or tissues are imported, they must meet
equivalent national standards of quality and safety. The traceability and
serious adverse reaction and serious adverse event notification
requirements may be set out in national law.
(d) There may be some instances where processing of blood, tissues and cells
used as starting materials for ATMPs will be conducted at blood or tissue
establishments. This is permissible only if authorised by national law (e.g.
the material would be otherwise compromised and processing involves only
minimal manipulation).
(e) Blood, tissue and cells are released by the Responsible Person (RP) in the
blood or tissue establishment before shipment to the ATMP manufacturer.
After that, normal medicinal product starting material controls apply. The
test results of all tissues / cells supplied by the tissue establishment should
be available to the manufacturer of the medicinal product. Such information
must be used to make appropriate material segregation and storage
decisions. In cases where manufacturing must be initiated prior to receiving
test results from the tissue establishment, tissue and cells may be shipped
to the medicinal product manufacturer, provided controls are in place to
prevent cross-contamination with tissue and cells that have been released
by the RP in the tissue establishment.
(f) A technical agreement clearly defining the responsibilities should be in

place between all involved parties (e.g. manufacturers, tissue
establishment, sponsors, MAH).
(g) The transport of blood, tissues and cells to the manufacturing site must be
controlled by a written agreement between the responsible parties. The
manufacturing sites should have documentary evidence of adherence to
the specified storage and transport conditions.
(h) Continuation of traceability requirements started at tissue establishments

through to the recipient(s), and vice versa, including materials in contact
with the cells or tissues should be maintained.

Seed Lot and Cell Bank System
5.30 A system of master and working virus seed lots and/or cell banks is
recommended if the production of allogeneic ATMP involves cell culture or
propagation in embryos and animals. This can prevent the unwanted drift of
properties, which might ensue from repeated subcultures or multiple generations.
5.31 The number of generations (doublings, passages) between the seed lot or cell
bank, the active substance and finished product should be consistent with
specifications in the MA or CTA.
5.32 As part of product lifecycle management, establishment of seed lots and cell
banks, including master and working generations, as well as maintenance and
storage, should be performed under appropriate GMP conditions. This should
include an appropriately controlled environment to protect the seed lot and the
cell bank and the personnel handling it. During the establishment of the seed lot
and cell bank, no other living or infectious material (e.g. virus, cell lines or cell
strains) should be handled simultaneously in the same area or by the same
persons. For all stages prior to the establishment of the master seed or cell bank
generation, principles of GMP may be applied. For all pre-master bank stages,
documentation should be available to support traceability. All issues related to
components used during the development with potential impact on product safety
(e.g. reagents of biological origin) from initial sourcing and genetic development
should be documented.
5.33 Following the establishment of master and working cell banks and master and
working seed lots, quarantine and release procedures should be followed. This
should include adequate characterisation and testing for contaminants. Their
on-going suitability for use should be further demonstrated by the consistency of
the characteristics and quality of the successive batches of product. Evidence of
the stability and recovery of the seeds and banks should be documented and
records should be kept in a manner permitting trend evaluation.
5.34 Seed lots and cell banks should be stored and used in such a way as to minimise
the risks of contamination (e.g. stored in the vapour phase of liquid nitrogen in
sealed containers) or alteration. Control measures for the storage of different
seeds and/or cells in the same area or equipment should prevent mix-up and take
into account the infectious nature of the materials to prevent cross-contamination.
5.35 Cell based ATMPs are often generated from a cell stock obtained from limited
number of passages. In contrast with the two-tiered system of Master and
Working cell banks, the number of production runs from a cell stock is limited by
the number of aliquots obtained after expansion and does not cover the entire life
cycle of the product. Cell stock changes should be addressed in the MA/CTA and
thereby covered by a validation and comparability protocol, as the inter-donor
variability may change the product.
5.36 Storage containers should be sealed, clearly labelled and kept at an appropriate
temperature. A stock inventory must be kept. The storage temperature and,
where used, the liquid nitrogen levels should be continuously monitored.
Deviation from set limits and corrective and preventive action taken should be
recorded.

5.37 It is desirable to split stocks and to store the split stocks at different locations to
minimise the risks of total loss. The controls at such locations should provide the
assurances outlined in the preceding paragraphs.
5.38 The storage and handling conditions for stocks should be managed according to
the same procedures and parameters. Once containers are removed from the
seed lot / cell bank management system, the containers should not be returned
to stock.
CHAPTER 6 QUALITY CONTROL

6.1 In-process controls have a greater importance in ensuring the consistency of the
quality of ATMPs than for conventional products. In-process control testing
should be performed at appropriate stages of production to control those
conditions that are important for the quality of the finished product.
General
6.2 The head of quality control is responsible for control of ATMP active substances,
starting materials, raw materials and other materials such as primary packaging
materials and any other material in direct contact with the product during
manufacture as well as medical devices that are used in combined ATMPs.
Further, the head of quality control is responsible to control the quality of the
ATMP throughout all stages of manufacture. In case of autologous products or
allogeneic products in a donor-matched scenario, the match between the origin
of the starting material and the recipient should be verified.
6.3 Samples should be representative of the batch of materials or products from

which they are taken. Other samples may also be taken to monitor the worst-case
part of a process (e.g. beginning or end of a process). The sampling plan used
should be appropriately justified and based on a risk management approach.
Certain types of cells (e.g. autologous cells used in ATMPs) may be available in
limited quantities and, where allowed in the CTA or MA, a modified testing and
sample retention strategy may be developed and documented. (Replaces PIC/S
6.4 Sample containers should bear a label indicating the contents, with the batch
number, the date of sampling and the containers from which samples have been
drawn. They should be managed in a manner to minimize the risk of mix-up and
to protect the samples from adverse storage conditions. When containers are too
small, the use of a qualified bar code or other means that permit access to this
information should be considered. (Replaces PIC/S GMP Guide Part I Section
6.13)
6.5 In line with requirements of Annex 19, a reference sample of a batch of starting
material, raw materials, packaging material and finished product should be
drawn. As a general principle, a reference sample should be of sufficient size to
permit the carrying out on at least two occasions of the full analytical controls on
the batch foreseen in the CTA or MA. In case of a continuous process, where the
ATMP active substance will immediately be turned into the ATMP drug product,
only a reference sample of the ATMP drug product needs to be drawn. However,
it is acknowledged that drawing reference samples may not always be feasible

due to scarcity of the materials or limited size of the batches (e.g. autologous
products, allogeneic products in a matched donor scenario, products for ultra-
rare diseases, and products for use in first-in-man clinical trials with a very small-
scale production). In these cases, alternative approaches should be justified and
authorised in the corresponding CTA/MA.
6.6 Samples of the starting materials should generally be kept for two years after the
batch release. However, it is acknowledged that the retention of samples may be
challenging due to scarcity of the materials. Due to this intrinsic limitation, it is
justified not to keep reference samples of the cells/tissues used as starting
materials in the case of autologous ATMPs and certain allogeneic ATMPs (i.e.
matched donor scenario). In other cases, where the scarcity of the materials is
also a concern, the sampling strategy may be adapted based on risk assessment
and appropriately implemented mitigation measures. For cases where the
starting material is an established cell bank system, there is no need to keep cell
bank vials specifically for the purpose of reference samples.
6.7 In line with requirements of Annex 19, a sample of a fully packaged unit (retention
sample) should be kept per batch for at least one year after the expiry date
(national requirements might differ). A retention sample is, however, not expected
in the case of autologous products or allogeneic products, where justified (e.g. in
a matched donor scenario), as the unit produced with the patient’s tissues/cells
constitutes what should be administered to the patient. When it is not possible to
keep a retention sample, photographs or copies of the label are acceptable for
inclusion in the batch records.
6.8 Shorter retention periods as mentioned in Section 6.6 and 6.7 might be justified
based on the stability and shelf life of the product. In cases of short shelf life, the
manufacturer should consider if the retention of the sample under conditions that
prolong the shelf life (such as cryopreservation) is representative for the intended
purpose. For instance, cryopreservation of fresh-cells may render the sample
inadequate for characterisation purposes but the sample may be adequate for
sterility or viral safety controls (the volume of the samples can be reduced
according to the intended purpose). When cryostorage of a sample is considered
inadequate for the intended purpose, the manufacturer should consider
alternative approaches that are scientifically justified.
On-going stability programme
6.9 The protocol for the on-going stability programme can be different from that of the
initial long term stability study as submitted in the MA dossier provided that this
is justified and documented in the protocol (e.g. the frequency of testing, or when
updating to ICH/VICH recommendations). Stability studies on the reconstituted
and thawed product are performed during product development and need not be
monitored on an on-going basis. The use of surrogate materials (i.e. material
derived from healthy volunteers) or alternative scientifically sounds approaches
are acceptable in case of autologous products (or matched donor scenario)
where the entire batch needs to be administered to the patient. (Replaces PIC/S

Release
6.10 In general, batches of ATMPs should only be released for sale or supply to the
market after certification by an Authorised Person. The batch release
specifications are not limited to analytical results (also refer to out of specification
(OOS) results). In line with PIC/S GMP Guide Part I Sections 1.4 (xv), 2.6. and
6.34 the Authorised Person should assess the quality of each batch considering
processing records, results from environmental monitoring, monitoring of process
parameters, analytical results and all deviations from standard procedures and
protocols. Until a batch is certified, it should remain at the site of manufacture or
be shipped under quarantine to another site, which has been approved for that
purpose by the relevant Competent Authority (if applicable) and is controlled
appropriately within the manufacturer’s quality system. Generally, a finished
product that does not meet release specifications should not be administered to
a patient unless otherwise justified.
6.11 Where authorised by national law, the administration of a product that does not
meet the release specification might be performed under exceptional
circumstances (such as when there is no alternative treatment available that
would provide the same therapeutic outcome and the administration of the failed
products could be lifesaving).
6.12 In cases, referred to in point 6.11, where product does not meet release
specification, the responsibility and the decision of the patient treatment are solely
of the treating physician and are beyond the remit of this PIC/S annex. The
Authorised Person, the MAH and/or the Sponsor of the clinical trial should
consider the following in making the product available:
The treating physician should provide in writing a rationale and/or request to the
Authorised Person and MAH.
(a) Batch manufacturing records and documentation provided to the treating

physician should clearly state that the batch has failed the release
specifications and describe the parameters that have not been met.
(b) When responding to a treating physician’s request, the MAH should provide
its evaluation of the risks of product administration. However, it is solely the
physician’s decision to administer the finished product that does not meet
release specifications.
(c) The Authorised Person (or delegate) should report the supply of the product
to the relevant Competent Authorities, on behalf of the MAH in accordance
with their legal obligations.
6.13 The clinical trial Sponsor or MAH should have procedures in place that describe
steps to be taken if product does not meet release specification but may be
released to permit treatment. Individual instances that do not meet release
specifications may be addressed through lot-by-lot release programmes and
specific case-by-case, risk-based assessments, where such programs exist
within national law.

6.14 For ATMPs with a short shelf life, where established analytical tests might not
permit batch certification prior to product administration, alternative methods of
obtaining equivalent data should be considered (e.g. rapid microbiological
methods).
Subject to approval from the Competent Authority, batch certification of short

shelf life products performed prior to completion of all product quality control is
permitted when the testing timelines would not allow for effective distribution to a
patient.
(a) A suitable control strategy must be in place, built on enhanced understanding

of the product and process performance. This must take into account the
controls and attributes of starting materials, raw materials and intermediates.
(b) The procedure for batch certification should provide an exact and detailed
description of the entire release procedure, including responsibilities of the
different personnel involved in assessment of production and analytical data.
(c) The procedure for batch certification and release of short shelf life ATMP
may be carried out in two or more stages:
i. Assessment by designated person(s) of batch processing records,

results from environmental monitoring (where available) which should
cover production conditions, all deviations from standard procedures
and protocols as well as the available analytical results for review in
preparation for the initial certification by the Authorised Person.
ii. Assessment of the final analytical tests and other information available
for final certification by the Authorised Person. A procedure should be
in place to describe the measures to be taken (including liaison with
clinical staff) where out of specification test results are obtained. Such
events should be fully investigated and the relevant corrective and
preventive actions taken to prevent recurrence.
(d) Increased reliance on process validation should be considered as supporting

data for batch release in absence of a complete analytical results panel, even
in case of investigational ATMP.
(e) A continuous assessment of the effectiveness of the pharmaceutical quality

system must be in place. This includes the records being kept in a manner,
which permits trend evaluation.

Batch release process in cases of decentralised / point of care

manufacturing
6.15 In the exceptional circumstances where approved by the Competent Authority

and in accordance with CTA or MA or other national requirements, manufacturing
of the ATMP may take place in sites close to the patient (e.g. ATMPs with short
shelf life, clinical advantage of using fresh cells as opposed to freezing the
starting materials/finished product, advantages of using automated equipment,
etc.). This includes manufacturing models where partial manufacturing occurs at
a central site and finishing occurs at a local site. It also includes manufacturing
models where there are no steps occurring at a central site and the active
substance is provided to a number of local sites where full manufacture occurs.
In such cases, steps in the manufacturing of the ATMPs may occur in multiple
sites that may be also located in treatment centres (point of care) including
hospitals. National law might require GMP-manufacturing authorisations and/ or
authorisations for the procurement and/or manufacture of blood, cells and tissues
intended to be used for ATMP manufacturing at the central site and the satellite
sites.
6.16 The batch certification and release process becomes particularly important in the
case of ATMPs manufactured under a decentralised system as manufacturing in
multiple sites increases the risk of variability for the product. In particular, through
the batch certification and release process it must be ensured that each batch
released at any of the sites has been manufactured and quality controlled in
accordance with the requirements of the CTA or MA and other relevant regulatory
requirements including compliance with GMP. The steps of the batch certification
and release process should be clearly documented in a standard operating
procedure (SOP). The following conditions need to be respected:
(a) A "responsible site", should be identified. The responsible site is responsible

for the oversight of the decentralised sites. During the product life cycle, the
responsible site:
i. must have availability of an Authorised Person;
ii. must ensure that those involved in the batch certification and release
process are adequately qualified and trained for their tasks;
iii. should perform audits to confirm compliance with the batch certification
and release process (as descripted in SOP);
iv. must ensure that there is a written contract/technical agreement

between the responsible site and the decentralised sites establishing
the responsibilities of each party, and
v. must ensure that there are written arrangements to:
 timely report quality defects, deviations or non-conformity to the

central site;
 ensure deviations are investigated to identify root cause(s) and

implement corrective and preventive measures as appropriate; and

 ensure deviations are approved by a delegated person (after having

assessed the impact on quality, safety and efficacy), with the
involvement of the Authorised Person as appropriate.
(b) The Authorised Person should have ultimate responsibility for the batch
certification (responsibility cannot be delegated). However, it should be
possible for the Authorised Person of the responsible site to rely on
data/information that is transmitted to the Authorised Person by qualified and
trained personnel at the decentralised sites.
When permitted by national law, the Authorised Person may delegate release
to trained and qualified personnel at the decentralised site to act under the
direction of the Authorised Person for exceptional situations (e.g. life
threatening cases or off-hours). The following conditions apply:
i. There is a detailed algorithm that determines the cases when the

product can be released at the local site without the preliminary
approval of the Authorised Person, including deviations that do not
require the intervention of the Authorised Person. If technology permits
this step can be performed by a validated computer system.
ii. The Authorised Person reviews all releases that have occurred at a
decentralised site within an appropriately justified timeframe to confirm
the adequacy of the releases including:
 determining that the local sites can continue release;
 if any product needs to be recalled or a product alert needs to be

issued (see recall section in Chapter 8);
 if any provision in the release procedure and /or technical

agreement needs modification; and
 the product has not been released without Authorised Person

authorisation when required.
CHAPTER 7 OUTSOURCED ACTIVITIES
OTHERS
7.1 Collection of starting materials and highly specialised testing in the jurisdictions
that are subject to licensing (e.g. karyotype testing, exome sequencing) can be
outsourced to non GMP licensed third party, as allowed by national law, provided:
(a) there is a rationale and a justification in the quality system;
(b) the contract giver takes responsibility to ensure that the contract acceptor
demonstrates an appropriate level of GMP commensurate to the risk to the
product and the activities performed using the principles of Annex 20; and

(c) that proportionate qualifications/validations as appropriate are conducted

(with reference to Annex 15 and Annex 20) to demonstrate that the activities
are not detrimental to the quality of the product manufactured.
CHAPTER 8 COMPLAINTS AND PRODUCT RECALL

PRODUCT RECALLS AND OTHER POTENTIAL RISK-REDUCING ACTIONS
8.1 If additional donor (human or animal) health information becomes available after
procurement, which affects product quality, a ‘look-back’ procedure needs to be
initiated. This involves an analysis of the risk(s) and of the need for corrective or
preventive measures.
8.2 In addition to recalls, other risk-reducing actions may be considered to manage

the risks presented by quality defects, such as the transmission of appropriate
information to healthcare professionals which may be important for:
(a) a single batch product (e.g. autologous ATMP where the entire batch has
been administered), or
(b) products where patient treatment interruption presents a higher risk than
continued use of the recalled product.
In such cases, the MAH/manufacturer needs to provide information to the treating

physician and to the Competent Authority. Quality defect notifications,
pharmacovigilance signals and other notifications should also be sent as set in
national law.
(Replaces PICS GMP Guide Part I Section 8.31)
8.3 In order to test the robustness of the recall procedure (or healthcare professional
notification) consideration should be given to performing mock recall or mock
transmission of appropriate information to healthcare professionals. Such
evaluations should extend to both within office-hour situations as well as out-of-
office hour situations.
The frequency of the mock recall (or mock transmission of appropriate

information to healthcare professionals) should be justified by the manufacturer
considering factors such as the stage of the product development and the
complexity of the supply. For authorised products, a yearly frequency is
recommended unless otherwise justified.
(Replaces PICS GMP Guide Part I Section 8.30)

PART B: SPECIFIC GUIDANCE ON SELECTED PRODUCT TYPES

B1. ANIMAL SOURCED PRODUCTS
This guidance applies to animal materials, which includes materials from establishments
such as abattoirs. Since the supply chains can be extensive and complex, controls based
on QRM principles need to be applied, see also requirements of appropriate
pharmacopoeial monographs, including the need for specific tests at defined stages.
Documentation to demonstrate the supply chain traceability5 and clear roles of
participants in the supply chain, typically including a sufficiently detailed and current
process map, should be in place.
B 1.1 Monitoring programmes should be in place for animal disease that is of concern
to human health. Organisations should take into account reports from trustworthy
sources on national disease prevalence when compiling their assessment of risk
and mitigation factors. Such organisations include the World Organisation for
Animal Health (OIE, Office International des Epizooties). This should be
supplemented by information on health monitoring and control programme(s) at
national and local levels, the latter to include the sources (e.g. farm or feedlot)
from which the animals are drawn and the control measures in place during
transport to the abattoirs.
B 1.2 Control measures for starting and raw materials at establishments such as
abattoirs should include appropriate elements of a Quality Management System
to assure a satisfactory level of operator training, materials traceability, control
and consistency. These measures may be drawn from sources outside PIC/S
GMP but should be shown to provide equivalent levels of control. Xenogeneic
starting material should comply with other national laws.
B 1.3 Control measures for starting or raw materials should be in place, which prevent
interventions, which may affect the quality of materials, or which at least provides
evidence of such activities, during their progression through the manufacturing
and supply chain. This includes the movement of material between sites of initial
collection, partial and final purification(s), storage sites, hubs, consolidators and
brokers. Details of such arrangements should be recorded within the traceability
system and any breaches recorded, investigated and actions taken.
B 1.4 Regular audits of the starting or raw material supplier should be undertaken which
verify compliance with controls for materials at the different stages of
manufacture. Issues must be investigated to a depth appropriate to their
significance, for which full documentation should be available. Systems should
also be in place to ensure that effective corrective and preventive actions are
taken.
B 1.5 Cells, tissues and organs intended for the manufacture of xenogeneic cell based
medicinal products should be obtained only from animals that have been bred in
captivity (barrier facility) specifically for this purpose and under no circumstances
should cells, tissues and organs from wild animals or from abattoirs be used.
Tissues of founder animals similarly should not be used. The health status of the
animals should be monitored and documented.
5 See PIC/S GMP Chapter 5

B2. GENE THERAPY MEDICINAL PRODUCTS (GTMPs)
There are several types of gene therapy products. Synthetic GTMPs are within the scope
of the guidance in this section. For cell-based gene therapy products, some aspects of
the guidance in Section B3 may also be applicable.
B2.1 The manufacture and testing of GTMPs raises specific issues regarding the
safety and quality of the final product and safety issues for recipients and staff. A
risk based approach for operator, environment and patient safety and the
implementation of controls based on the biological hazard class should be
applied. National requirements and, if applicable, international safety measures
should be applied.
B2.2 A description of the production of viral and non-viral vectors, nucleic acids (e.g.
plasmids, linear DNA, mRNA, siRNA) and genetically modified cells should be
available in sufficient detail to ensure the traceability of the products from the
starting material (plasmids, gene of interest and regulatory sequences, cell
banks, and viral or non-viral vector stock) to the finished product.
B2.3 The following considerations apply to the ex-vivo gene transfer to recipient cells:
(a) Traceability requirements must be maintained. (refer to Section 4.3 to 4.8)
(b) There should be a clear batch definition, from cell source to final product
container(s). (refer Section 4.2)
(c) For products that utilise non-biological means to deliver the gene, their
physico-chemical properties should be documented and tested.
(d) Although the vector used for the manipulation of the cell will not be part of
the final product, all early processes (e.g. design to construction to
manufacturing of the plasmid, as well as establishment of cell banks) in the
manufacture of viral vectors are considered critical and their quality needs
to be under control. In the case that due to national requirements the
manufacture of viral vectors are not required under full GMP sufficient
quality standards (“principles of GMP”) should be applied in their
manufacture.
Manufacture of Viral Vectors and Plasmids under “principles of GMP”
B2.4 Annex 2A and elements of Part II of the PIC/S GMP Guide can be considered for
the manufacturing of viral vectors and plasmids where appropriate (refer to the
examples in light grey in Table 1).
Manufacturers of viral vectors and plasmids should have a quality management

system in place that allows them to apply sections of the guideline most relevant
to ensure the quality of the starting materials having regard to the relevant risks
for the quality, safety and efficacy of the finished product.
B2.5 The ATMP manufacturer is responsible for appropriate quality of the viral vectors
and plasmids used as starting materials. Special attention should be given to
requirements described in section 5.23 to 5.28 of this guideline.

(a) The ATMP manufacturer should follow national requirements and apply QRM
considering the risk presented by the vector to the safety and quality of the
ATMP to justify which sections of Annex 2A and elements of Part II of the
PIC/S GMP Guide are applicable for manufacture and testing of viral vectors
and plasmids. A defined and controlled manufacturing process should be
implemented as a result.
(b) Sufficient quality standards should be applied for the manufacture of

plasmids used for the establishment of vectors or early stages of mRNA
GTMPs (refer to Table 1). The design through to construction of the nucleic
acid (plasmid) preparation by molecular biological and in silico methods is
considered under the scope of research and development and therefore not
part of the respective Annex.
(c) Relevant provisions in Annex 1 are also applicable. The manufacturer should
justify the applicability extent using QRM. In general, products that can be
sterile filtered should follow the relevant sections in the Annex 1, otherwise
aseptic manufacturing provisions should be followed.
B2.6 If the manufacturing of the vectors is outsourced, the ATMP manufacturer should
assess the risk presented by the vector to the quality and safety of the ATMP and
thereby select a suitable vector supplier that is able to comply with the GMP
standards required by national legislation.
The appropriate sections of Annex 2A and elements of Part II of the PIC/S GMP
Guide relevant for the specific product should be determined in the agreement
between the ATMP manufacturer and the vector manufacturer and cover relevant
aspects (e.g. quality management, documentation, raw materials, cell banks,
production, testing and control, storage, and other aspects of handling and
distribution, as appropriate). In addition the vector manufacturer should be part
of the ATMP manufacturer’s vendor qualification programme. The level of
supervision and further testing by the ATMP manufacturer should be
proportionate to the risks posed by the individual materials.
B3 SOMATIC HUMAN AND XENOGENEIC CELL THERAPY PRODUCTS

AND TISSUE ENGINEERED PRODUCTS AND COMBINED ATMPs
For genetically modified cell-based products that are not classified as GTMPs, some
aspects of guidance in Section B2 may be applicable.
B3.1 In the manufacture of such products involving human or xenogeneic cells

special attention should be given to traceability requirements (refer to Section
4.3 to 4.8) and definition of a batch (refer to Section 4.2).
B3.2 Authorised sources of cellular products, bio-molecules, bio-materials,
scaffolds, matrices, and other substances that are licensed medicinal
products or medical devices should be used where available.
B3.3 During the life cycle of the product where devices, including custom-made
devices, are incorporated as part of the product, an appropriate Quality
Agreement should be made between manufacturer and device suppliers to
assure consistent quality of the device.

COMMON GLOSSARY TO ANNEX 2A AND 2B

The Glossary in the main GMP Guide applies also to Annex 2A & B. Entries in this
common glossary are only included where the terms are used in Annex 2A & B and
require further explanation. Definitions, which already exist, have been deemed
appropriate.
ATMP Active substance

The active substance of a product is defined in the relevant CTA or MA authorisation
dossier. The ATMP active substance is regarded equivalent to an API.
Adjuvant
A chemical or biological substance that enhances the immune response against an
antigen.
Advanced Therapy Medicinal Products (ATMP)

ATMP means any of the following medicinal products for human use:
(a) Gene therapy medicinal product (GTMP):
‘GTMP’ means a biological medicinal product, which has the following

characteristics:
i. It contains an active substance, which contains or consists of a

recombinant nucleic acid used in or administered to human beings with
a view to regulating, repairing, replacing, adding or deleting a genetic
sequence;
ii. Its therapeutic, prophylactic or diagnostic effect relates directly to the

recombinant nucleic acid sequence it contains, or to the product of
genetic expression of this sequence.
Normally GTMPs shall not include vaccines against infectious diseases which
would be regulated as per Annex 2B. However, the Competent Authority can
make a determination that should follow Annex 2A when this is beneficial and
appropriate (e.g. mRNA vaccines that are manufactured using the same
platform).
(b) Somatic cell therapy medicinal product:
‘Somatic cell therapy medicinal product’ means a biological medicinal product,

which has the following characteristics:
i. contains or consists of cells or tissues that have been subject to

substantial manipulation so that biological characteristics, physiological
functions or structural properties relevant for the intended clinical use
have been altered, or of cells or tissues that are not intended to be used
for the same essential function(s) in the recipient and the donor;
ii. is presented as having properties for, or is used in or administered to

human beings with a view to treating, preventing or diagnosing a

disease through the pharmacological, immunological or metabolic

action of its cells or tissues.
(c) Tissue engineered product:
‘Tissue engineered product’ means a product that:
i. contains or consists of engineered cells or tissues, and
ii. is presented as having properties for, or is used in or administered to

human beings with a view to regenerating, repairing or replacing a
human tissue.
A tissue-engineered product may contain cells or tissues of human or animal

origin, or both. The cells or tissues may be viable or non-viable. It may also
contain additional substances, such as cellular products, bio-molecules,
biomaterials, chemical substances, scaffolds or matrices. Products containing or
consisting exclusively of non-viable human or animal cells and/or tissues, which
do not contain any viable cells or tissues and which do not act principally by
pharmacological, immunological or metabolic action, shall be excluded from this
definition.
Cells or tissues shall be considered ‘engineered’ if they fulfil at least one of the
following conditions:
i. the cells or tissues have been subject to substantial manipulation, so

that biological characteristics, physiological functions or structural
properties relevant for the intended regeneration, repair or replacement
are achieved; or
ii. the cells or tissues are not intended to be used for the same essential
function or functions in the recipient as in the donor.
(d) Combined ATMPs:
‘Combined ATMP’ means an advanced therapy medicinal product that fulfils the
following conditions:
i. it must incorporate, as an integral part of the product, one or more

medical devices or one or more active implantable medical devices, and
ii. its cellular or tissue part must contain viable cells or tissues or its cellular
or tissue part containing non-viable cells or tissues must be liable to act
upon the human body with action that can be considered as primary to
that of the devices referred to.
(e) A product that is classified or determined to be an ATMP by the PIC/S

participating authority in its own jurisdiction according to national law.
Allergoids
Allergens, which are chemically modified to reduce IgE reactivity.

Antibody
Proteins produced by the B-lymphocytes that bind to specific antigens. Antibodies may
be divided into 2 main types based on key differences in their method of manufacture.
Monoclonal antibodies (MAb)

Homogenous antibody population obtained from a single clone of lymphocytes or
by recombinant technology and which bind to a single epitope.
Polyclonal antibodies
Derived from a range of lymphocyte clones, produced in human and animals in
response to the epitopes on most ‘non-self’ molecules
Antigens
Substances (e.g. toxins, foreign proteins, bacteria, tissue cells) capable of inducing
specific immune responses.
Area
A specific set of rooms within a building associated with the manufacturing of any one
product or multiple products that has a common air-handling unit.
Authorised Person
Person recognised by the authority as having the necessary basic scientific and technical
background and experience.
Note: For expanded clarity beyond the definition in the PIC/S GMP Guide, the Authorised
Person performs certification of batches in line with MA/CTA. After certification, the
batches of medicinal products can be released for sale or supply to the market. The
Authorised Person has the overall responsibility for release of the products.
Bioburden
The level and type (i.e. objectionable or not) of micro-organism present in raw materials,
media, biological substances, intermediates or products. Regarded as contamination
when the level and/or type exceed specifications.
Biological medicinal product

A biological medicinal product is a product, of which the active substance is a biological
substance. A biological substance is a substance that is produced by or extracted from
a biological source and that needs for its characterisation and the determination of its
quality a combination of physico-chemical-biological testing, together with the production
process and its control.
Biosafety level (BSL)

The containment conditions required to safely handle organisms of different hazards
ranging from BSL1 (lowest risk, unlikely to cause human disease) to BSL4 (highest risk,
cause severe disease, likely to spread and no effective prophylaxis or treatment
available).
Campaign manufacture
The manufacture of a series of batches of the same product in sequence in a given
period of time followed by strict adherence to accepted control measures before
transfer to another product. The products are not run at the same time but may be run
on the same equipment.

Closed system
Where an active substance or product is not exposed to the immediate room
environment during manufacture.
Contained use
An operation, in which genetically modified organisms are cultured, stored, used,
transported, destroyed or disposed of and for which barriers (physical / chemical /
biological) are used to limit their contact with the general population and the environment.
Critical Process Parameter (CPP)

A process parameter whose variability has an impact on a CQA and therefore should be
monitored or controlled to ensure the process produces the desired quality. (ICH Q8R2)
Critical Quality Attribute (CQA)

A physical, chemical, biological, or microbiological property or characteristic that should
be within an appropriate limit, range, or distribution to ensure the desired product quality.
(ICH Q8R2)
Ex-vivo
Where procedures are conducted on tissues or cells outside the living body and returned
to the living body.
Feeder cells
Cells used in co-culture to maintain pluripotent stem cells. For human embryonic stem
cell culture, typical feeder layers include mouse embryonic fibroblasts (MEFs) or human
embryonic fibroblasts that have been treated to prevent them from dividing.
Fermenter
In case of (mammalian) cell lines, the term fermenter should be understood as
bioreactor.
Gene
A sequence of DNA that codes for one (or more) protein(s).
Gene transfer
A process to transfer a gene in cells, involving an expression system contained in a
delivery system known as a vector, which can be of viral, as well as non-viral origin. After
gene transfer, genetically modified cells are also termed transduced cells.
Genetically modified organism (GMO)

An organism, with the exception of human beings, in which the genetic material has been
altered in a way that does not occur naturally by mating and/or natural recombination.
For the purpose of this annex, GMO is intended to cover mutations that are not occurring
because of a natural event but are generated by human intervention.
Hapten
A low molecular weight molecule that is not in itself antigenic unless conjugated to a
‘carrier’ molecule.
Hybridoma
An immortalised cell line that secrete desired (monoclonal) antibodies and are typically
derived by fusing B-lymphocytes with tumour cells.

In-vivo
Procedures conducted in living organisms.
Look-back
Documented procedure to trace ATMPs active substances or products, which may be
adversely affected by the use or incorporation of animal or human materials either when
such materials fail release tests due to the presence of contaminating agent or when
conditions of concern become apparent in the source animal or human.
Master cell bank (MCB)

An aliquot of a single pool of cells, which generally has been prepared from the selected
cell clone under defined conditions, dispensed into multiple containers and stored under
defined conditions. The MCB is used to derive all working cell banks.
Master transgenic bank

As above but for transgenic plants or animals.
Master virus seed (MVS)

As above, but in relation to viruses.
Material directly in contact with the ATMP during manufacture and storage
Non exhaustive example list: Processing containers (e.g. fermenters, cell culture flasks
and plates, blood bag systems, single use equipment used in automated manufacturing
platforms, beads for separation techniques, chromatographic column material), cryo-
containers for storage and primary packaging material.
Monosepsis (axenic)
A single organism in culture, which is not contaminated with any other.
Multi-product facility
A facility that manufactures, concurrently or in campaign mode, a range of different
ATMPs active substances and products and within which equipment train either may or
may not be dedicated to specific substances or products.
Plasmid
A plasmid is a piece of DNA usually present in a bacterial cell as a circular entity
separated from the cell chromosome; it can be modified by molecular biology techniques,
purified out of the bacterial cell and used to transfer its DNA to another cell.
Primary cell lot

A pool of primary cells minimally expanded to attain a sufficient number for a limited
number of applications.
Principles of GMP:
The Annex 2A in conjunction with PIC/S GMP guidelines and annexes describes the
manufacture of ATMP active substances and ATMP drug products. However, aspects of
these guidelines are also relevant for early stages in the ATMP manufacture (e.g.
manufcatur of viral vectors, plasmids) where full GMP is not required under national
legislation. As a result, the ATMP manufacturer should make sure that all relevant GMP
aspects for the manufacturing of those materials are implemented that ensure process
control and consistency, investigation of anomalies and control of change.

Processing aids
Substance used in the manufacture of the active substance and medicinal product, which
may be present in the finished product e.g. anti-foaming agents, puffer and media
additives (salts, pH indicators), enzymes not considered under raw materials
Quality Target Product Profile (QTPP)

A prospective summary of the quality characteristics of a drug product that ideally will be
achieved to ensure the desired quality, taking into account safety and efficacy of the drug
product. (ICHQ8R2)
Raw materials
All materials that come in direct contact with the product during the manufacturing
process but are not necessarily part of the final formulation (e.g. cryoprotectants, feeder
cells, reagents, culture media, buffers, serum, enzymes, cytokines, and growth factors).
Responsible Person (RP) for blood or tissue establishment

This term is equivalent to the EU term “Responsible Person”. The RP is responsible for
the release of the starting material to the ATMP manufacturer. Blood or tissue
establishment: this term is equivalent to the EU term and for the purpose of this annex
is the facility that is authorised according to national law to perform processing (minimal
manipulation) of the starting material of human origin.
Scaffold
A support, delivery vehicle or matrix that may provide structure for or facilitate the
migration, binding or transport of cells and/or bioactive molecules.
Somatic cells
Cells, other than reproductive (germ line) cells, which make up the body of a human or
animal. These cells may be autologous (from the patient), allogeneic (from another
human being) or xenogeneic (from animals) somatic living cells, that have been
manipulated or altered ex vivo, to be administered in humans to obtain a therapeutic,
diagnostic or preventive effect.
Specified pathogen free (SPF)

Animal materials (e.g. chickens, embryos or cell cultures) used for the production or
quality control of biological medicinal products derived from groups (e.g. flocks or herds)
of animals free from specified pathogens (SPF). Such flocks or herds are defined as
animals sharing a common environment and having their own caretakers who have no
contact with non-SPF groups.
Transgenic
An organism that contains a foreign gene in its normal genetic component for the
expression of biological pharmaceutical materials.
Vector
An agent of transmission, which transmits genetic information from one cell or organism
to another, e.g. plasmids, liposomes, viruses.
Viral vector
A vector derived from a virus and modified by means of molecular biology techniques in
a way as to retain some, but not all, the parental virus genes; if the genes responsible
for virus replication capacity are deleted, the vector is made replication-incompetent.
Viral Vector replication incompetent / devoid

No ability of the vector to replicate.

Viral Vector replication limited / defective / conditional replication

A constrained ability to replicate where the intent is for the vector may be to target a
particular tissue or target cell type with a planned integration required for clinical efficacy
of the gene therapy.
Working cell bank (WCB)

A homogeneous pool of cells preferably derived from a MCB, which are distributed
uniformly into a number of containers, stored in such a way to ensure stability and
intended for use in production.
Working transgenic bank (WTB)

As above but for transgenic plants or animals.
Working virus seed (WVS)

As above but in relation to viruses.
Zoonosis (zoonotic)
Animal diseases that can be transmitted to humans.

Annex 2B Manufacture of biological medicinal substances and products for human use
ANNEX 2B
MANUFACTURE OF BIOLOGICAL MEDICINAL

SUBSTANCES AND PRODUCTS FOR HUMAN USE
SCOPE
The methods employed in the manufacture of biological active substances and
biological medicinal products for human use (‘biological active substances and
medicinal products’) are a critical factor in shaping the appropriate regulatory
control. Biological active substances and medicinal products can be defined
therefore largely by reference to their method of manufacture. This annex
provides guidance on the full range of active substances and medicinal products
defined as biological with the exception of Advanced Therapy Medicinal Products
(“ATMPs”). The ATMPs are not covered by the present guideline. Manufacturers
of ATMPs should refer to PIC/S Annnex 2A Manufacture of Advanced Therapy
Medicinal Products for Human Use.
This annex is divided into two main parts:

a) Part A contains supplementary guidance on the manufacture of biological
active substances and medicinal products, from control over seed lots and
cell banks through to finishing activities and testing.
b) Part B contains further guidance on selected types of biological active
substances and medicinal products.
This annex, along with several other annexes of the PIC/S Guide to GMP,
provides guidance which supplements that in Part I and in Part II of the Guide.
There are two aspects to the scope of this annex:
a) Stage of manufacture - for biological active substances to the point
immediately prior to their being rendered sterile, the primary guidance
source is Part II. Guidance for the subsequent manufacturing steps of
biological products are covered in Part I.
b) Type of product - this annex provides guidance on the full range of
medicinal products defined as biological with the exception of ATMPs.
These two aspects are shown in Table 1; it should be noted that this table is
illustrative only and is not meant to describe the precise scope. It should also be
understood that in line with the corresponding table in Part II of the Guide, the
level of GMP increases in detail from early to later steps in the manufacture of
biological active substances but GMP principles should always be adhered to.
The inclusion of some early steps of manufacture within the scope of this Annex
does not imply that those steps will be routinely subject to inspection by the
authorities.

Antibiotics are not defined as biological medicinal products, however where

biological stages of manufacture occur, guidance in this Annex may be used.
Guidance for medicinal products derived from fractionated human blood or

plasma is covered in Annex 14 and for non-transgenic plant products in Annex 7.
In certain cases, other legislation may be applicable to the starting materials for
biologicals. For example,
(a) Tissue and cells used as starting materials for medicinal products,
donation, procurement, testing, processing, preservation, storage and
distribution of human tissues and cells of tissue and cells may be covered
by national legislation. Such tissues and cells may provide the active
substances for some biological medicinal product within the scope of this
annex at which point GMP and other medicinal product legislation
requirements apply.
(b) Blood or blood components used as starting materials for medicinal
products, national legislation may provide the technical requirements for
the selection of donors, collection, testing, processing, storage, and
distribution of human blood and blood components1.
Additionally, the manufacture and control of genetically modified organisms
needs to comply with local and national requirements. Appropriate containment
should be established and maintained in facilities where any genetically modified
micro-organism is handled2. Advice should be obtained according to national
legislation in order to establish and maintain the appropriate Biological Safety
Level. There should be no conflicts with GMP requirements.
Table 1. Illustrative guide to manufacturing activities within the scope of Annex 2B
Type and
Example
source of Application of this guide to manufacturing steps shown in grey
product
material
1. Animal or Heparins, insulin, Collection of plant, Cutting, mixing, and Isolation and Formulation,
plant sources: enzymes, organ, animal / or initial purification filling
non-transgenic proteins, allergen material or fluid3 processing
extract,
immunosera
2. Virus or Viral or bacterial Establishment & Cell culture and/or Inactivation when Formulation,
bacteria / vaccines; maintenance of fermentation applicable, isolation filling
fermentation / enzymes, proteins MCB4, WCB, and purification
cell culture MVS, WVS
3. Biotechnology Recombinant Establishment & Cell culture and /or Isolation, Formulation,
fermentation/ cell products, MAb, maintenance of fermentation purification, filling
culture allergens, MCB and WCB, modification
vaccines MSL, WSL
1 In the EEA, this is Directive 2002/98/EC and its Commission Directives.

2 In the EEA, this is Directive 2009/41/EC on contained use of genetically modified micro-organisms.
3 See section B1 for the extent to which GMP principles apply.
4 See section on ‘Seed lot and cell bank system’ for the extent to which GMP applies.

4. Animal Recombinant Master and Collection, cutting, Isolation, purification Formulation,

sources: proteins working transgenic mixing, and/or initial and modification filling
transgenic bank processing
5. Plant sources: Recombinant Master and Growing, Initial extraction, Formulation,

transgenic proteins, working transgenic harvesting5 isolation, filling
vaccines, bank purification,
allergens modification
Urine derived Collection of fluid6 Mixing, and/or Isolation and Formulation,

6. Human
enzymes, initial processing purification filling
sources
hormones
7. Human Products from Donation, Initial processing, Cell isolation, Formulation,

sources cells and tissues, procurement and isolation and culture, purification, combination,
not classified as testing of starting purification. combination with filling
ATMPs tissue / cells7 non-cellular
components
Increasing GMP requirements
See Glossary for explanation of acronyms.
PRINCIPLE
The manufacture of biological active substances and medicinal products involves
certain specific considerations arising from the nature of the products and the
processes. The ways in which biological medicinal products are manufactured,
controlled and administered make some particular precautions necessary.
Unlike conventional medicinal products, which are manufactured using chemical

and physical techniques capable of a high degree of consistency, the
manufacture of biological active substances and medicinal products involves
biological processes and materials, such as cultivation of cells or extraction from
living organisms. These biological processes may display inherent variability, so
that the range and nature of by-products may be variable. As a result, quality risk
management (QRM) principles are particularly important for this class of
materials and should be used to develop the control strategy across all stages of
manufacture so as to minimise variability and to reduce the opportunity for
contamination and cross-contamination.
Since materials and processing conditions used in cultivation processes are

designed to provide conditions for the growth of specific cells and
microorganisms, this provides extraneous microbial contaminants the opportunity
5 In the EEA: HMPC guideline on Good Agricultural and Collection Practice - EMEA/HMPC/246816/2005
may be applied to growing, harvesting and initial processing in open fields.
6 For principles of GMP apply, see explanatory text in ‘Scope’.
7 In the EEA, human tissues and cells must comply with Directive 2004/23/EC and implementing Directives
at these stages.

to grow. In addition, some products may be limited in their ability to withstand a

wide range of purification techniques particularly those designed to inactivate or
remove adventitious viral contaminants. The design of the processes, equipment,
facilities, utilities, the conditions of preparation and addition of buffers and
reagents, sampling and training of the operators are key considerations to
minimise such contamination events.
Specifications related to products (such as those in Pharmacopoeial

monographs, Clinical Trial Authorisation (CTA), and Marketing Authorisation
(MA)) will dictate whether and to what stage substances and materials can have
a defined level of bioburden or need to be sterile. Similarly, manufacturing must
be consistent with other specifications set out in the CTA or MA (e.g. number of
generations (doublings, passages) between the seed lot or cell bank).
For biological materials that cannot be sterilized (e.g. by filtration), processing

must be conducted aseptically to minimise the introduction of contaminants.
Where they exist, other guidance documents should be consulted on the
validation of specific manufacturing methods, e.g. virus removal or inactivation.
The application of appropriate environmental controls and monitoring and,
wherever feasible, in-situ cleaning and sterilisation systems together with the use
of closed systems can significantly reduce the risk of accidental contamination
and cross-contamination.
Control usually involves biological analytical techniques, which typically have a

greater variability than physico-chemical determinations. A robust manufacturing
process is therefore crucial and in-process controls take on a particular
importance in the manufacture of biological active substances and medicinal
products.
Biological medicinal products which incorporate human tissues or cells must

comply with national requirements for the coding, processing, preservation,
storage and distribution of human tissues and cells.8 Collection and testing of this
material must be done in accordance with an appropriate quality system and in
accordance with applicable national requirements9. Furthermore, national
requirements10 on traceability apply from the donor (while maintaining donor
confidentiality) through stages applicable at the Tissue Establishment and then
continued under medicines legislation through to the institution where the product
is used.
Biological active substances and medicinal products must comply with the
applicable national guidance on minimising the risk of transmitting animal
spongiform encephalopathy agents via human and veterinary medicinal
products.
8 In the EEA, these are Directive 2004/23/EC and Directive 2006/17/EC.

9 In the EEA, this is the Commission Directive 2006/86/EC.
10 In the EEA, this is Directive 2006/86/EC.

PART A: GENERAL GUIDANCE
PERSONNEL
1. Personnel (including those concerned with cleaning, maintenance or quality
control) employed in areas where biological active substances and products are
manufactured and tested should receive training, and periodic retraining, specific
to the products manufactured and to their work, including any specific security
measures to protect product, personnel and the environment.
2. The health status of personnel should be taken into consideration for product
safety. Where necessary, personnel engaged in production, maintenance, testing
and animal care (and inspections) should be vaccinated with appropriate specific
vaccines and have regular health checks.
3. Any changes in the health status of personnel, which could adversely affect the
quality of the product, should preclude work in the production area and
appropriate records kept. Production of BCG vaccine and tuberculin products
should be restricted to staff who are carefully monitored by regular checks of
immunological status or chest X-ray. Health monitoring of staff should be
commensurate with the risk, medical advice should be sought for personnel
involved with hazardous organisms.
4. Where required to minimise the opportunity for cross-contamination, restrictions

on the movement of all personnel (including quality control (QC), maintenance
and cleaning staff) should be controlled on the basis of QRM principles. In
general, personnel should not pass from areas where exposure to live
micro-organisms, genetically modified organisms, toxins or animals to areas
where other products, inactivated products or different organisms are handled. If
such passage is unavoidable, the contamination control measures should be
based on QRM principles.
PREMISES AND EQUIPMENT

5. As part of the control strategy, the degree of environmental control of particulate
and microbial contamination of the production premises should be adapted to the
active substance, intermediate or finished product and the production step,
bearing in mind the potential level of contamination of the starting materials and
the risks to the product. The environmental monitoring programme should be
supplemented by the inclusion of methods to detect the presence of specific
microorganisms (i.e. host organism, yeasts, moulds, anaerobes, etc) where
indicated by the QRM process.
6. Manufacturing and storage facilities, processes and environmental classifications

should be designed to prevent the extraneous contamination of products.
Prevention of contamination is more appropriate than detection and removal,
although contamination is likely to become evident during processes such as
fermentation and cell culture. Where processes are not closed and there is
therefore exposure of the product to the immediate room environment (e.g. during
additions of supplements, media, buffers, gasses,) control measures should be
put in place, including engineering and environmental controls on the basis of

QRM principles. These QRM principles should take into account the principles
and guidance from the appropriate sections of Annex 111 when selecting
environmental classification cascades and associated controls.
7. Dedicated production areas should be used for the handling of live cells.
Dedicated production area should be used for the manufacture of pathogenic
organisms (i.e. Biosafety level 3 or 4).
8. Manufacture in a multi-product facility may be acceptable where the following, or

equivalent (as appropriate to the product types involved) considerations and
measures are part of an effective control strategy to prevent cross-contamination:
(a) Knowledge of key characteristics of all cells, organisms and any
adventitious agents (e.g. pathogenicity, detectability, persistence,
susceptibility to inactivation) within the same facility.
(b) Where production is characterised by multiple small batches from different
starting materials, factors such as the health status of donors and the risk
of total loss of product should be taken into account when considering the
acceptance of concurrent working during development of the control
strategy.
(c) Live organisms and spores are prevented from entering non-related areas
or equipment by addressing all potential routes of cross-contamination and
utilizing single use components and engineering measures such as closed
systems.
(d) Control measures to remove the organisms and spores before the
subsequent manufacture of other products, these control measures should
also take the heating, ventilation and air conditioning (HVAC) system into
account. Cleaning and decontamination for the organisms and spores
should be validated.
(e) Environmental monitoring, specific for the micro-organism being
manufactured, where the micro-organisms are capable of persistence in
the manufacturing environment and where methods are available, is
conducted in adjacent areas during manufacture and after completion of
cleaning and decontamination. Attention should also be given to risks
arising with use of certain monitoring equipment (e.g. airborne particle
monitoring) in areas handling live and/or spore forming organisms.
(f) Products, equipment, ancillary equipment (e.g. for calibration and
validation) and disposable items are only moved within and removed from
such areas in a manner that prevents contamination of other areas, other
products and different product stages (e.g. prevent contamination of
inactivated or toxoided products with non-inactivated products).
(g) Campaign based manufacturing.
11 Although the title of Annex 1 refers to the manufacture of sterile medicinal products it is not the intention
to force the manufacture of sterile product at a stage when a low bioburden is appropriate and authorised.
Its use is because it is the PIC/S GMP source of guidance on all of the classified manufacturing areas
including the lower grades D and C.

9. For finishing (secondary) operations12, the need for dedicated facilities will
depend on consideration of the above together with additional considerations
such as the specific needs of the biological medicinal product and on the
characteristics of other products, including any non-biological products, in the
same facility. Other control measures for finishing operations may include the
need for specific addition sequences, mixing speeds, time and temperature
controls, limits on exposure to light and containment and cleaning procedures in
the event of spillages.
10. The measures and procedures necessary for containment (i.e. for environment
and operator safety) should not conflict with those for product quality.
11. Air handling units should be designed, constructed and maintained to minimise
the risk of cross-contamination between different manufacturing areas and may
need to be specific for an area. Consideration, based on QRM principles, should
be given to the use of single pass air systems.
12. Positive pressure areas should be used to process sterile products but negative
pressure in specific areas at the point of exposure of pathogens is acceptable for
containment reasons. Where negative pressure areas or safety cabinets are used
for aseptic processing of materials with particular risks (e.g. pathogens), they
should be surrounded by a positive pressure clean zone of appropriate grade.
These pressure cascades should be clearly defined and continuously monitored
with appropriate alarm settings.
13. Equipment used during handling of live organisms and cells, including those for
sampling, should be designed to prevent any contamination during processing.
14. Primary containment13 should be designed and periodically tested to ensure the
prevention of escape of biological agents into the immediate working
environment.
15. The use of 'clean in place' and ‘steam in place’ (‘sterilisation in place’) systems
should be used where possible. Valves on fermentation vessels should be
completely steam sterilisable.
16. Air vent filters should be hydrophobic and validated for their scheduled life span
with integrity testing at appropriate intervals based on appropriate QRM
principles.
17. Drainage systems must be designed so that effluents can be effectively

neutralised or decontaminated to minimise the risk of cross-contamination. Local
regulation must be complied with to minimise the risk of contamination of the
external environment according to the risk associated with the biohazardous
nature of waste materials.
18. Due to the variability of biological products or manufacturing processes,

relevant/critical raw materials (such as culture media and buffers) have to be
measured or weighed during the production process. In these cases, small stocks
12 Formulation, filling and packaging

13 See main GMP Glossary on ‘Containment’.

of these raw materials may be kept in the production area for a specified duration
based on defined criteria such as for the duration of manufacture of the batch or
of the campaign.
ANIMALS
19. A wide range of animal species are used in the manufacture of a number of
biological medicinal products. These can be divided into 2 broad types of
sources:
(a) Live groups, herds, flocks: examples include polio vaccine (monkeys),
immunosera to snake venoms and tetanus (horses, sheep and goats),
allergens (cats), rabies vaccine (rabbits, mice and hamsters), transgenic
products (goats, cattle).
(b) Animal materials derived post-mortem and from establishments such as
abattoirs: examples include, abattoir sources for enzymes, anticoagulants
and hormones (sheep and pigs).
In addition, animals may also be used in quality control either in generic assays,
e.g. pyrogenicity, or specific potency assays, e.g. pertussis vaccine (mice),
pyrogenicity (rabbits), BCG vaccine (guinea-pigs).
20. In addition to compliance with TSE regulations, other adventitious agents that are
of concern (zoonotic diseases, diseases of source animals) should be monitored
by an ongoing health programme and recorded. Specialist advice should be
obtained in establishing such programmes. Instances of ill-health occurring in the
source/donor animals should be investigated with respect to their suitability and
the suitability of in-contact animals for continued use (in manufacture, as sources
of starting and raw materials, in quality control and safety testing), the decisions
must be documented. A look-back procedure should be in place which informs
the decision making process on the continued suitability of the biological active
substanceor medicinal productin which the animal sourced starting or raw
materials have been used or incorporated. This decision-making process may
include the re-testing of retained samples from previous collections from the
same donor animal (where applicable) to establish the last negative donation.
The withdrawal period of therapeutic agents used to treat source/donor animals
must be documented and used to determine the removal of those animals from
the programme for defined periods.
21. Particular care should be taken to prevent and monitor infections in the source /
donor animals. Measures should include the sourcing, facilities, husbandry,
biosecurity procedures, testing regimes, control of bedding and feed materials.
This is of special relevance to specified pathogen free animals where
pharmacopoeial monograph requirements must be met. Housing and health
monitoring should be defined for other categories of animals (e.g. healthy flocks
or herds).
22. For products manufactured from transgenic animals, traceability should be

maintained in the creation of such animals from the source animals.

23. Note should be taken of national requirements on the protection of animals used
for scientific purposes14. Housing for animals used in production and control of
biological active substances and medicinal products should be separated from
production and control areas.
24. For different animal species, key criteria should be defined, monitored, and
recorded. These may include age, weight and health status of the animals.
25. Animals, biological agents, and tests carried out should be the subject of an
identification system to prevent any risk of confusion and to control all identified
hazards.
DOCUMENTATION
26. Starting and raw materials may need additional documentation on the source,
origin, distribution chain, method of manufacture, and controls applied, to assure
an appropriate level of control including their microbiological quality.
27. Some product types may require specific definition of what materials constitutes
a batch, particularly cells.
28. Where human cell or tissue donors are used, full traceability is required from
starting and raw materials, including all substances coming into contact with the
cells or tissues through to confirmation of the receipt of the products at the point
of use whilst maintaining the privacy of individuals and confidentiality of health
related information15. Traceability records must be retained for 30 years after the
expiry date of the medicinal product. Particular care should be taken to maintain
the traceability of products for special use cases, such as donor-matched cells.
National requirements16 in regards to traceability requirements and notification of
serious adverse reactions and events apply to blood components when they are
used as starting or raw materials in the manufacturing process of medicinal
products.
PRODUCTION
29. Given the variability inherent in many biological active substances and medicinal
products, steps to increase process robustness thereby reducing process
variability and enhancing reproducibility at the different stages of the product
lifecycle such as process design should be reassessed during Product Quality
Reviews.
30. Since cultivation conditions, media and reagents are designed to promote the
growth of cells or microbial organisms, typically in an axenic state, particular
attention should be paid in the control strategy to ensure there are robust steps
that prevent or minimise the occurrence of unwanted bioburden and associated
metabolites and endotoxins. For medicinal products from cells and tissues where

15 In the EEA, see Article 15 of Regulation 1394/ 2007.
16 In the EEA, these are Directives 2002/98/EC and 2005/61/EC.

production batches are frequently small the risk of cross-contamination between

cell preparations from different donors with various health status should be
controlled under defined procedures and requirements.
STARTING AND RAW MATERIALS

31. The source, origin and suitability of biological starting and raw materials (e.g.
cryoprotectants, feeder cells, reagents, culture media, buffers, serum, enzymes,
cytokines, growth factors) should be clearly defined. Where the necessary tests
take a long time, it may be permissible to process starting materials before the
results of the tests are available, the risk of using a potentially failed material and
its potential impact on other batches should be clearly understood and assessed
under the principles of QRM. In such cases, release of a finished product is
conditional on satisfactory results of these tests. The identification of all starting
materials should be in compliance with the requirements appropriate to its stage
of manufacture. For biological medicinal products further guidance can be found
in Part I and Annex 8 and for biological active substances in Part II.
32. The risk of contamination of starting and raw materials during their passage along
the supply chain must be assessed, with particular emphasis on TSE. Materials
that come into direct contact with manufacturing equipment or the product (such
as media used in media fill experiments and lubricants that may contact the
product) must also be taken into account.
33. Given that the risks from the introduction of contamination and the consequences
to the finished product is the same irrespective of the stage of manufacture,
establishment of a control strategy to protect the product and the preparation of
solutions, buffers and other additions should be based on the principles and
guidance contained in the appropriate sections of Annex 1. The controls required
for the quality of starting and raw materials and on the aseptic manufacturing
process, assume greater importance particularly for products, in respect of which
final sterilisation is not possible. Where a CTA or MA provides for an allowable
type and level of bioburden, for example at active substance stage, the control
strategy should address the means by which this is maintained within the
specified limits.
34. Where sterilisation of starting and raw materials is required, it should be carried
out where possible by heat. Where necessary, other appropriate methods may
also be used for inactivation of biological materials (e.g. irradiation and filtration).
35. Reduction in bioburden associated with procurement of living tissues and cells
may require the use of other measures such as antibiotics at early manufacturing
stages. This should be avoided, but where it is necessary their use should be
justified, they should be removed from the manufacturing process at the stage
specified in the CTA or MA.

36. The donation, procurement and testing of human tissues and cells used as
starting materials for biological medicinal products should be in accordance with
national law requirements. 17 Traceability for human tissues and cells used as
starting materials for biological medicinal products should be maintained from the
donor to the batch of a finished medicinal product. Appropriate arrangements
should be made between the manufacturer and the supplier of tissues and cells
regarding the transfer of health donor information that may become available
after the supply of the starting material and which may have an impact on the
quality or safety of the medicinal product manufactured therefrom.
(a) Their procurement, donation and testing is regulated in some countries18.
Such supply sites must hold appropriate approvals from the national
competent authority(ies) which should be verified as part of starting
material supplier management.
(b) Where such human cells or tissues are imported, they must meet
equivalent national standards of quality and safety19. The traceability and
serious adverse reaction and serious adverse event notification
requirements may be set out in national legislation20.
(c) There may be some instances where processing of cells and tissues used
as starting materials for biological medicinal products will be conducted at
tissue establishments21.
(d) Tissue and cells are released by the Responsible Person (RP) in the tissue
establishment before shipment to the medicinal product manufacturer, after
which normal medicinal product starting material controls apply. The test
results of all tissues / cells supplied by the tissue establishment should be
available to the manufacturer of the medicinal product. Such information
must be used to make appropriate material segregation and storage
decisions. In cases where manufacturing must be initiated prior to receiving
test results from the tissue establishment, tissue and cells may be shipped
to the medicinal product manufacturer provided controls are in place to
prevent cross-contamination with tissue and cells that have been released
by the RP in the tissue establishment.
(e) The transport of human tissues and cells to the manufacturing site must be
controlled by a written agreement between the responsible parties. The
manufacturing sites should have documentary evidence of adherence to
the specified storage and transport conditions.
(f) Continuation of traceability requirements started at tissue establishments
through to the recipient(s), and vice versa, including materials in contact
with the cells or tissues, should be maintained.
(g) A technical agreement should be in place between the responsible parties
(e.g. manufacturers, tissue establishment, Sponsors, MA Holder) which
defines the tasks of each party, including the RP and Authorised Person.
17 In the EEA, this is Directive 2004/23/EC or for blood-derived cells, compliance with Directive 2002/98
regarding donation, procurement and testing.
18 In the EEA, this is Directive 2004/23/EC and its Commission directives.
19 In the EEA, they must be equivalent to those laid down in Directive 2004/23/EC.
21 In the EEA, such processing steps, are under the scope of 2004/23/EC and the Responsible Person
(RP).

37. (…)22
38. Where human or animal cells are used in the manufacturing process as feeder
cells, appropriate controls over the sourcing, testing, transport and storage
should be in place23, including control of compliance with national requirements
for human cells.
SEED LOT AND CELL BANK SYSTEM

39. In order to prevent the unwanted drift of properties which might ensue from
repeated subcultures or multiple generations, the production of biological
medicinal substances and products obtained by microbial culture, cell culture or
propagation in embryos and animals should be based on a system of master and
working virus seed lots and/or cell banks.
40. The number of generations (doublings, passages) between the seed lot or cell
bank, the biological active substance and the finished product should be
consistent with specifications in the CTA or MA.
41. As part of product lifecycle management, establishment of seed lots and cell
banks, including master and working generations, should be performed under
appropriate GMP conditions. This should include an appropriately controlled
environment to protect the seed lot and the cell bank and the personnel handling
it. During the establishment of the seed lot and cell bank, no other living or
infectious material (e.g. virus, cell lines or cell strains) should be handled
simultaneously in the same area or by the same persons. For all stages prior to
the establishment of the master seed or cell bank generation, principles of GMP
may be applied. For all pre-master bank stages, documentation should be
available to support traceability. All issues related to components used during the
development with potential impact on product safety (e.g. reagents of biological
origin) from initial sourcing and genetic development should be documented. For
vaccines the requirements of pharmacopoeial monographs will apply24.
42. Following the establishment of master and working cell banks and master and
working seed lots, quarantine and release procedures should be followed. This
should include adequate characterization and testing for contaminants. Their
on-going suitability for use should be further demonstrated by the consistency of
the characteristics and quality of the successive batches of product. Evidence of
the stability and recovery of the seeds and banks should be documented and
records should be kept in a manner permitting trend evaluation.
43. Seed lots and cell banks should be stored and used in such a way as to minimize
the risks of contamination (e.g. stored in the vapour phase of liquid nitrogen in
sealed containers) or alteration. Ensuring compliance with measures for the
storage of different seeds and/or cells in the same area or equipment should
22 This line has been intentionally left blank to harmonise with the formatting structure of the EU GMP
Guide.
23 In the EEA, this includes compliance with Directive 2004/23 EC for human cells.
24 In the EEA, this is Ph Eur monograph 2005;153 “Vaccines for human use”.

prevent mix-up and take into account the infectious nature of the materials to
prevent cross contamination.
44. (…)25
45. Storage containers should be sealed, clearly labelled and kept at an appropriate
temperature. A stock inventory must be kept. The storage temperature should be
recorded continuously and, where used, the liquid nitrogen level monitored.
Deviation from set limits and corrective and preventive action taken should be
recorded.
46. It is desirable to split stocks and to store the split stocks at different locations so
as to minimize the risks of total loss. The controls at such locations should provide
the assurances outlined in the preceding paragraphs.
47. The storage and handling conditions for stocks should be managed according to
the same procedures and parameters. Once containers are removed from the
seed lot / cell bank management system, the containers should not be returned
to stock.
OPERATING PRINCIPLES
48. Change management should, on a periodic basis, take into account the effects,
including cumulative effects of changes (e.g. to the process) on the quality, safety
and efficacy of the finished product.
49. Critical operational (process) parameters, or other input parameters which affect
product quality, need to be identified, validated, documented and be shown to be
maintained within requirements.
50. A control strategy for the entry of articles and materials into production areas
should be based on QRM principles. For aseptic processes, heat stable articles
and materials entering a clean area or clean/contained area should preferably do
so through a double-ended autoclave or oven. Heat labile articles and materials
should enter through an air lock with interlocked doors where they are subject to
effective surface sanitisation procedures. Sterilisation of articles and materials
elsewhere is acceptable provided that they are multiple wrappings, as
appropriate to the number of stages of entry to the clean area, and enter through
an airlock with the appropriate surface sanitisation precautions.
51. The growth promoting properties of culture media should be demonstrated to be

suitable for its intended use. If possible, media should be sterilized in situ. In-line
sterilizing filters for routine addition of gases, media, acids or alkalis, anti-foaming
agents etc. to fermenters should be used where possible.
52. Addition of materials or cultures to fermenters and other vessels and sampling
should be carried out under carefully controlled conditions to prevent
Guide.

contamination. Care should be taken to ensure that vessels are correctly

connected when addition or sampling takes place.
53. Continuous monitoring of some production processes (e.g. fermentation) may be

necessary; such data should form part of the batch record. Where continuous
culture is used, special consideration should be given to the quality control
requirements arising from this type of production method.
54. Centrifugation and blending of products can lead to aerosol formation and
containment of such activities to minimise cross-contamination is necessary.
55. Accidental spillages, especially of live organisms, must be dealt with quickly and
safely. Qualified decontamination measures should be available for each
organism or groups of related organisms. Where different strains of single
bacteria species or very similar viruses are involved, the decontamination
process may be validated with one representative strain, unless there is reason
to believe that they may vary significantly in their resistance to the agent(s)
involved.
56. If obviously contaminated, such as by spills or aerosols, or if a potential

hazardous organism is involved, production and control materials, including
paperwork, must be adequately disinfected, or the information transferred out by
other means.
57. In cases where a virus inactivation or removal process is performed during

manufacture, measures should be taken to avoid the risk of recontamination of
treated products by non-treated products.
58. For products that are inactivated by the addition of a reagent (e.g.
micro-organisms in the course of vaccine manufacture) the process should
ensure the complete inactivation of live organism. In addition to the thorough
mixing of culture and inactivant, consideration should be given to contact of all
product-contact surfaces exposed to live culture and, where required, the transfer
to a second vessel.
59. A wide variety of equipment is used for chromatography. QRM principles should
be used to devise the control strategy on matrices, the housings and associated
equipment when used in campaign manufacture and in multi-product
environments. The re-use of the same matrix at different stages of processing is
discouraged. Acceptance criteria, operating conditions, regeneration methods,
life span and sanitization or sterilisation methods of columns should be defined.
60. Where irradiated equipment and materials are used, Annex 12 should be
consulted for further guidance.
61. There should be a system to assure the integrity and closure of containers after
filling where the final products or intermediates represent a special risk and
procedures to deal with any leaks or spillages. Filling and packaging operations
need to have procedures in place to maintain the product within any specified
limits, e.g. time and/or temperature.
62. Activities in handling vials containing live biological agents, must be performed
in such a way to prevent the contamination of other products or egress of the live

agents into the work environment or the external environment. The viability of
such organisms and their biological classification should take into consideration
as part of the management of such risks.
63. Care should be taken in the preparation, printing, storage and application of
labels, including any specific text for patient-specific product of the contents on
the immediate and outer packaging.
In the case of autologous products, the unique patient identifier and the statement
“for autologous use only” should be indicated on the outer packaging or, where
there is no outer packaging, on the immediate packaging.
64. The compatibility of labels with ultra-low storage temperatures, where such
temperatures are used, should be verified.
65. Where donor (human or animal health) information becomes available after
procurement, which affects product quality, it should be taken into account in
recall procedures.
QUALITY CONTROL
66. In-process controls have a greater importance in ensuring the consistency of the
quality of biological active substance and medicinal products than for
conventional products. In-process control testing should be performed at
appropriate stages of production to control those conditions that are important for
the quality of the finished product.
67. Where intermediates can be stored for extended periods of time (days, weeks or
longer), consideration should be given to the inclusion of finished product batches
made from materials held for their maximum in-process periods in the on-going
stability programme.
68. (…) 26
69. For cellular products, sterility tests should be conducted on antibiotic-free cultures
of cells or cell banks to provide evidence for absence of bacterial and fungal
contamination and to be able to detection fastidious organisms where
appropriate.
70. For biological medicinal products with a short shelf life, which for the purposes
of the annex is taken to mean a period that does not permit release when sterility
testing results are provided after 14 days or less, and which need batch
certification before completion of all end product quality control tests (e.g. sterility
tests) a suitable control strategy must be in place. Such controls need to be built
on enhanced understanding of product and process performance and take into
account the controls and attributes of starting and raw materials. The exact and
detailed description of the entire release procedure, including the responsibilities
of the different personnel involved in assessment of production and analytical
Guide.

data is essential. A continuous assessment of the effectiveness of the quality

assurance system must be in place including records kept in a manner which
permit trend evaluation.
Where end product tests are not available due to their short shelf life, alternative
methods of obtaining equivalent data to permit batch certification should be
considered (e.g. rapid microbiological methods). The procedure for batch
certification and release may be carried out in two or more stages:
(a) Assessment by designated person(s) of batch processing records, results

from environmental monitoring (where available) which should cover
production conditions, all deviations from normal procedures and the
available analytical results for review in preparation for the initial
certification by the Responsible Person.
(b) Assessment of the final analytical tests and other information available for
final certification by the Authorised Person. A procedure should be in place
to describe the measures to be taken (including liaison with clinical staff)
where out of specification test results are obtained. Such events should be
fully investigated and the relevant corrective and preventive actions taken
to prevent recurrence documented.
PART B: SPECIFIC GUIDANCE ON SELECTED PRODUCT

TYPES
B1. ANIMAL SOURCED PRODUCTS27

This guidance applies to animal materials which includes materials from
establishments such as abattoirs. Since the supply chains can be extensive and
complex, controls based on QRM principles need to be applied, see also
requirements of appropriate pharmacopoeial monographs, including the need for
specific tests at defined stages. Documentation to demonstrate the supply chain
traceability28 and clear roles of participants in the supply chain, typically including
a sufficiently detailed and current process map, should be in place.
1. Monitoring programmes should be in place for animal disease that are of concern
to human health. Organisations should take into account reports from trustworthy
sources on national disease prevalence when compiling their assessment of risk
and mitigation factors. Such organisations include the World Organisation for
Animal Health (OIE, Office International des Epizooties29). This should be
supplemented by information on health monitoring and control programme(s) at
national and local levels, the latter to include the sources (e.g. farm or feedlot)
from which the animals are drawn and the control measures in place during
transport to the abattoirs.
2. Where abattoirs are used to source animal tissues, they should be shown to
operate to stringent standards. Account should be taken of reports from national
27 In the EEA, see also PhEur monograph requirements, 0333

28 See PIC/S GMP Chapter 5.
29 http://www.oie.int/eng/en_index.htm

regulatory organisations30 which verify compliance with the requirements of food

safety and quality, veterinary and plant health legislation.
3. Control measures for starting or raw materials at establishments such as

abattoirs should include appropriate elements of a Quality Management System
to assure a satisfactory level of operator training, materials traceability, control
and consistency. These measures may be drawn from sources outside PIC/S
GMP but should be shown to provide equivalent levels of control.
4. Control measures for starting or raw materials should be in place which prevent
interventions which may affect the quality of materials, or which at least provides
evidence of such activities, during their progression through the manufacturing
and supply chain. This includes the movement of material between sites of initial
collection, partial and final purification(s), storage sites, hubs, consolidators and
brokers. Details of such arrangements should be recorded within the traceability
system and any breaches recorded, investigated and actions taken.
5. Regular audits of the starting or raw material supplier should be undertaken which
verify compliance with controls for materials at the different stages of
manufacture. Issues must be investigated to a depth appropriate to their
significance, for which full documentation should be available. Systems should
also be in place to ensure that effective corrective and preventive actions are
taken.
B2. ALLERGEN PRODUCTS

Materials may be manufactured by extraction from natural sources or
manufactured by recombinant DNA technology.
1. Source materials should be described in sufficient detail to ensure consistency in

their supply, e.g. common and scientific name, origin, nature, contaminant limits,
method of collection. Those derived from animals should be from healthy
sources. Appropriate biosecurity controls should be in place for colonies (e.g.
mites, animals) used for the extraction of allergens. Allergen products should be
stored under defined conditions to minimise deterioration.
2. The production process steps including pre-treatment, extraction, filtration,

dialysis, concentration or freeze-drying steps should be described in detail and
validated.
3. The modification processes to manufacture modified allergen extracts (e.g.

allergoids, conjugates) should be described. Intermediates in the manufacturing
process should be identified and controlled.
4. Allergen extract mixtures should be prepared from individual extracts from single
source materials. Each individual extract should be considered as one active
substance.
30 In the EEA, this is the Food and Veterinary Office http://ec.europa.eu/food/fvo/index_en.htm.

B.3 ANIMAL IMMUNOSERA PRODUCTS

1. Particular care should be exercised on the control of antigens of biological origin
to assure their quality, consistency and freedom from adventitious agents. The
preparation of materials used to immunise the source animals (e.g. antigens,
hapten carriers, adjuvants, stabilising agents), the storage of such material
immediately prior to immunisation should be in accordance with documented
procedures.
2. The immunisation, test bleed and harvest bleed schedules should conform to
those approved in the CTA or MA.
3. The manufacturing conditions for the preparation of antibody sub-fragments (e.g.

Fab or F(ab’)2) and any further modifications must be in accordance with
validated and approved parameters. Where such enzymes are made up of
several components, their consistency should be assured.
B.4 VACCINES
1. Where eggs are used, the health status of all source flocks used in the production
of eggs (whether specified pathogen free or healthy flocks) should be assured.
2. The integrity of containers used to store intermediate products and the hold times
must be validated.
3. Vessels containing inactivated products should not be opened or sampled in

areas containing live biological agents.
4. The sequence of addition of active ingredients, adjuvants and excipients during

the formulation of an intermediate or final product must be in compliance with
specifications.
5. Where organisms with a higher biological safety level (e.g. pandemic vaccine
strains) are to be used in manufacture or testing, appropriate containment
arrangements must be in place. The approval of such arrangements should be
obtained from the appropriate national authority(ies) and the approval documents
be available for verification.
B.5 RECOMBINANT PRODUCTS

1. Process condition during cell growth, protein expression and purification must be
maintained within validated parameters to assure a consistent product with a
defined range of impurities that is within the capability of the process to reduce
to acceptable levels. The type of cell used in production may require increased
measures to be taken to assure freedom from viruses. For production involving
multiple harvest, the period of continuous cultivation should be within specified
limits.

2. The purification processes to remove unwanted host cell proteins, nucleic acids,
carbohydrates, viruses and other impurities should be within defined validated
limits.
B6. MONOCLONAL ANTIBODY PRODUCTS

1. Monoclonal antibodies may be manufactured from murine hybridomas, human
hybridomas or by recombinant DNA technology. Control measures appropriate
to the different source cells (including feeder cells if used) and materials used to
establish the hybridoma / cell line should be in place to assure the safety and
quality of the product. It should be verified that these are within approved limits.
Freedom from viruses should be given particular emphasis. It should be noted
that data originating from products generated by the same manufacturing
technology platform may be acceptable to demonstrate suitability.
2. Criteria to be monitored at the end of a production cycle and for early termination
of production cycles should be verified that these are within approved limits.
3. The manufacturing conditions for the preparation of antibody sub-fragment (e.g.

Fab, F(ab’)2, scFv) and any further modifications (e.g. radio labelling, conjugation,
chemical linking) must be in accordance with validated parameters.
B7. TRANSGENIC ANIMAL PRODUCTS

Consistency of starting material from a transgenic source is likely to be more
problematic than is normally the case for non-transgenic biotechnology sources.
Consequently, there is an increased requirement to demonstrate batch-to-batch
consistency of product in all respects.
1. A range of species may be used to produce biological medicinal products, which

may be expressed into body fluids (e.g. milk) for collection and purification.
Animals should be clearly and uniquely identified and backup arrangements
should be put in place in the event of loss of the primary marker.
2. The arrangements for housing and care of the animals should be defined such
that they minimise the exposure of the animals to pathogenic and zoonotic
agents. Appropriate measures to protect the external environment should be
established. A health-monitoring programme should be established and all
results documented, any incident should be investigated and its impact on the
continuation of the animal and on previous batches of product should be
determined. Care should be taken to ensure that any therapeutic products used
to treat the animals do not contaminate the product.
3. The genealogy of the founder animals through to production animals must be

documented. Since a transgenic line will be derived from a single genetic founder
animal, materials from different transgenic lines should not be mixed.
4. The conditions under which the product is harvested should be in accordance

with CTA or MA conditions. The harvest schedule and conditions under which
animals may be removed from production should be performed according to
approved procedures and acceptance limits.

B8. TRANSGENIC PLANT PRODUCTS

Consistency of starting material from a transgenic source is likely to be more
problematic than is normally the case for non-transgenic biotechnology sources.
Consequently, there is an increased requirement to demonstrate batch-to-batch
consistency of product in all respects.
1. Additional measures, over and above those given in Part A, may be required to
prevent contamination of master and working transgenic banks by extraneous
plant materials and relevant adventitious agents. The stability of the gene within
defined generation numbers should be monitored.
2. Plants should be clearly and uniquely identified, the presence of key plant
features, including health status, across the crop should be verified at defined
intervals through the cultivation period to assure consistency of yield between
crops.
3. Security arrangements for the protection of crops should be defined, wherever

possible, such that they minimise the exposure to contamination by
microbiological agents and cross-contamination with non-related plants.
Measures should be in place to prevent materials such as pesticides and
fertilisers from contaminating the product. A monitoring programme should be
established and all results documented, any incident should be investigated and
its impact on the continuation of the crop in the production programme should be
determined.
4. Conditions under which plants may be removed from production should be

defined. Acceptance limits should be set for materials (e.g. host proteins) that
may interfere with the purification process. It should be verified that the results
are within approved limits.
5. Environmental conditions (temperature, rain), which may affect the quality

attributes and yield of the recombinant protein from time of planting, through
cultivation to harvest and interim storage of harvested materials should be
documented. The principles in documents such as ‘Guideline on Good
Agricultural and Collection Practice for Starting Materials of Herbal Origin’31
should be taken into account when drawing up such criteria.
GLOSSARY
See Annex 2A
31 EMA, WHO or equivalent

Annex 3 Manufacture of radiopharmaceuticals
ANNEX 3
MANUFACTURE OF RADIOPHARMACEUTICALS
PRINCIPLE
The manufacture of radiopharmaceuticals should be undertaken in accordance with
the principles of Good Manufacturing Practice for Medicinal Products Part I and
II. This annex specifically addresses some of the practices, which may be specific
for radiopharmaceuticals.
Note i. Preparation of radiopharmaceuticals in radiopharmacies (hospitals or certain

pharmacies), using Generators and Kits with a marketing authorisation or a
national licence, is not covered by this guideline, unless covered by national
requirement.
Note ii. According to radiation protection regulations it should be ensured that any
medical exposure is under the clinical responsibility of a practitioner. In diagnostic
and therapeutic nuclear medicine practices a medical physics expert should be
available.
Note iii. This annex is also applicable to radiopharmaceuticals used in clinical trials.
Note iv. Transport of radiopharmaceuticals is regulated by the International Atomic

Energy Association (IAEA) and radiation protection requirements.
Note v. It is recognised that there are acceptable methods, other than those
described in this annex, which are capable of achieving the principles of Quality
Assurance. Other methods should be validated and provide a level of Quality
Assurance at least equivalent to those set out in this annex.
INTRODUCTION
1. The manufacturing and handling of radiopharmaceuticals is potentially
hazardous. The level of risk depends in particular upon the types of radiation, the
energy of radiation and the half-lives of radioactive isotopes. Particular attention
must be paid to the prevention of cross-contamination, to the retention of
radionuclide contaminants, and to waste disposal.
2. Due to short shelf-life of their radionuclides, some radiopharmaceuticals may be

released before completion of all quality control tests. In this case, the exact
and detailed description of the whole release procedure including the
responsibilities of the involved personnel and the continuous assessment of the
effectiveness of the quality assurance system is essential.
3. This guideline is applicable to manufacturing procedures employed by industrial

manufacturers, Nuclear Centres/Institutes and PET Centres for the production
and quality control of the following types of products:

 Radiopharmaceuticals
 Positron Emitting (PET) Radiopharmaceuticals
 Radioactive Precursors for radiopharmaceutical production
 Radionuclide Generators
Type of manufacture Non - GMP * GMP part II & I (Increasing) including relevant annexes
Radiopharmaceuticals Reactor/Cyclotron Chemical Purification Processing, Aseptic or final

PET Radiopharmaceuticals Production synthesis steps formulation and sterilization
Radioactive Precursors dispensing
Radionuclide Generators Reactor/Cyclotron Processing
Production
* Target and transfer system from cyclotron to synthesis rig may be considered
as the first step of active substance manufacture.
4. The manufacturer of the final radiopharmaceutical should describe and justify the
steps for manufacture of the active substance and the final medicinal product and
which GMP (part I or II) applies for the specific process/manufacturing steps.
5. Preparation of radiopharmaceuticals involves adherence to regulations on

radiation protection.
6. Radiopharmaceuticals to be administered parenterally should comply with

sterility requirements for parenterals and, where relevant, aseptic working
conditions for the manufacture of sterile medicinal products, which are covered
in PIC/S GMP Guide, Annex 1.
7. Specifications and quality control testing procedures for the most commonly used
radiopharmaceuticals are specified in the European (or other relevant)
Pharmacopoeia or in the marketing authorisation.
Clinical Trials
8. Radiopharmaceuticals intended for use in clinical trials as investigational

medicinal products should in addition be produced in accordance with the
principles in PIC/S GMP Guide, Annex 13.
QUALITY ASSURANCE
9. Quality assurance is of even greater importance in the manufacture of
radiopharmaceuticals because of their particular characteristics, low volumes
and in some circumstances the need to administer the product before testing is
complete.
10. As with all pharmaceuticals, the products must be well protected against
contamination and cross-contamination. However, the environment and the
operators must also be protected against radiation. This means that the role of
an effective quality assurance system is of the utmost importance.

11. It is important that the data generated by the monitoring of premises and
processes are rigorously recorded and evaluated as part of the release process.
12. The principles of qualification and validation should be applied to the

manufacturing of radiopharmaceuticals and a risk management approach should
be used to determine the extent of qualification/validation, focusing on a
combination of Good Manufacturing Practice and Radiation Protection.
PERSONNEL
13. All manufacturing operations should be carried out under the responsibility of
personnel with additional competence in radiation protection. Personnel involved
in production, analytical control and release of radiopharmaceuticals should be
appropriately trained in radiopharmaceutical specific aspects of the quality
management system. The Authorised Person should have the overall
responsibility for release of the products.
14.. All personnel (including those concerned with cleaning and maintenance)
employed in areas where radioactive products are manufactured should receive
additional training adapted to this class of products. .
15. Where production facilities are shared with research institutions, the research
personnel must be adequately trained in GMP regulations and the QA function
must review and approve the research activities to ensure that they do not pose
any hazard to the manufacturing of radiopharmaceuticals.
General
16. Radioactive products should be manufactured in controlled (environmental and

radioactive) areas. All manufacturing steps should take place in self-contained
facilities dedicated to radiopharmaceuticals
17. Measures should be established and implemented to prevent cross-

contamination from personnel, materials, radionuclides etc. Closed or contained
equipment should be used whenever appropriate. Where open equipment is
used, or equipment is opened, precautions should be taken to minimize the risk
of contamination. The risk assessment should demonstrate that the
environmental cleanliness level proposed is suitable for the type of product being
manufactured.
18. Access to the manufacturing areas should be via a gowning area and should be
restricted to authorised personnel.
19. Workstations and their environment should be monitored with respect to

radioactivity, particulate and microbiological quality as established during
performance qualification (PQ).

20. Preventive maintenance, calibration and qualification programmes should be

operated to ensure that all facilities and equipment used in the manufacture of
radiopharmaceutical are suitable and qualified. These activities should be carried
out by competent personnel and records and logs should be maintained.
21. Precautions should be taken to avoid radioactive contamination within the facility.
Appropriate controls should be in place to detect any radioactive contamination,
either directly through the use of radiation detectors or indirectly through a
swabbing routine.
22. Equipment should be constructed so that surfaces that come into contact with the
product are not reactive, additive or absorptive so as to alter the quality of the
radiopharmaceutical.
23. Re-circulation of air extracted from area where radioactive products are handled
should be avoided unless justified. Air outlets should be designed to minimize
environmental contamination by radioactive particles and gases and appropriate
measures should be taken to protect the controlled areas from particulate and
microbial contamination.
24. In order to contain radioactive particles, it may be necessary for the air pressure
to be lower where products are exposed, compared with the surrounding areas.
However, it is still necessary to protect the product from environmental
contamination. This may be achieved by, for example, using barrier technology
or airlocks, acting as pressure sinks.
Sterile production
25. Sterile radiopharmaceuticals may be divided into those, which are manufactured
aseptically, and those, which are terminally sterilised. The facility should maintain
the appropriate level of environmental cleanliness for the type of operation being
performed. For manufacture of sterile products the working zone where products
or containers may be exposed to the environment, the cleanliness requirements
should comply with the requirements described in the PIC/S GMP Guide,
Annex 1.
26. For manufacture of radiopharmaceuticals a risk assessment may be applied to

determine the appropriate pressure differences, air flow direction and air quality.
27. In case of use of closed and automated systems (chemical synthesis, purification,
on-line sterile filtration) a grade C environment (usually “Hot-cell”) will be suitable.
Hot-cells should meet a high degree of air cleanliness, with filtered feed air, when
closed. Aseptic activities must be carried out in a grade A area.
28. Prior to the start of manufacturing, assembly of sterilised equipment and

consumables (tubing, sterilised filters and sterile closed and sealed vials to a
sealed fluid path) must be performed under aseptic conditions
DOCUMENTATION
29. All documents related to the manufacture of radiopharmaceuticals should be
prepared, reviewed, approved and distributed according to written procedures.

30. Specifications should be established and documented for raw materials, labelling
and packaging materials, critical intermediates and the finished
radiopharmaceutical. Specifications should also be in place for any other critical
items used in the manufacturing process, such as process aids, gaskets, sterile
filtering kits, that could critically impact on quality.
31. Acceptance criteria should be established for the radiopharmaceutical including

criteria for release and shelf life specifications (examples: chemical identity of the
isotope, radioactive concentration, purity, and specific activity).
32. Records of major equipment use, cleaning, sanitisation or sterilisation and

maintenance should show the product name and batch number, where
appropriate, in addition to the date and time and signature for the persons
involved in these activities.
33. Records should be retained for at least 3 years unless another timeframe is
specified in national requirements.
PRODUCTION
34. Production of different radioactive products in the same working area (i.e. hot-
cell, LAF unit), at the same time should be avoided in order to minimise the risk
of cross-contamination or mix-up.
35. Special attention should be paid to validation including validation of computerised

systems which should be carried out in accordance in compliance PIC/S GMP
Guide, Annex 11. New manufacturing processes should be validated
prospectively.
36. The critical parameters should normally be identified before or during validation
and the ranges necessary for reproducible operation should be defined.
37. Integrity testing of the membrane filter should be performed for aseptically filled
products, taking into account the need for radiation protection and maintenance
of filter sterility.
38. Due to radiation exposure it is accepted that most of the labelling of the direct
container, is done prior to manufacturing. Sterile empty closed vials may be
labelled with partial information prior to filling providing that this procedure does
not compromise sterility or prevent visual control of the filled vial.

QUALITY CONTROL
39. Some radiopharmaceuticals may have to be distributed and used on the basis of
an assessment of batch documentation and before all chemical and microbiology
tests have been completed.
Radiopharmaceutical product release may be carried out in two or more stages,
before and after full analytical testing:
a) Assessment by a designated person of batch processing records, which should

cover production conditions and analytical testing performed thus far, before
allowing transportation of the radiopharmaceutical under quarantine status to the
clinical department.
b) Assessment of the final analytical data, ensuring all deviations from normal
procedures are documented, justified and appropriately released prior to
documented certification by the Authorised Person. Where certain test results are
not available before use of the product, the Authorised Person should
conditionally certify the product before it is used and should finally certify the
product after all the test results are obtained.
40. Most radiopharmaceuticals are intended for use within a short time and the period
of validity with regard to the radioactive shelf-life, must be clearly stated.
41. Radiopharmaceuticals having radionuclides with long half-lives should be tested

to show, that they meet all relevant acceptance criteria before release and
certification by the Authorised Person.
42. Before testing is performed samples can be stored to allow sufficient radioactivity
decay. All tests including the sterility test should be performed as soon as
possible.
43. A written procedure detailing the assessment of production and analytical data,
which should be considered before the batch is dispatched, should be
established.
44. Products that fail to meet acceptance criteria should be rejected. If the material
is reprocessed, pre-established procedures should be followed and the finished
product should meet acceptance criteria before release. Returned products may
not be reprocessed and must be stored as radioactive waste.
45. A procedure should also describe the measures to be taken by Authorised

Person if unsatisfactory test results (Out-of-Specification) are obtained after
dispatch and before expiry. Such events should be investigated to include the
relevant corrective and preventative actions taken to prevent future events.
This process must be documented.
46. Information should be given to the clinical responsible persons, if necessary. To

facilitate this, a traceability system should be implemented for
radiopharmaceuticals.
47. A system to verify the quality of starting materials should be in place. Supplier
approval should include an evaluation that provides adequate assurance that the

material consistently meets specifications. The starting materials, packaging

materials and critical process aids should be purchased from approved suppliers.
REFERENCE AND RETENTION SAMPLES

48. For radiopharmaceuticals sufficient samples of each batch of bulk formulated
product should be retained for at least six months after expiry of the finished
medicinal product unless otherwise justified through risk management.
49. Samples of starting materials, other than solvents gases or water used in the
manufacturing process should be retained for at least two years after the release
of the product. That period may be shortened if the period of stability of the
material as indicated in the relevant specification is shorter.
50. Other conditions may be defined by agreement with the competent authority, for
the sampling and retaining of starting materials and products manufactured
individually or in small quantities or when their storage could raise special
problems.
DISTRIBUTION
51. Distribution of the finished product under controlled conditions, before all
appropriate test results are available, is acceptable for radiopharmaceuticals,
providing the product is not administered by the receiving institute until
satisfactory test results has been received and assessed by a designated person.
GLOSSARY
Preparation: handling and radiolabelling of kits with radionuclide eluted from
generators or radioactive precursors within a hospital. Kits, generators and
precursors should have a marketing authorisation or a national licence.
Manufacturing: production, quality control and release and delivery of

radiopharmaceuticals from the active substance and starting materials.
Hot–cells: shielded workstations for manufacture and handling of radioactive

materials. Hot-cells are not necessarily designed as an isolator.
Authorised person: Person recognised by the authority as having the necessary

basic scientific and technical background and experience.

Annex 4 Manufacture of veterinary medicinal products other than immunologicals
ANNEX 4
MANUFACTURE OF VETERINARY MEDICINAL

PRODUCTS OTHER THAN IMMUNOLOGICALS
MANUFACTURE OF PREMIXES FOR MEDICATED FEEDING

STUFFS
For the purposes of these paragraphs,
- a medicated feeding stuff is any mixture of a veterinary medicinal product or

products and feed or feeds which is ready prepared for marketing and intended
to be fed to animals without further processing because of its curative or
preventative properties or other properties (e.g. medical diagnosis, restoration,
correction or modification of physiological functions in animals):
- a pre-mix for medicated feeding stuffs is any veterinary medicinal product

prepared in advance with a view to the subsequent manufacture of medicated
feeding stuffs.
1. The manufacture of premixes for medicated feeding stuffs requires the use of
large quantities of vegetable matter which is likely to attract insects and rodents.
Premises should be designed, equipped and operated to minimize this risk (point
3.4.) and should also be subject to a regular pest control programme.
2. Because of the large volume of dust generated during the production of bulk
material for premixes, specific attention should be given to the need to avoid
cross contamination and facilitate cleaning (point 3.14), for example through the
installation of sealed transport systems and dust extraction, whenever possible.
The installation of such systems does not, however, eliminate the need for regular
cleaning of production areas.
3. Parts of the process likely to have a significant adverse influence on the stability
of the active ingredients) (e.g. use of steam in pellet manufacture) should be
carried out in an uniform manner from batch to batch.
4. Consideration should be given to undertake the manufacture of premixes in

dedicated areas which, if at all possible, do not form part of a main manufacturing
plant. Alternatively, such dedicated areas should be surrounded by a buffer zone
in order to minimize the risk of contamination of other manufacturing areas.

Annex 4 Manufacture of veterinary medicinal products other than immunologicals
THE MANUFACTURE OF ECTOPARASITICIDES

5. In derogation from point 3.6, ectoparasiticides for external application to animals,
which are veterinary medicinal products, and subject to marketing authorisation,
may be produced and filled on a campaign basis in pesticide specific areas.
However, other categories of veterinary medicinal products should not be
produced in such areas.
6. Adequate validated cleaning procedures should be employed to prevent cross

contamination, and steps should be taken to ensure the secure storage of the
veterinary medicinal product in accordance with the guide.
THE MANUFACTURE OF VETERINARY MEDICINAL PRODUCTS

CONTAINING PENICILLINS
7. The use of penicillins in veterinary medicine does not present the same risks of
hypersensitivity in animals as in humans. Although incidents of hypersensitivity
have been recorded in horses and dogs, there are other materials which are toxic
to certain species, e.g. the ionophore antibiotics in horses. Although desirable,
the requirements that such products be manufactured in dedicated,
self-contained facilities (point 3.6) may be dispensed with in the case of facilities
dedicated to the manufacture of veterinary medicinal products only. However, all
necessary measures should be taken to avoid cross contamination and any risk
to operator safety in accordance with the guide. In such circumstances,
penicillin-containing products should be manufactured on a campaign basis and
should be followed by appropriate, validated decontamination and cleaning
procedures.
RETENTION OF SAMPLES (POINT 1.4. VIII AND POINT 6.14.)

8. It is recognized that because of the large volume of certain veterinary medicinal
products in their final packaging, in particular premixes, it may not be feasible for
manufacturers to retain samples from each batch in its final packaging. However,
manufacturers should ensure that sufficient representative samples of each
batch are retained and stored in accordance with the guide.
9. In all cases, the container used for storage should be composed of the same
material as the market primary container in which the product is marketed.
STERILE VETERINARY MEDICINAL PRODUCTS

10. Where this has been accepted by the competent authorities, terminally sterilized
veterinary medicinal products may be manufactured in a clean area of a lower
grade than the grade required in the annex on "Sterile preparations", but at least
in a grade D environment.

Annex 5 Manufacture of immunological veterinary medicinal products
ANNEX 5
MANUFACTURE OF IMMUNOLOGICAL VETERINARY

MEDICAL PRODUCTS
PRINCIPLE
The manufacture of immunological veterinary medicinal products has special
characteristics which should be taken into consideration when implementing and
assessing the quality assurance system.
Due to the large number of animal species and related pathogenic agents, the
variety of products manufactured is very wide and the volume of manufacture is
often low; hence, work on a campaign basis is common. Moreover, because of
the very nature of this manufacture (cultivation steps, lack of terminal sterilization,
etc.), the products must be particularly well protected against contamination and
cross-contamination. The environment also must be protected especially when
the manufacture involves the use of pathogenic or exotic biological agents and
the worker must be particularly well protected when the manufacture involves the
use of biological agents pathogenic to man.
These factors, together with the inherent variability of immunological veterinary

medicinal products and the relative inefficiency in particular of final product quality
control tests in providing adequate information about products, means that the
role of the quality assurance system is of the utmost importance. The need to
maintain control over all of the following aspects of GMP, as well as those outlined
in this Guide, cannot be overemphasized. In particular, it is important that the
data generated by the monitoring of the various aspects of GMP (equipment,
premises, product etc.) are rigorously assessed and informed decisions, leading
to appropriate action, are made and recorded.
PERSONNEL
1. All personnel (including those concerned with cleaning and maintenance)
employed in areas where immunological products are manufactured should be
given training in and information on hygiene and microbiology. They should
receive additional training specific to the products with which they work.
2. Responsible personnel should be formally trained in some or all of the following

fields: bacteriology, biology, biometry, chemistry, immunology, medicine,
parasitology, pharmacy, pharmacology, virology and veterinary medicine and
should also have an adequate knowledge of environmental protection measures.

3. Personnel should be protected against possible infection with the biological

agents used in manufacture. In the case of biological agents known to cause
disease in humans, adequate measures should be taken to prevent infection of
personnel working with the agent or with experimental animals.
Where relevant, the personnel should be vaccinated and subject to medical

examination.
4. Adequate measures should be taken to prevent biological agents being taken

outside the manufacturing plant by personnel acting as a carrier. Dependent on
the type of biological agent, such measures may include complete change of
clothes and compulsory showering before leaving the production area.
5. For immunological products, the risk of contamination or cross-contamination by

personnel is particularly important.
Prevention of contamination by personnel should be achieved by a set of

measures and procedures to ensure that appropriate protective clothing is used
during the different stages of the production process.
Prevention of cross-contamination by personnel involved in production should be

achieved by a set of measures and procedures to ensure that they do not pass
from one area to another unless they have taken appropriate measures to
eliminate the risk of contamination. In the course of a working day, personnel
should not pass from areas where contamination with live microorganisms is
likely or where animals are housed to premises where other products or
organisms are handled. If such a passage is unavoidable, clearly defined
decontamination procedures, including change of clothing and shoes, and, where
necessary, showering, should be followed by staff involved in any such
production.
Personnel entering a contained area where organisms had not been handled in
open circuit operations in the previous twelve hours to check on cultures in
sealed, surface decontaminated flasks would not be regarded as being at risk of
contamination, unless the organism involved was an exotic.
PREMISES
6. Premises should be designed in such a way as to control both the risk to the
product and to the environment.
This can be achieved by the use of containment, clean, clean/contained or

controlled areas.
7. Live biological agents should be handled in contained areas. The level of

containment should depend on the pathogenicity of the microorganism and
whether it has been classified as exotic.
8. Inactivated biological agents should be handled in clean areas. Clean areas

should also be used when handling non-infected cells isolated from multicellular
organisms and, in some cases, filtration-sterilized media.

9. Open circuit operations involving products or components not subsequently

sterilized should be carried out within a laminar air flow work station (grade A) in
a grade B area.
10. Other operations where live biological agents are handled (quality control,
research and diagnostic services, etc.) should be appropriately, contained and
separated if production operations are carried out in the same building. The level
of containment should depend on the pathogenicity of the biological agent and
whether they have been classified as exotic. Whenever diagnostic activities are
carried out, there is the risk of introducing highly pathogenic organisms.
Therefore, the level of containment should be adequate to cope with all such
risks. Containment may also be required if quality control or other activities are
carried out in buildings in close proximity to those used for production.
11. Containment premises should be easily disinfected and should have the following
characteristics:
a) The absence of direct venting to the outside;
b) a ventilation with air at negative pressure. Air should be extracted through

HEPA filters and not be recirculated except to the same area, and
provided further HEPA filtration is used (normally this condition would be
met by routing the recirculated air through the normal supply HEPAs for
that area). However, recycling of air between areas may be permissible
provided that it passes through two exhaust HEPAs, the first of which is
continuously monitored for integrity, and there are adequate measures for
safe venting of exhaust air should this filter fail;
c) air from manufacturing areas used for the handling of exotic organisms
should be vented through 2 sets of HEPA filters in series, and that from
production areas not recirculated;
d) a system for the collection and disinfect ion of liquid effluents including
contaminated condensate from sterilizers, biogenerators, etc. Solid
wastes, including animal carcasses, should be disinfected, sterilized or
incinerated as appropriate. Contaminated filters should be removed using
a safe method;
e) changing rooms designed and used as air locks, and equipped with
washing and showering facilities if appropriate. Air pressure differentials
should be such that there is no flow of air between the work area and the
external environment or risk of contamination of outer clothing worn
outside the area;
f) an air lock system for the passage of equipment, which is constructed so

that there is no flow of contaminated air between the work area and the
external environment or risk of contamination of equipment within the
lock. The air lock should be of a size which enables the effective surface
decontamination of materials being passed through it. Consideration
should be given to having a timing device on the door interlock to allow
sufficient time for the decontamination process to be effective.
g) in many instances, a barrier double-door autoclave for the secure removal

of waste materials and introduction of sterile items.

12. Equipment passes and changing rooms should have an interlock mechanism or
other appropriate system to prevent the opening of more than one door at a time.
Changing rooms should be supplied with air filtered to the same standard as that
for the work area, and extracts to produce an adequate air circulation
independent of that of the work area. Equipment passes should normally be
ventilated in the same way, but unventilated passes, or those equipped with
supply air only, may be acceptable.
13. Production operations such as cell maintenance, media preparation, virus

culture, etc. likely to cause contamination should be performed in separate areas.
Animals and animal products should be handled with appropriate precautions.
14. Production areas where biological agents particularly resistant to disinfect ion
(e.g. spore-forming bacteria) are handled should be separated and dedicated to
that particular purpose until the biological agents have been inactivated.
15. With the exception of blending and subsequent filling operations, one biological
agent only should be handled at a time within an area.
16. Production areas should be designed to permit disinfect ion between campaigns,
using validated methods.
17. Production of biological agents may take place in controlled areas provided it is
carried out in totally enclosed and heat sterilized equipment, all connections
being also heat sterilized after making and before breaking. it may be acceptable
for connections to be made under local laminar air flow provided these are few in
number and proper aseptic techniques are used and there is no risk of leakage.
The sterilization parameters used before breaking the connections must be
validated for the organisms being used. Different products may be placed in
different biogenerators, within the same area, provided that there is no risk of
accidental cross-contamination. However, organisms generally subject to special
requirements for containment should be in areas dedicated to such products.
18. Animal houses where animals intended or used for production are
accommodated, should be provided with the appropriate containment and/or
clean area measures, and should be separate from other animal accommodation.
Animal houses where animals used for quality control, involving the use of
pathogenic biological agents, are accommodated, should be adequately
contained.
19. Access to manufacturing areas should be restricted to authorised personnel.

Clear and concise written procedures should be posted as appropriate.
20. Documentation relating to the premises should be readily available in a plant

master file.
The manufacturing site and buildings should be described in sufficient detail (by
means of plans and written explanations) so that the designation and conditions
of use of all the rooms are correctly identified as well as the biological agents
which are handled in them. The flow of people and product should also be clearly
marked.
The animal species accommodated in the animal houses or otherwise on the site
should be identified.

The activities carried out in the vicinity of the site should also be indicated.
Plans of contained and/or clean area premises, should describe the ventilation
system indicating inlets and outlets, filters and their specifications, the number of
air changes per hour, and pressure gradients. They should indicate which
pressure gradients are monitored by pressure indicator.
EQUIPMENT
21. The equipment used should be designed and constructed so that it meets the
particular requirements for the manufacture of each product.
Before being put into operation the equipment should be qualified and validated
and subsequently be regularly maintained and validated.
22. Where appropriate, the equipment should ensure satisfactory primary
containment of the biological agents.
Where appropriate, the equipment should be designed and constructed as to
allow easy and effective decontamination and/or sterilization.
23. Closed equipment used for the primary containment of the biological agents
should be designed and constructed as to prevent any leakage or the formation
of droplets and aerosols.
Inlets and outlets for gases should be protected so as to achieve adequate
containment e.g. by the use of sterilizing hydrophobic filters.
The introduction or removal of material should take place using a sterilizable
closed system, or possibly in an appropriate laminar air flow.
24. Equipment where necessary should be properly sterilized before use, preferably
by pressurized dry steam. other methods can be accepted if steam sterilization
cannot be used because of the nature of the equipment. It is important not to
overlook such individual items as bench centrifuges and water baths.
Equipment used for purification, separation or concentration should be sterilized
or disinfected at least between use for different products. The effect of the
sterilization methods on the effectiveness and validity of-the equipment should
be studied in order to determine the life span of the equipment.
All sterilization procedures should be validated.
25. Equipment should be designed so as to prevent any mix-up between different
organisms or products. Pipes, valves and filters should be identified as to their
function.
Separate incubators should be used for infected and non infected containers and
also generally for different organisms or cells. Incubators containing more that
one organism or cell type will only be acceptable if adequate steps are taken to
seal, surface decontaminate and segregate the containers. Culture vessels, etc.
should be individually labelled. The cleaning and disinfection of the items can be
particularly difficult and should receive special attention.

Equipment used for the storage of biological agents or products should be

designed and used in such a manner as to prevent any possible mix-up. All stored
items should be clearly and unambiguously labelled and in leak-proof containers.
Items such as cells and organisms seed stock should be stored in dedicated
equipment.
26. Relevant equipment, such as that requiring temperature control, should be fitted
with recording and/or alarm systems.
To avoid breakdowns, a system of preventive maintenance, together with trend

analyses of recorded data, should be implemented.
27. The loading of freeze driers requires an appropriate clean/contained area.
Unloading freeze driers contaminates the immediate environment. Therefore, for

single-ended freeze driers, the clean room should be decontaminated before a
further manufacturing batch is introduced into the area, unless this contains the
same organisms, and double door freeze driers should be sterilized after each
cycle unless opened in a clean area.
Sterilization of freeze driers should be done in accordance with item 23. In case
of campaign working, they should at least be sterilized after each campaign.
ANIMALS AND ANIMAL HOUSES

28. ...
29. Animal houses should be separated from the other production premises and
suitably designed.
30. The sanitary status of the animals used for production should be defined,
monitored, and recorded. Some animals should be handled as defined in specific
monographs (e.g. Specific Pathogens Free flocks).
31. Animals, biological agents, and tests carried out should be the subject of an
identification system so as to prevent any risk of confusion and to control all
possible hazards.
DISINFECTION - WASTE DISPOSAL

32. Disinfect ion and/or wastes and effluents disposal may be particularly important
in the case of manufacture of immunological products. Careful consideration
should therefore be given to procedures and equipment aiming at avoiding
environmental contamination as well as to their validation and qualification.
PRODUCTION
33. Because of the wide variety of products, the frequently large number of stages
involved in the manufacture of immunological veterinary medicinal products and
the nature of the biological processes, careful attention must be paid to

adherence to validated operating procedures, to the constant monitoring of

production at all stages and to in-process controls.
Additionally, special consideration should be given to starting materials, media

and the use of a seed lot system.
STARTING MATERIALS
34. The suitability of starting materials should be clearly defined in written
specifications. These should include details of the supplier, the method of
manufacture, the geographical origin and the animal species from which the
materials are derived. The controls to be applied to starting materials must be
included. Microbiological controls are particularly important.
35. The results of tests on starting materials must comply with the specifications.
Where the tests take a long time (e.g. eggs from SPF flocks) it may be necessary
to process starting materials before the results of analytical controls are available.
In such cases, the release of a finished product is conditional upon satisfactory
results of the tests on starting materials.
36. Special attention should be paid to a knowledge of the supplier's quality

assurance system in assessing the suitability of a source and the extent of quality
control testing required.
37. Where possible, heat is the preferred method for sterilizing starting materials. If
necessary, other validated methods, such as irradiation, may be used.
Media
38. The ability of media to support the desired growth should be properly validated in
advance.
39. Media should preferably be sterilized in situ or in line. Heat is the preferred
method. Gases, media, acids, alkalis, defoaming agents and other materials
introduced into sterile biogenerators should themselves be sterile.
Seed lot and cell bank system
40. In order to prevent the unwanted drift of properties which might ensue from
repeated subcultures or multiple generations, the production of immunological
veterinary medicinal products obtained by microbial, cell or tissue culture, or
propagation in embryos and animals, should be based on a system of seed lots
and/or cell banks.
41. The number of generations (doublings, passages) between the seed lot or cell
bank and the finished product should be consistent with the dossier of
authorisation for marketing.
42. Seed lots and cell banks should be adequately characterized and tested for
contaminants. Acceptance criteria for new seed lots should be established. Seed
lots and cell banks should be established, stored and used in such a way as to

minimize the risks of contamination, or any alteration. During the establishment

of the seed lot and cell bank, no other living or infectious material (e.g. virus or
cell lines) should be handled simultaneously in the same area or by the same
person.
43. Establishment of the seed lot and cell bank should be performed in a suitable
environment to protect the seed lot and the cell bank and, if applicable, the
personnel handling it and the external environment.
44. The origin, form and storage conditions of seed material should be described in
full. Evidence of the stability and recovery of the seeds and banks should be
provided. Storage containers should be hermetically sealed, clearly labelled and
stored at an appropriate temperature. Storage conditions should be properly
monitored. An inventory should be kept and each container accounted for.
45. Only authorised personnel should be allowed to handle the material and this
handling should be done under the supervision of a responsible person. Different
seed lots or cell banks should be stored in such a way to avoid confusion or
cross-contamination errors. It is desirable to split the seed lots and cell banks and
to store the parts at different locations so as to minimize the risk of total loss.
Operating principles
46. The formation of droplets and the production of foam should be avoided or
minimized during manufacturing processes. centrifugation and blending
procedures which can lead to droplet formation should be carried out in
appropriate contained or clean/contained areas to prevent transfer of live
organisms.
47. Accidental spillages, especially of live organisms, must be dealt with quickly and
safely. Validated decontamination measures should be available for each
organism. Where different strains of single bacteria species or very similar
viruses are involved, the process need be validated against only one of them,
unless there is reason to believe that they may vary significantly in their
resistance to the agent(s) involved.
48. Operations involving the transfer of materials such as sterile media, cultures or
product should be carried out in pre-sterilized closed systems wherever possible.
Where this is not possible, transfer operations must be protected by laminar
airflow work stations.
49. Addition of media or cultures to biogenerators and other vessels should be

carried out under carefully controlled conditions to ensure that contamination is
not introduced. Care must be taken to ensure that vessels are correctly
connected when addition of cultures takes place.
50. When necessary, for instance when two or more fermentors are within a single
area, sampling and addition ports, and connectors (after connection, before the
flow of product, and again before disconnection) should be sterilized with steam.
In other circumstances, chemical disinfection of ports and laminar air flow
protection of connections may be acceptable.

51. Equipment, glassware, the external surfaces of product containers and other
such materials must be disinfected before transfer from a contained area using a
validated method (see 47 above). Batch documentation can be a particular
problem. only the absolute minimum required to allow operations to GMP
standards should enter and leave the area. If obviously contaminated, such as
by spills or aerosols, or if the organism involved is an exotic, the paperwork must
be adequately disinfected through an equipment pass, or the information
transferred out by such means as photocopy or fax.
52. Liquid or solid wastes such as the debris after harvesting eggs, disposable culture
bottles, unwanted cultures or biological agents, are best sterilized or disinfected
before transfer from a contained area. However, alternatives such as sealed
containers or piping may be appropriate in some cases.
53. Articles and materials, including documentation, entering a production room

should be carefully controlled to ensure that only materials concerned with
production are introduced. There should be a system which ensures that
materials entering a room are reconciled with those leaving so that accumulation
of materials within the room does not occur.
54. Heat stable articles and materials entering a clean area or clean/contained area
should do so through a double-ended autoclave or oven. Heat labile articles and
materials should enter through an airlock with interlocked doors where they are
disinfected. Sterilization of articles and materials elsewhere is acceptable
provided that they are double wrapped and enter through an airlock with the
appropriate precautions.
55. Precautions must be taken to avoid contamination or confusion during incubation.

There should be a cleaning and disinfection procedure for incubators. Containers
in incubators should be carefully and clearly labelled.
56. With the exception of blending and subsequent filling operations (or when totally
enclosed systems are used) only one live biological agent may be handled within
a production room at any given time. Production rooms must be effectively
disinfected between the handling of different live biological agents.
57. Products should be inactivated by the addition of inactivant accompanied by

sufficient agitation. The mixture should then be transferred to a second sterile
vessel, unless the container is of such a size and shape as to be easily inverted
and shaken so as to wet all internal surfaces with the final culture/ inactivant
mixture.
58. Vessels containing inactivated product should not be opened or sampled in areas
containing live biological agents. All subsequent processing of inactivated
products should take place in clean areas grade A-B or enclosed equipment
dedicated to inactivated products.
59. Careful consideration should be given to the validation of methods for

sterilization, disinfection, virus removal and inactivation.
60. Filling should be carried out as soon as possible following production. Containers
of bulk product prior to filling should be sealed, appropriately labelled and stored
under specified conditions of temperature.

61. There should be a system to assure the integrity and closure of containers after
filling.
62. The capping of vials containing live biological agents must be performed in such
a way that ensures that contamination of other products or escape of the live
agents into other areas or the external environment does not occur.
63. For various reasons there may be a delay between the filling of final containers
and their labelling and packaging. Procedures should be specified for the storage
of unlabelled containers in order to prevent confusion and to ensure satisfactory
storage conditions. Special attention should be paid to the storage of heat labile
or photosensitive products. Storage temperatures should be specified.
64. For each stage of production, the yield of product should be reconciled with that
expected from that process. Any significant discrepancies should be investigated.
QUALITY CONTROL
65. In-process controls play a specially important role in ensuring the consistency of
the quality of biological medicinal products. Those controls which are crucial for
the quality (e.g. virus removal) but which cannot be carried out on the finished
product, should be performed at an appropriate stage of production.
66. It may be necessary to retain samples of intermediate products in sufficient

amount and under appropriate storage conditions to allow repetition or
confirmation of a batch control.
67. There may be a requirement for the continuous monitoring of data during a
production process, for example monitoring of physical parameters during
fermentation.
68. Continuous culture of biological products is a common practice and special

consideration needs to be given to the quality control requirements arising from
this type of production method.

Annex 6 Manufacture of medicinal gases
ANNEX 6
MANUFACTURE OF MEDICINAL GASES
PRINCIPLE
This Annex deals with the manufacture of active substance gases and the
manufacture of medicinal gases.
The delineation between the manufacture of the active substance and the
manufacture of the medicinal product should be clearly defined in each Marketing
Authorisation dossier. Normally, the production and purification steps of the gas
belong to the field of manufacture of active substances. Gases enter the
pharmaceutical field from the first storage of gas intended for such use.
Manufacture of active substance gases should comply with the Basic

Requirements of this Guide (Part II), with the relevant part of this Annex, and with
the other Annexes of the Guide if relevant.
Manufacture of medicinal gases should comply with the basic requirements of

this Guide (Part I), with the relevant part of this Annex and with the other Annexes
of the Guide if relevant.
In the exceptional cases of continuous processes where no intermediate storage

of gas between the manufacture of the active substance and the manufacture of
the medicinal product is possible, the whole process (from starting materials of
active substance to medicinal finished product) should be considered as
belonging to the pharmaceutical field. This should be clearly stated in the
Marketing Authorisation dossier.
The Annex does not cover the manufacture and handling of medicinal gases in
hospitals unless this is considered industrial preparation or manufacturing.
However, relevant parts of this Annex may be used as a basis for such activities.
Manufacture of active substance gases
Active substance gases can be prepared by chemical synthesis or be obtained

from natural sources followed by purification steps, if necessary (as for example
in an air separation plant).
1. The processes corresponding to these two methods of manufacturing active

substance gases should comply with Part II of the Basic Requirements. However:
(a) the requirements regarding starting materials for active substances (Part II,
Chapter 7) do not apply to the production of active substance gases by air
separation (however, the manufacturer should ensure that the quality of
ambient air is suitable for the established process and any changes in the
quality of ambient air do not affect the quality of the active substance gas);

(b) the requirements regarding on-going stability studies (Part II, Chapter 11.5),
which are used to confirm storage conditions and expiry/retest dates (Part II,
Chapter 11.6), do not apply in case initial stability studies have been replaced
by bibliographic data; and
(c) the requirements regarding reserve/retention samples (Part II, Chapter 11.7)
do not apply to active substance gases, unless otherwise specified.
2. The production of active substance gases through a continuous process (e.g. air
separation) should be continuously monitored for quality. The results of this
monitoring should be kept in a manner permitting trend evaluation.
3. In addition:
(a) transfers and deliveries of active substance gases in bulk should comply with
the same requirements as those mentioned below for the medicinal gases
(sections 19 to 21 of this Annex);
(b) filling of active substance gases into cylinders or into mobile cryogenic
vessels should comply with the same requirements as those mentioned
below for the medicinal gases (sections 22 to 37 of this Annex) as well as
Part II Chapter 9.
Manufacture of medicinal gases
Manufacture of medicinal gases is generally carried out in closed equipment.

Consequently, environmental contamination of the product is minimal. However,
risks of contamination (or cross contamination with other gases) may arise, in
particular because of the reuse of containers.
4. Requirements applying to cylinders should also apply to cylinders bundles

(except storage and transportation under cover).
PERSONNEL
5. All personnel involved in the manufacture and distribution of medicinal gases
should receive an appropriate GMP training applying to this type of products.
They should be aware of the critically important aspects and potential hazards
for patients from these products.
6. Personnel of subcontractors that could influence the quality of medicinal gases

(such as personnel in charge of maintenance of cylinders or valves) should be
appropriately trained.


Premises
7. Cylinders and mobile cryogenic vessels should be checked, prepared, filled and
stored in a separate area from non-medicinal gases, and there should be no
exchange of cylinders/mobile cryogenic vessels between these areas. However,
it could be accepted to check, prepare, fill and store other gases in the same
areas, provided they comply with the specifications of medicinal gases and that
the manufacturing operations are performed according to GMP standards.
8. Premises should provide sufficient space for manufacturing, testing and storage
operations to avoid the risk of mix-up. Premises should be designated to provide:
a) separate marked areas for different gases;
b) clear identification and segregation of cylinders/mobile cryogenic vessels at

various stages of processing (e.g. “waiting checking”, "awaiting filling",
"quarantine", "certified", “rejected “,“prepared deliveries”).
The method used to achieve these various levels of segregation will depend on
the nature, extent and complexity of the overall operation. Marked-out floor areas,
partitions, barriers, signs, labels or other appropriate means could be used.
9. Empty cylinders/home cryogenic vessels after sorting or maintenance, and filled

cylinders/home cryogenic vessels should be stored under cover, protected from
adverse weather conditions. Filled cylinders/mobile cryogenic vessels should be
stored in a manner that ensures that they will be delivered in a clean state,
compatible with the environment in which they will be used.
10. Specific storage conditions should be provided as required by the Marketing

Authorisation (e.g. for gas mixtures where phase separation occurs on freezing).
Equipment
11. Equipment should be designed to ensure the correct gas is filled into the correct
container. There should normally be no cross connections between pipelines
carrying different gases. If cross connections are needed (e.g. filling equipment
of mixtures), qualification should ensure that there is no risk of cross
contamination between the different gases. In addition, the manifolds should be
equipped with specific connections. These connections may be subject to
international or national standards. The use of connections meeting different
standards at the same filling site should be carefully controlled, as well as the use
of adaptors needed in some situations to bypass the specific fill connection
systems.
12. Tanks and tankers should be dedicated to a single and defined quality of gas.
However, medicinal gases may be stored or transported in the same tanks, other
containers used for intermediate storage, or tankers, as the same non-medicinal
gas, provided that the quality of the latter is at least equal to the quality of the
medicinal gas and that GMP standards are maintained. In such cases, quality
risk management should be performed and documented.

13. A common system supplying gas to medicinal and non-medicinal gas manifolds
is only acceptable if there is a validated method to prevent backflow from the non-
medicinal gas line to the medicinal gas line.
14. Filling manifolds should be dedicated to a single medicinal gas or to a given

mixture of medicinal gases. In exceptional cases, filling gases used for other
medical purposes on manifolds dedicated to medicinal gases may be acceptable
if justified and performed under control. In these cases, the quality of the non-
medicinal gas should be at least equal to the required quality of the medicinal gas
and GMP standards should be maintained. Filling should then be carried out by
campaigns.
15. Repair and maintenance operations (including cleaning and purging) of

equipment, should not adversely affect the quality of the medicinal gases. In
particular, procedures should describe the measures to be taken after repair and
maintenance operations involving breaches of the system’s integrity. Specifically
it should be demonstrated that the equipment is free from any contamination that
may adversely affect the quality of the finished product before releasing it for use.
Records should be maintained.
16. A procedure should describe the measures to be taken when a tanker is back
into medicinal gas service (after transporting non-medicinal gas in the conditions
mentioned in section 12, or after a maintenance operation). This should include
analytical testing.
DOCUMENTATION
17. Data included in the records for each batch of cylinders / mobile cryogenic
vessels must ensure that each filled cylinder is traceable to significant aspects of
the relevant filling operations. As appropriate, the following should be entered:
a) the name of the product;

b) batch number;
c) the date and the time of the filling operations;
d) identification of the person(s) carrying out each significant step (e.g. line
clearance, receipt, preparation before filling, filling etc.);
e) batch(es) reference(s) for the gas(es) used for the filling operation as referred
to in section 22, including status;
f) equipment used (e.g. filling manifold);
g) quantity of cylinders/mobile cryogenic vessels before filling, including
individual identification references and water capacity(ies);
h) pre-filling operations performed (see section 30);
i) key parameters that are needed to ensure correct fill at standard conditions;
j) results of appropriate checks to ensure the containers have been filled;
k) a sample of the batch label;

l) specification of the finished product and results of quality control tests

(including reference to the calibration status of the test equipment);
m) quantity of rejected cylinders/mobile cryogenic vessels, with individual
identification references and reasons for rejections;
n) details of any problems or unusual events, and signed authorisation for any
deviation from filling instructions; and
o) certification statement by the Authorised Person, date and signature.
18. Records should be maintained for each batch of gas intended to be delivered into
hospital tanks. These records should, as appropriate, include the following (items
to be recorded may vary depending on local legislation):
a) name of the product;

b) batch number;
c) identification reference for the tank (tanker) in which the batch is certified;
d) date and time of the filling operation;
e) identification of the person(s) carrying out the filling of the tank (tanker);
f) reference to the supplying tanker (tank), reference to the source gas as
applicable;
g) relevant details concerning the filling operation;
h) specification of the finished product and results of quality control tests
(including reference to the calibration status of the test equipment);
i) details of any problems or unusual events, and signed authorisation for any
deviation from filling instructions; and
j) certification statement by the Authorised Person, date and signature.
PRODUCTION
Transfers and deliveries of cryogenic and liquefied gas
19. The transfers of cryogenic or liquefied gases from primary storage, including
controls before transfers, should be in accordance with validated procedures
designed to avoid any contamination. Transfer lines should be equipped with
non-return valves or other suitable alternatives. Flexible connections, and
coupling hoses and connectors should be flushed with the relevant gas before
use.
20. The transfer hoses used to fill tanks and tankers should be equipped with
product-specific connections. The use of adaptors allowing the connection of
tanks and tankers not dedicated to the same gases should be adequately
controlled.
21. Deliveries of gas may be added to tanks containing the same quality of gas
provided that a sample is tested to ensure that the quality of the delivered gas is

acceptable. This sample may be taken from the gas to be delivered or from the
receiving tank after delivery.
Note: See specific arrangements in section 42 for filling of tanks retained by

customers at the customer’s premises.
Filling and labelling of cylinders and mobile cryogenic vessels
22. Before filling cylinders and mobile cryogenic vessels, a batch (batches) of gas(es)
should be determined, controlled according to specifications and approved for
filling.
23. In the case of continuous processes as those mentioned in ‘Principle’, there

should be adequate in-process controls to ensure that the gas complies with
specifications.
24. Cylinders, mobile cryogenic vessels and valves should conform to appropriate
technical specifications and any relevant requirements of the Marketing
Authorisation. They should be dedicated to a single medicinal gas or to a given
mixture of medicinal gases. Cylinders should be colour-coded according to
relevant standards. They should preferably be fitted with minimum pressure
retention valves with non-return mechanism in order to get adequate protection
against contamination.
25. Cylinders, mobile cryogenic vessels and valves should be checked before first
use in production, and should be properly maintained. Where medical devices
have gone through a conformity assessment procedure1, the maintenance should
address the medical device manufacturer’s instructions.
26. Checks and maintenance operations should not affect the quality and the safety
of the medicinal product. The water used for the hydrostatic pressure testing
carried out on cylinders should be at least of drinking quality.
27. As part of the checks and maintenance operations, cylinders should be subject
to an internal visual inspection before fitting the valve, to make sure they are not
contaminated with water or other contaminants. This should be done:
 when they are new and initially put into medicinal gas service;
 following any hydrostatic statutory pressure test or equivalent test where the
valve is removed;
 whenever the valve is replaced.
After fitting, the valve should be kept closed to prevent any contamination from
entering the cylinder. If there is any doubt about the internal condition of the
cylinder, the valve should be removed and the cylinder internally inspected to
ensure it has not been contaminated.
28. Maintenance and repair operations of cylinders, mobile cryogenic vessels and
valves are the responsibility of the manufacturer of the medicinal product. If
1
In the EU/EEA, these devices are marked «CE».

subcontracted, they should only be carried out by approved subcontractors, and

contracts including technical agreements should be established. Subcontractors
should be audited to ensure that appropriate standards are maintained.
29. There should be a system in place to ensure traceability of cylinders, mobile

cryogenic vessels and valves.
30. Checks to be performed before filling should include:

a) in the case of cylinders, a check, carried out according to defined procedure,
to ensure there is a positive residual pressure in each cylinder;
 if the cylinder is fitted with a minimum pressure retention valve, when
there is no signal indicating there is a positive residual pressure, the
correct functioning of the valve should be checked, and if the valve is
shown not to function properly the cylinder should be sent to
maintenance,
 if the cylinder is not fitted with a minimum pressure retention valve, when
there is no positive residual pressure the cylinder should be put aside for
additional measures, to make sure it is not contaminated with water or
other contaminants; additional measures could consist of internal visual
inspection followed by cleaning using a validated method;
b) a check to ensure that all previous batch labels have been removed;
c) a check that any damaged product labels have been removed and replaced;
d) a visual external inspection of each cylinder, mobile cryogenic vessel and

valve for dents, arc burns, debris, other damage and contamination with oil
or grease; cleaning should be done if necessary;
e) a check of each cylinder or mobile cryogenic vessel outlet connection to

determine that it is the proper type for the particular gas involved;
f) a check of the date of the next test to be performed on the valve (in the case
of valves that need to be periodically tested);
g) a check of the cylinders or mobile cryogenic vessels to ensure that any tests
required by national or international regulations (e.g. hydrostatic pressure
test or equivalent for cylinders) have been conducted and still is valid; and
h) a check to determine that each container is colour-coded as specified in the

Marketing Authorisation (colour-coding of the relevant national / international
standards).
31. A batch should be defined for filling operations.
32. Cylinders which have been returned for refilling should be prepared with care in
order to minimise risks for contamination in line with the procedures defined in
the Marketing Authorisation. These procedures, which should include evacuation
and/or purging operations, should be validated.

Note: For compressed gases a maximum theoretical impurity of 500 ppm v/v
should be obtained for a filling pressure of 200 bar at 15°C (and equivalent for
other filling pressures).
33. Mobile cryogenic vessels that have been returned for refilling should be prepared
with care in order to minimise the risks of contamination, in line with the
procedures defined in the Marketing Authorisation. In particular, mobile vessels
with no residual pressure should be prepared using a validated method.
34. There should be appropriate checks to ensure that each cylinder/mobile

cryogenic vessel has been properly filled.
35. Each filled cylinder should be tested for leaks using an appropriate method, prior
to fitting the tamperevident seal or device (see section 36). The test method
should not introduce any contaminant into the valve outlet and, if applicable,
should be performed after any quality sample is taken.
36. After filling, cylinders valves should be fitted with covers to protect the outlets
from contamination. Cylinders and mobile cryogenic vessels should be fitted with
tamper-evident seals or devices.
37. Each cylinder or mobile cryogenic vessel should be labelled. The batch number
and the expiry date may be on a separate label.
38. In the case of medicinal gases produced by mixing two or more different gases
(in-line before filling or directly into the cylinders); the mixing process should be
validated to ensure that the gases are properly mixed in every cylinder and that
the mixture is homogeneous.
QUALITY CONTROL
39. Each batch of medicinal gas (cylinders, mobile cryogenic vessels, hospital tanks)
should be tested in accordance with the requirements of the Marketing
Authorisation and certified.
40. Unless different provisions are required in the Marketing Authorisation, the
sampling plan and the analysis to be performed should comply, in the case of
cylinders with the following requirements.
a) In the case of a single medicinal gas filled via a multi-cylinder manifold, the
gas from at least one cylinder from each manifold filling cycle should be tested
for identity and assay each time the cylinders are changed on the manifold.
b) In the case of a single medicinal gas filled put into cylinders one at a time, the
gas from at least one cylinder of each uninterrupted filling cycle should be
tested for identity and assay. An example of an uninterrupted filling cycle is
one shift's production using the same personnel, equipment, and batch of gas
to be filled.
c) In the case of a medicinal gas produced by mixing two or more gases in a

cylinder from the same manifold, the gas from every cylinder should be tested

for assay and identity of each component gas. For excipients, if any, testing
on identity could be performed on one cylinder per manifold filling cycle (or
per uninterrupted filling cycle in case of cylinders filled one at a time). Fewer
cylinders may be tested in case of validated automated filling system.
d) Premixed gases should follow the same principles as single gases when
continuous in-line testing of the mixture to be filled is performed.
Premixed gases should follow the same principle as medicinal gases

produced by mixing gases in the cylinders when there is no continuous in-line
testing of the mixture to be filled.
Testing for water content should be performed unless otherwise justified.
Other sampling and testing procedures that provide at least equivalent level of
quality assurance may be justified
41. Unless different provisions are required in the Marketing Authorisation, final
testing on mobile cryogenic vessels should include a test for assay and identity
on each vessel. Testing by batches should only be carried out if it has been
demonstrated that the critical attributes of the gas remaining in each vessel
before refilling have been maintained.
42. Cryogenic vessels retained by customers (hospital tanks or home cryogenic

vessels), which are refilled in place from dedicated tankers do not need to be
sampled after filling, provided that a certificate of analysis on the contents of the
tanker accompanies the delivery. However, it should be demonstrated that the
specification of the gas in the vessels is maintained over the successive refillings.
43. Reference and retention samples are not required, unless otherwise specified.
44. On-going stability studies are not required in case initial stability studies have
been replaced by bibliographic data.
TRANSPORTATION OF PACKAGED GASES

45. Filled gas cylinders and home cryogenic vessels should be protected during
transportation so that, in particular, they are delivered to customers in a clean
state compatible with the environment in which they will be used.
GLOSSARY
Definition of terms relating to manufacture of medicinal gases, which are not given in the
glossary of the current PIC/S Guide to GMP, but which are used in this Annex are given
below.
Active substance gas

Any gas intended to be an active substance for a medicinal product.

Air separation
Separation of atmospheric air into its constituent gases using fractional distillation at
cryogenic temperatures.
Compressed gas
Gas which, when packaged under pressure is entirely gaseous at all temperatures above
–500 C.
Container
A container is a cryogenic vessel, (tank, tanker or other type of mobile cryogenic vessel),
a cylinder, a cylinder bundle or any other package that is in direct contact with the gas.
Cryogenic gas
Gas which liquefies at 1.013 bar at temperatures below –1500 C.
Cylinder
Container usually cylindrical suited for compressed, liquefied or dissolved gas, fitted with
a device to regulate the spontaneous outflow of gas at atmospheric pressure and room
temperature.
Cylinder bundle
An assembly of cylinders, which are fastened together interconnected by a manifold,
transported and used as a unit.
Evacuate
To remove the residual gas from a container / system to a pressure less than 1.013 bar
using a vacuum system.
Gas
Any substance that is completely gaseous at 1.013 bar and +200 C or has a vapour
pressure exceeding 3 bar at + 500 C.
Home cryogenic vessel

Mobile cryogenic vessel designed to hold liquid oxygen and dispense gaseous oxygen
at patients’ home.
Hydrostatic pressure test

Test performed as required by national or international regulations in order to ensure that
pressure containers are able to withstand pressures up to the container’s design
pressure.
Liquefied gas
A gas which, when packaged for transport, is partially liquid (or solid) at a temperature
above –500 C.
Manifold
Equipment or apparatus designed to enable one or more gas containers to be emptied
and filled at the same time.

Maximum theoretical residual impurity

Gaseous impurity coming from a possible backflow that remains after the cylinders pre-
treatment before filling. The calculation of the maximum theoretical residual impurity is
only relevant for compressed gases and supposes that these gases act as perfect gases.
Medicinal gas
Any gas or mixture of gases classified as a medicinal product.
Minimum pressure retention valve

A cylinder valve, which maintains a positive pressure above atmospheric pressure in a
gas cylinder after use, in order to prevent internal contamination of the cylinder.
Mobile cryogenic vessel

Mobile thermally insulated container designed to maintain the contents in a liquid state.
In the Annex, this term does not include the tankers.
Non-return valve
Valve which permits flow in one direction only.
Purge
To remove the residual gas from a container / system by first pressurising and then
venting the gas used for purging to 1.013 bar.
Tank
Static thermally insulated container designed for the storage of liquefied or cryogenic
gas. They are also called “Fixed cryogenic vessels”.
Tanker
In the context of the Annex, thermally insulated container fixed on a vehicle for the
transport of liquefied or cryogenic gas.
Valve
Device for opening and closing containers.
Vent
To remove the residual gas from a container / system down to 1.013 bar, by opening the
container / system to atmosphere.

Annex 7 Manufacture of herbal medicinal products
ANNEX 7
MANUFACTURE OF HERBAL MEDICINAL PRODUCTS
PRINCIPLE
Because of their often complex and variable nature, control of starting materials,
storage and processing assume particular importance in the manufacture of
herbal medicinal products.
The “starting material” in the manufacture of an herbal medicinal product1 can be

a medicinal plant, an herbal substance2 or an herbal preparation1. The herbal
substance should be of suitable quality and supporting data should be provided
to the manufacturer of the herbal preparation/herbal medicinal product. Ensuring
consistent quality of the herbal substance may require more detailed information
on its agricultural production. The selection of seeds, cultivation and harvesting
conditions represent important aspects of the quality of the herbal substance and
can influence the consistency of the finished product. Recommendations on an
appropriate quality assurance system for good agricultural and collection practice
are provided in national or international guidance documents on Good
Agricultural and Collection Practice for starting materials of herbal origin3.
This Annex applies to all herbal starting materials: medicinal plants, herbal
substances or herbal preparations.
1
Throughout the annex and unless otherwise specified, the term “herbal medicinal product / preparation”
includes “traditional herbal medicinal product / preparation”.
2 The terms herbal substance and herbal preparation are considered to be equivalent to the terms herbal
drug and herbal drug preparation respectively.
3 European Medicines Agency (EMA), World Health Organization (WHO) or equivalent.

Table illustrating the application of Good Practices to the manufacture of

herbal medicinal products 4
Activity Good Agricultural Part II of Part I of

and Collection the GMP the GMP
Practice (GACP) # Guide † Guide †
Cultivation, collection and harvesting of
plants, algae, fungi and lichens, and
collection of exudates
Cutting, and drying of plants, algae,
fungi, lichens and exudates *
Expression from plants and distillation**
Comminution, processing of exudates,
extraction from plants, fractionation,
purification, concentration or
fermentation of herbal substances
Further processing into a dosage form
including packaging as a medicinal
product
Explanatory Notes
†
..The GMP classification of the herbal material is dependent upon the use made
of it by the manufacturing authorisation holder. The material may be classified as
an active substance, an intermediate or a finished product. It is the responsibility
of the manufacturer of the medicinal product to ensure that the appropriate GMP
classification is applied.
* Manufacturers should ensure that these steps are carried out in accordance
with the marketing authorisation / registration. For those initial steps that take
place in the field, as justified in the marketing authorisation / registration, the
national or international standards of Good Agricultural and Collection Practice
for starting materials of herbal origin (GACP)# are applicable. GMP is applicable
to further cutting and drying steps.
** Regarding the expression from plants and distillation, if it is necessary for

these activities to be an integral part of harvesting to maintain the quality of the
product within the approved specifications, it is acceptable that they are
performed in the field, provided that the cultivation is in compliance with national
or international standards of GACP#. These circumstances should be regarded
as exceptional and justified in the relevant marketing authorisation / registration
documentation. For activities carried out in the field, appropriate documentation,
control, and validation according to the GMP principles should be assured.
Regulatory authorities may carry out GMP inspections of these activities in order
to assess compliance.
4 This table expands in detail the herbal section of Table 1 in Part II of the GMP Guide.
# EMA, WHO or equivalent

PREMISES
Storage areas
1. Herbal substances should be stored in separate areas. The storage area should
be equipped in such a way as to give protection against the entry of insects or
other animals, especially rodents. Effective measures should be taken to prevent
the spread of any such animals and micro-organisms brought in with the crude
substance, to prevent fermentation or mould growth and to prevent cross-
contamination. Different enclosed areas should be used to quarantine incoming
herbal substances and for the approved herbal substances.
2. The storage area should be well aerated and the containers should be located in
such a way as to allow free circulation of air.
3. Special attention should be paid to the cleanliness and good maintenance of the
storage areas particularly when dust is generated.
4. Storage of herbal substances and herbal preparations may require special

conditions of humidity, temperature or light protection; these conditions should
be provided and monitored.
Production area
5. Specific provisions should be made during sampling, weighing, mixing and

processing operations of herbal substances and herbal preparations whenever
dust is generated, to facilitate cleaning and to avoid cross-contamination, as for
example, dust extraction, dedicated premises, etc.
Equipment
6. The equipment, filtering materials etc. used in the manufacturing process must
be compatible with the extraction solvent, in order to prevent any release or
undesirable absorption of substance that could affect the product.
DOCUMENTATION
Specifications for starting materials
7. Herbal medicinal product manufacturers must ensure that they use only herbal
starting materials manufactured in accordance with GMP and the Marketing
Authorisation dossier. Comprehensive documentation on audits of the herbal
starting material suppliers carried out by, or on behalf of the herbal medicinal
product manufacturer should be made available. Audit trails for the active
substance are fundamental to the quality of the starting material. The
manufacturer should verify, where appropriate, whether the suppliers of the
herbal substance / preparation are in compliance with Good Agricultural and
Collection Practice5 and – if not – apply appropriate controls in line with Quality
Risk Management (QRM).
5
EMA, WHO or equivalent

8. To fulfil the specification requirements described in the basic requirements of the

Guide (Chapter 4), documentation for herbal substances / preparations should
include:
 the binomial scientific name of plant (genus, species, subspecies / variety and
author (e.g. Linnaeus); other relevant information such as the cultivar name
and the chemotype should also be provided, as appropriate;
 details of the source of the plant (country or region of origin and where
applicable, cultivation, time of harvesting, collection procedures, possible
pesticides used, possible radioactive contamination, etc.);
 which part(s) of the plant is/are used;
 when a dried plant is used, the drying system should be specified;
 a description of the herbal substance and its macro and microscopic
examination;
 suitable identification tests including, where appropriate, identification tests
for constituents with known therapeutic activity, or markers. Specific
distinctive tests are required where an herbal substance is liable to be
adulterated / substituted. A reference authentic specimen should be available
for identification purposes;
 the water content for herbal substances, determined in accordance with the
relevant Pharmacopoeia;
 assay of constituents of known therapeutic activity or, where appropriate, of
markers; the methods suitable to determine possible pesticide contamination
and limits accepted in accordance with relevant Pharmacopoeia methods or,
in absence of thereof, with an appropriate validated method, unless otherwise
justified;
 tests to determine fungal and/or microbial contamination, including aflatoxins,
other mycotoxins, pest-infestations and limits accepted, as appropriate;
 tests for toxic metals and for likely contaminants and adulterants, as
appropriate;
 tests for foreign materials, as appropriate;
 any other additional test according to the relevant Pharmacopoeia general
monograph on herbal substances or to the specific monograph of the herbal
substance, as appropriate.
Any treatment used to reduce fungal/microbial contamination or other infestation

should be documented. Specifications and procedures should be available and
should include details of process, tests and limits for residues.

Processing instructions
9. The processing instructions should describe the different operations carried out
upon the herbal substance such as cleaning, drying, crushing and sifting, and
include drying time and temperatures, and methods used to control cut size or
particle size.
10. In particular, there should be written instructions and records, which ensure that
each container of herbal substance is carefully examined to detect any
adulteration/substitution or presence of foreign matter, such as metal or glass
pieces, animal parts or excrement, stones, sand, etc., or rot and signs of decay.
11. The processing instructions should also describe security sieving or other
methods of removing foreign materials and appropriate procedures for
cleaning/selection of plant material before the storage of the approved herbal
substance or before the start of manufacturing.
12. For the production of an herbal preparation, instructions should include details of
solvent, time and temperatures of extraction, details of any concentration stages
and methods used.
QUALITY CONTROL
Sampling
13. Due to the fact that medicinal plant/herbal substances are heterogeneous in
nature, their sampling should be carried out with special care by personnel with
particular expertise. Each batch should be identified by its own documentation.
14. A reference sample of the plant material is necessary, especially in those cases
where the herbal substance is not described in the relevant Pharmacopoeia.
Samples of unmilled plant material are required if powders are used.
15. Quality Control personnel should have particular expertise and experience in
herbal substances, herbal preparations and/or herbal medicinal products in order
to be able to carry out identification tests and recognise adulteration, the
presence of fungal growth, infestations, non-uniformity within a delivery of crude
material, etc.
16. The identity and quality of herbal substances, herbal preparations and herbal
medicinal products should be determined in accordance with the relevant current
national or international guidance on quality and specifications of herbal
medicinal products and traditional herbal medicinal products and, where relevant,
to specific pharmacopoeial monographs.
_________________

Annex 8 Sampling of starting and packaging materials
ANNEX 8
SAMPLING OF STARTING AND PACKAGING

MATERIALS
PRINCIPLE
Sampling is an important operation in which only a small fraction of a batch is
taken. Valid conclusions on the whole cannot be based on tests which have been
carried out on non-representative samples. Correct sampling is thus an essential
part of a system of Quality Assurance.
Note: Sampling is dealt with in Chapter 6 of the Guide to GMP, items 6.11 to
6.14. These supplementary guidelines give additional guidance on the
sampling of starting and packaging materials.
PERSONNEL
1. Personnel who take samples should receive initial and on-going regular training
in the disciplines relevant to correct sampling. This training should include:
 sampling plans,
 written sampling procedures,
 the techniques and equipment for sampling,
 the risks of cross-contamination,
 the precautions to be taken with regard to unstable and/or sterile substances,
 the importance of considering the visual appearance of materials, containers
and labels,
 the importance of recording any unexpected or unusual circumstances.
STARTING MATERIALS
2. The identity of a complete batch of starting materials can normally only be
ensured if individual samples are taken from all the containers and an identity
test performed on each sample. It is permissible to sample only a proportion of
the containers where a validated procedure has been established to ensure that
no single container of starting material will be incorrectly identified on its label.

Annex 8 Sampling of starting and packaging materials
3. This validation should take account of at least the following aspects:

 nature and status of the manufacturer and of the supplier and their
understanding of the GMP requirements of the Pharmaceutical Industry;
 the Quality Assurance system of the manufacturer of the starting material;
 the manufacturing conditions under which the starting material is produced
and controlled;
 the nature of the starting material and the medicinal products in which it will
be used.
Under such arrangements, it is possible that a validated procedure exempting

identity testing of each incoming container of starting material could be accepted
for:
 starting materials coming from a single product manufacturer or plant;
 starting materials coming directly from a manufacturer or in the
manufacturer's sealed container where there is a history of reliability and
regular audits of the manufacturer's Quality Assurance system are conducted
by the purchaser (the manufacturer of the medicinal products or by an
officially accredited body.
It is improbable that a procedure could be satisfactorily validated for:

 starting materials supplied by intermediaries such as brokers where the
source of manufacture is unknown or not audited;
 starting materials for use in parenteral products.
4. The quality of a batch of starting materials may be assessed by taking and testing
a representative sample. The samples taken for identity testing could be used for
this purpose. The number of samples taken for the preparation of a
representative sample should be determined statistically and specified in a
sampling plan. The number of individual samples which may be blended to form
a composite sample should also be defined, taking into account the nature of the
material, knowledge of the supplier and the homogeneity of the composite
sample.
PACKAGING MATERIAL
5. The sampling plan for packaging materials should take account of at least the
following: the quantity received, the quality required, the nature of the material
(e.g. primary packaging materials and/or printed packaging materials), the
production methods, and the knowledge of Quality Assurance system of the
packaging materials manufacturer based on audits. The number of samples
taken should be determined statistically and specified in a sampling plan.

Annex 9 Manufacture of liquids, creams and ointments
ANNEX 9
MANUFACTURE OF LIQUIDS, CREAMS AND

OINTMENTS
PRINCIPLE
Liquids, creams and ointments may be particularly susceptible to microbial and
other contamination during manufacture. Therefore special measures must be
taken to prevent any contamination.
Note: The manufacture of liquids, creams and ointments must be done in

accordance with the GMP described in the PIC Guide to GMP and with
the other supplementary guidelines, where applicable. The present
guidelines only stress points which are specific to this manufacture.

1. The use of closed systems of processing and transfer is recommended in order
to protect the product from contamination. Production areas where the products
or open clean containers are exposed should normally be effectively ventilated
with filtered air.
2. Tanks, containers, pipework and pumps should be designed and installed so that
they may be readily cleaned and if necessary sanitised. In particular, equipment
design should include a minimum of dead-legs or sites where residues can
accumulate and promote microbial proliferation.
3. The use of glass apparatus should be avoided wherever possible. High quality
stainless steel is often the material of choice for product contact parts.
PRODUCTION
4. The chemical and microbiological quality of water used in production should be
specified and monitored. Care should be taken in the maintenance of water
systems in order to avoid the risk of microbial proliferation. After any chemical
sanitization of the water systems, a validated flushing procedure should be
followed to ensure that the sanitising agent has been effectively removed.
5. The quality of materials received in bulk tankers should be checked before they
are transferred to bulk storage tanks.
6. Care should be taken when transferring materials via pipelines to ensure that
they are delivered to their correct destination.

Annex 9 Manufacture of liquids, creams and ointments
7. Materials likely to shed fibres or other contaminants, like cardboard or wooden

pallets, should not enter the areas where products or clean containers are
exposed.
8. Care should be taken to maintain the homogeneity of mixtures, suspensions, etc.

during filling. Mixing and filling processes should be validated. Special care
should be taken at the beginning of a filling process, after stoppages and at the
end of the process to ensure that homogeneity is maintained.
9. When the finished product is not immediately packaged, the maximum period of
storage and the storage conditions should be specified and respected.

Annex 10 Manufacture of pressurised metered dose aerosol preparations for inhalation
ANNEX 10
MANUFACTURE OF PRESSURISED METERED DOSE

AEROSOL PREPARATIONS FOR INHALATION
PRINCIPLE
Manufacture of pressurised aerosol products for inhalation with metering valves
requires some special provisions arising from the particular nature of this
pharmaceutical form. It should occur under conditions which minimise microbial and
particulate contamination. Assurance of the quality of the valve components and, in
the case of suspensions, of uniformity is also of particular importance.
Note: The manufacture of metered dose aerosols must be done in accordance with
the GMP described in the PIC Guide to GMP and with the other
supplementary guidelines, where applicable. The present guidelines only
stress points which are specific to this manufacture.
GENERAL
1. There are presently two common manufacturing and filling methods as follows:
a) Two-shot system (pressure filling). The active ingredient is suspended in a

high boiling point propellant, the dose is filled into the container, the valve is
crimped on and the lower boiling point propellant is injected through the valve
stem to make up the finished product. The suspension of active ingredient in
propellant is kept cool to reduce evaporation loss.
b) One-shot process (cold filling). The active ingredient is suspended in a

mixture of propellants and held either under high pressure and/or at a low
temperature. The suspension is then filled directly into the container in one
shot.

2. Manufacture and filling should be carried out as far as possible in a closed system.
3. Where products or clean components are exposed, the area should be fed with
filtered air, should comply with the requirements of at least a Grade D environment
and should be entered through airlocks.

Annex 10 Manufacture of pressurised metered dose aerosol preparations for inhalation
PRODUCTION AND QUALITY CONTROL

4. Metering valves for aerosols are a more complex engineering article than most
pharmaceutical components. Specifications, sampling and testing should be
appropriate for this situation. Auditing the Quality Assurance system of the valve
manufacturer is of particular importance.
5. All fluids (e.g. liquid or gaseous propellants) should be filtered to remove particles
greater than 0.2 micron. An additional filtration where possible immediately before
filling is desirable.
6. Containers and valves should be cleaned using a validated procedure appropriate

to the use of the product to ensure the absence of any contaminants such as
fabrication aids (e.g. lubricants) or undue microbiological contaminants. After
cleaning, valves should be kept in clean, closed containers and precautions taken
not to introduce contamination during subsequent handling, e.g. taking samples.
Containers should be provided to the filling line in a clean condition or cleaned on
line immediately before filling.
7. Precautions should be taken to ensure uniformity of suspensions at the point of fill

throughout the filling process.
8. When a two-shot filling process is used, it is necessary to ensure that both shots are
of the correct weight in order to achieve the correct composition. For this purpose,
100% weight checking at each stage is often desirable.
9. Controls after filling should ensure the absence of undue leakage. Any leakage test
should be performed in a way which avoids microbial contamination or residual
moisture.

Annex 11 Computerised systems
ANNEX 11
COMPUTERISED SYSTEMS
PRINCIPLE
This annex applies to all forms of computerised systems used as part of a GMP
regulated activities. A computerised system is a set of software and hardware
components which together fulfil certain functionalities.
The application should be validated; IT infrastructure should be qualified.
Where a computerised system replaces a manual operation, there should be no

resultant decrease in product quality, process control or quality assurance. There
should be no increase in the overall risk of the process.
GENERAL
1. Risk Management
Risk management should be applied throughout the lifecycle of the computerised

system taking into account patient safety, data integrity and product quality. As
part of a risk management system, decisions on the extent of validation and data
integrity controls should be based on a justified and documented risk assessment
of the computerised system.
2. Personnel
There should be close cooperation between all relevant personnel such as

Process Owner, System Owner, Authorised Persons and IT. All personnel should
have appropriate qualifications, level of access and defined responsibilities to
carry out their assigned duties.
3. Suppliers and Service Providers
3.1 When third parties (e.g. suppliers, service providers) are used e.g. to provide,
install, configure, integrate, validate, maintain (e.g. via remote access), modify or
retain a computerised system or related service or for data processing, formal
agreements must exist between the manufacturer and any third parties, and
these agreements should include clear statements of the responsibilities of the
third party. IT-departments should be considered analogous.
3.2 The competence and reliability of a supplier are key factors when selecting a
product or service provider. The need for an audit should be based on a risk
assessment.
3.3 Documentation supplied with commercial off-the-shelf products should be

reviewed by regulated users to check that user requirements are fulfilled.

3.4 Quality system and audit information relating to suppliers or developers of

software and implemented systems should be made available to inspectors on
request.
PROJECT PHASE
4. Validation
4.1 The validation documentation and reports should cover the relevant steps of the
life cycle. Manufacturers should be able to justify their standards, protocols,
acceptance criteria, procedures and records based on their risk assessment.
4.2 Validation documentation should include change control records (if applicable)
and reports on any deviations observed during the validation process.
4.3 An up to date listing of all relevant systems and their GMP functionality (inventory)
should be available.
For critical systems an up-to-date system description detailing the physical and
logical arrangements, data flows and interfaces with other systems or processes,
any hardware and software pre-requisites, and security measures should be
available.
4.4 User Requirements Specifications should describe the required functions of the
computerised system and be based on documented risk assessment and GMP
impact. User requirements should be traceable throughout the life-cycle.
4.5 The regulated user should take all reasonable steps to ensure that the system
has been developed in accordance with an appropriate quality management
system. The supplier should be assessed appropriately.
4.6 For the validation of bespoke or customised computerised systems there should
be a process in place that ensures the formal assessment and reporting of quality
and performance measures for all the life-cycle stages of the system.
4.7 Evidence of appropriate test methods and test scenarios should be

demonstrated. Particularly, system (process) parameter limits, data limits and
error handling should be considered. Automated testing tools and test
environments should have documented assessments for their adequacy.
4.8 If data are transferred to another data format or system, validation should include
checks that data are not altered in value and/or meaning during this migration
process.

OPERATIONAL PHASE
5. Data
Computerised systems exchanging data electronically with other systems should

include appropriate built-in checks for the correct and secure entry and
processing of data, in order to minimize the risks.
6. Accuracy Checks
For critical data entered manually, there should be an additional check on the
accuracy of the data. This check may be done by a second operator or by
validated electronic means. The criticality and the potential consequences of
erroneous or incorrectly entered data to a system should be covered by risk
management.
7. Data Storage
7.1 Data should be secured by both physical and electronic means against damage.
Stored data should be checked for accessibility, readability and accuracy. Access
to data should be ensured throughout the retention period.
7.2 Regular back-ups of all relevant data should be done. Integrity and accuracy of
backup data and the ability to restore the data should be checked during
validation and monitored periodically.
8. Printouts
8.1 It should be possible to obtain clear printed copies of electronically stored data.
8.2 For records supporting batch release it should be possible to generate printouts
indicating if any of the data has been changed since the original entry.
9. Audit Trails
Consideration should be given, based on a risk assessment, to building into the

system the creation of a record of all GMP-relevant changes and deletions (a
system generated "audit trail"). For change or deletion of GMP-relevant data the
reason should be documented. Audit trails need to be available and convertible
to a generally intelligible form and regularly reviewed.
10. Change and Configuration Management
Any changes to a computerised system including system configurations should

only be made in a controlled manner in accordance with a defined procedure.
11. Periodic Evaluation
Computerised systems should be periodically evaluated to confirm that they

remain in a valid state and are compliant with GMP. Such evaluations should
include, where appropriate, the current range of functionality, deviation records,

incidents, problems, upgrade history, performance, reliability, security and

validation status reports.
12. Security
12.1 Physical and/or logical controls should be in place to restrict access to

computerised system to authorised persons. Suitable methods of preventing
unauthorised entry to the system may include the use of keys, pass cards,
personal codes with passwords, biometrics, restricted access to computer
equipment and data storage areas.
12.2 The extent of security controls depends on the criticality of the computerised
system.
12.3 Creation, change, and cancellation of access authorisations should be recorded.
12.4 Management systems for data and for documents should be designed to record
the identity of operators entering, changing, confirming or deleting data including
date and time.
13. Incident Management
All incidents, not only system failures and data errors, should be reported and
assessed. The root cause of a critical incident should be identified and should
form the basis of corrective and preventive actions.
14. Electronic Signature
Electronic records may be signed electronically. Electronic signatures are

expected to:
a. have the same impact as hand-written signatures within the boundaries of the
company,
b. be permanently linked to their respective record,
c. include the time and date that they were applied.
15. Batch release
When a computerised system is used for recording certification and batch

release, the system should allow only Authorised Persons to certify the release
of the batches and it should clearly identify and record the person releasing or
certifying the batches. This should be performed using an electronic signature.
16. Business Continuity
For the availability of computerised systems supporting critical processes,

provisions should be made to ensure continuity of support for those processes in
the event of a system breakdown (e.g. a manual or alternative system). The time
required to bring the alternative arrangements into use should be based on risk
and appropriate for a particular system and the business process it supports.
These arrangements should be adequately documented and tested.

17. Archiving
Data may be archived. This data should be checked for accessibility, readability
and integrity. If relevant changes are to be made to the system (e.g. computer
equipment or programs), then the ability to retrieve the data should be ensured
and tested.
GLOSSARY
Application
Software installed on a defined platform/hardware providing specific functionality.
Bespoke/Customised computerised system

A computerised system individually designed to suit a specific business process.
Commercial off-the-shelf software

Software commercially available, whose fitness for use is demonstrated by a broad
spectrum of users.
IT Infrastructure
The hardware and software such as networking software and operation systems, which
makes it possible for the application to function.
Life cycle
All phases in the life of the system from initial requirements until retirement including
design, specification, programming, testing, installation, operation, and maintenance.
Process owner
The person responsible for the business process.
System owner
The person responsible for the availability, and maintenance of a computerised system
and for the security of the data residing on that system.
Third Party
Parties not directly managed by the holder of the manufacturing and/or import
authorisation.

Annex 12 Use of ionising radiation in the manufacture of medicinal products
ANNEX 12
USE OF IONISING RADIATION IN THE MANUFACTURE

OF MEDICINAL PRODUCTS
INTRODUCTION
Ionising radiation may be used during the manufacturing process for various
purposes including the reduction of bioburden and the sterilisation of starting
materials, packaging components or products and the treatment of blood
products.
There are two types of irradiation process: Gamma irradiation from a radioactive
source and high energy Electron irradiation (Beta radiation) from an accelerator.
Gamma irradiation: two different processing modes may be employed:
(i) Batch mode: the products is arranged at fixed locations around the
radiation source and cannot be loaded or unloaded while the radiation
source is exposed.
(ii) Continuous mode: an automatic system conveys the products into the
radiation cell, past the exposed radiation source along a defined path and
at an appropriate speed, and out of the cell.
Electron irradiation: the product is conveyed past a continuous or pulsed beam

of high energy electrons (Beta radiation) which is scanned back and forth across
the product pathway.
RESPONSIBILITIES
1. Treatment by irradiation may be carried out by the pharmaceutical manufacturer
or by an operator of a radiation facility under contract (a "contract manufacturer"),
both of whom must hold an appropriate manufacturing authorisation.
2. The pharmaceutical manufacturer bears responsibility for the quality of the

product including the attainment of the objective of irradiation. The contract
operator of the radiation facility bears responsibility for ensuring that the dose of
radiation required by the manufacturer is delivered to the irradiation container (i.e.
the outermost container in which the products are irradiated).
3. The required dose including justified limits will be stated in the marketing
authorisation for the product.

DOSIMETRY
4. Dosimetry is defined as the measurement of the absorbed dose by the use of
dosimeters. Both understanding and correct use of the technique is essential for
the validation, commissioning and control of the process.
5. The calibration of each batch of routine dosimeters should be traceable to a

national or international standard. The period of validity of the calibration should
be stated, justified and adhered to.
6. The same instrument should normally be used to establish the calibration curve
of the routine dosimeters and to measure the change in their absorbance after
irradiation. If a different instrument is used, the absolute absorbance of each
instrument should be established.
7. Depending on the type of dosimeter used, due account should be taken of

possible causes of inaccuracy including the change in moisture content, change
in temperature, time elapsed between irradiation and measurement, and the dose
rate.
8. The wavelength of the instrument used to measure the change in absorbance of

dosimeters and the instrument used to measure their thickness should be subject
to regular checks of calibration at intervals established on the basis of stability,
purpose and usage.
VALIDATION OF THE PROCESS

9. Validation is the action of proving that the process, i.e. the delivery of the intended
absorbed dose to the product, will achieve the expected results. The
requirements for validation are given more fully in the note for guidance on "the
use of ionising radiation in the manufacture of medicinal products".
10. Validation should include dose mapping to establish the distribution of absorbed
dose within the irradiation container when packed with product in a defined
configuration.
11. An irradiation process specification should include at least the following:
a) details of the packaging of the product;
b) the loading pattern(s) of product within the irradiation container. Particular

care needs to be taken, when a mixture of products is allowed in the
irradiation container, that there is no underdosing of dense product or
shadowing of other products by dense product. Each mixed product
arrangement must be specified and validated;
c) the loading pattern of irradiation containers around the source (batch

mode) or the pathway through the cell (continuous mode);
d) maximum and minimum limits of absorbed dose to the product [and

associated routine dosimetry];

e) maximum and minimum limits of absorbed dose to the irradiation

container and associated routine dosimetry to monitor this absorbed
dose;
f) other process parameters, including dose rate, maximum time of

exposure, number of exposures, etc.
When irradiation is supplied under contract at least parts (d) and (e) of the
irradiation process specification should form part of that contract.
COMMISSIONING OF THE PLANT

General
12. Commissioning is the exercise of obtaining and documenting evidence that the
irradiation plant will perform consistently within predetermined limits when
operated according to the process specification. In the context of this annex,
predetermined limits are the maximum and minimum doses designed to be
absorbed by the irradiation container. It must not be possible for variations to
occur in the operation of the plant which give a dose to the container outside
these limits without the knowledge of the operator.
13. Commissioning should include the following elements:
a. Design
b. Dose mapping;
c. Documentation;
d. Requirement for re-commissioning.
Gamma irradiators
Design
14. The absorbed dose received by a particular part of an irradiation container at any
specific point in the irradiator depends primarily on the following factors:
a) the activity and geometry of the source;

b) the distance from source to container;
c) the duration of irradiation controlled by the timer setting or conveyor
speed;
d) the composition and density of material, including other products,
between the source and the particular part of the container.
15. The total absorbed dose will in addition depend on the path of containers through
a continuous irradiator or the loading pattern in a batch irradiator, and on the
number of exposure cycles.

16. For a continuous irradiator with a fixed path or a batch irradiator with a fixed
loading pattern, and with a given source strength and type of product, the key
plant parameter controlled by the operator is conveyor speed or timer setting.
Dose Mapping
17. For the dose mapping procedure, the irradiator should be filled with irradiation
containers packed with dummy products or a representative product of uniform
density. Dosimeters should be placed throughout a minimum of three loaded
irradiation containers which are passed through the irradiator, surrounded by
similar containers or dummy products. If the product is not uniformly packed,
dosimeters should be placed in a larger number of containers.
18. The positioning of dosimeters will depend on the size of the irradiation container.
For example, for containers up to 1 x 1 x 0.5 m, a three-dimensional 20 cm grid
throughout the container including the outside surfaces might be suitable. If the
expected positions of the minimum and maximum dose are known from a
previous irradiator performance characterisation, some dosimeters could be
removed from regions of average dose and replaced to form a 10 cm grid in the
regions of extreme dose.
19. The results of this procedure will give minimum and maximum absorbed doses
in the product and on the container surface for a given set of plant parameters,
product density and loading pattern.
20. Ideally, reference dosimeters should be used for the dose mapping exercise
because of their greater precision. Routine dosimeters are permissible but it is
advisable to place reference dosimeters beside them at the expected positions
of minimum and maximum dose and at the routine monitoring position in each of
the replicate irradiation containers. The observed values of dose will have an
associated random uncertainty which can be estimated from the variations in
replicate measurements.
21. The minimum observed dose, as measured by the routine dosimeters, necessary
to ensure that all irradiation containers receive the minimum required dose will
be set in the knowledge of the random variability of the routine dosimeters used.
22. Irradiator parameters should be kept constant, monitored and recorded during
dose mapping. The records, together with the dosimetry results and all other
records generated, should be retained.
Electron Beam Irradiators

Design
23. The absorbed dose received by a particular portion of an irradiated product

depends primarily on the following factors:
a) the characteristics of the beam, which are: electron energy, average

beam current, scan width and scan uniformity;
b) the conveyor speed;
c) the product composition and density;

d) the composition, density and thickness of material between the output

window and the particular portion of product;
e) the output window to container distance.
24. Key parameters controlled by the operator are the characteristics of the beam
and the conveyor speed.
Dose Mapping
25. For the dose mapping procedure, dosimeters should be placed between layers
of homogeneous absorber sheets making up a dummy product, or between
layers of representative products of uniform density, such that at least ten
measurements can be made within the maximum range of the electrons.
Reference should also be made to sections 18 to 21.
26. Irradiator parameters should be kept constant, monitored and recorded during
dose mapping. The records, together with the dosimetry results and all other
records generated, should be retained.
Re-commissioning
27. Commissioning should be repeated if there is a change to the process or the

irradiator which could affect the dose distribution to the irradiation container (e.g.
change of source pencils). The extent to re-commissioning depends on the extent
of the change in the irradiator or the load that has taken place. If in doubt, re-
commission.
PREMISES
28. Premises should be designed and operated to segregate irradiated from non-
irradiated containers to avoid their cross-contamination. Where materials are
handled within closed irradiation containers, it may not be necessary to segregate
pharmaceutical from non-pharmaceutical materials, provided there is no risk of
the former being contaminated by the latter.
Any possibility of contamination of the products by radionuclide from the source

must be excluded.
PROCESSING
29. Irradiation containers should be packed in accordance with the specified loading
pattern(s) established during validation.
30. During the process, the radiation dose to the irradiation containers should be
monitored using validated dosimetry procedures. The relationship between this
dose and the dose absorbed by the product inside the container must have been
established during process validation and plant commissioning.

31. Radiation indicators should be used as an aid to differentiating irradiated from

non-irradiated containers. They should not be used as the sole means of
differentiation or as an indication of satisfactory processing.
32. Processing of mixed loads of containers within the irradiation cell should only be
done when it is known from commissioning trials or other evidence that the
radiation dose received by individual containers remains within the limits
specified.
33. When the required radiation dose is by design given during more than one
exposure or passage through the plant, this should be with the agreement of the
holder of the marketing authorisation and occur within a predetermined time
period. Unplanned interruptions during irradiation should be notified to the holder
of the marketing authorisation if this extends the irradiation process beyond a
previously agreed period.
34. Non-irradiated products must be segregated from irradiated products at all times.
Methods or doing this include the use of radiation indicators (31.) and appropriate
design of premises (28.).
Gamma irradiators
35. For continuous processing modes, dosimeters should be placed so that at least
two are exposed in the irradiation at all times.
36. For batch modes, at least two dosimeters should be exposed in positions related
to the minimum dose position.
37. For continuous process modes, there should be a positive indication of the
correct position of the source and an interlock between source position and
conveyor movement. Conveyor speed should be monitored continuously and
recorded.
38. For batch process modes source movement and exposure times for each batch
should be monitored and recorded.
39. For a given desired dose, the timer setting or conveyor speed requires
adjustment for source decay and source additions. The period of validity of the
setting or speed should be recorded and adhered to.
Electron Beam Irradiators
40. A dosimeter should be placed on every container.
41. There should be continuous recording of average beam current, electron energy,
scan-width and conveyor speed. These variables, other than conveyor speed,
need to be controlled within the defined limits established during commissioning
since they are liable to instantaneous change.

DOCUMENTATION
42. The numbers of containers received, irradiated and dispatched should be
reconciled with each other and with the associated documentation. Any
discrepancy should be reported and resolved.
43. The irradiation plant operator should certify in writing the range of doses received
by each irradiated container within a batch or delivery.
44. Process and control records for each irradiation batch should be checked and
signed by a nominated responsible person and retained. The method and place
or retention should be agreed between the plant operator and the holder of the
marketing authorisation.
45. The documentation associated with the validation and commissioning of the plant
should be retained for one year after the expiry date or at least five years after
the release of the last product processed by the plant, whichever is the longer.
MICROBIOLOGICAL MONITORING
46. Microbiological monitoring is the responsibility of the pharmaceutical
manufacturer. It may include environmental monitoring where product is
manufactured and pre-irradiation monitoring of the product as specified in the
marketing authorisation.

Annex 13 Manufacture of investigational medicinal products
ANNEX 13
MANUFACTURE OF INVESTIGATIONAL
MEDICINAL PRODUCTS
INTRODUCTION
These guidelines lay down appropriate tools to address specific issues
concerning investigational medicinal products with regard to good manufacturing
practice. The tools are flexible to provide for changes as knowledge of the
process increases and appropriate to the stage of development of the product.
An investigational medicinal product is a pharmaceutical form of an active

substance or placebo being tested or used as a reference in a clinical trial,
including a product with a marketing authorisation when used or assembled
(formulated or packaged) in a way different from the authorised form, or when
used for an unauthorised indication, or when used to gain further information
about the authorised form.
Unless otherwise defined in national law, manufacturing is defined as total and

partial manufacture, as well as the various processes of dividing up, packaging
and labelling (including blinding).
Investigational medicinal products shall be manufactured by applying

manufacturing practices which ensure the quality of such medicinal products in
order to safeguard the safety of the subject and the reliability and robustness of
clinical data generated in the clinical trial ("good manufacturing practice").
The good manufacturing practice requirements for investigational medicinal

products are set out in these guidelines. Various other parts of the PIC/S GMP
Guide provide useful guidance also and they should be considered.
Procedures need to be flexible to provide for changes as knowledge of the

process increases and appropriate to the stage of development of the products.
In clinical trials there may be added risk to the subjects compared to patients
treated with authorised medicinal products. The application of good
manufacturing practice for the manufacture and import of investigational
medicinal products is intended to ensure that subjects are not placed at undue
risk, and that the results of clinical trials are unaffected by inadequate quality,
safety or efficacy arising from unsatisfactory manufacture or import. (Note: the
reference to ‘Import’ here and in other parts of this annex refers to importation
activities into the relevant country, which should be performed in accordance with
applicable national laws/requirements.) Equally, it is intended to ensure that there
is consistency between batches of the same investigational medicinal product
used in the same or different clinical trials and that changes during the
development of an investigational medicinal product are adequately documented
and justified.

The production of investigational medicinal products involves added complexity

in comparison with authorised medicinal products by virtue of lack of fixed
routines, variety of clinical trial designs and consequent packaging designs.
Randomisation and blinding add to that complexity an increased risk of product
cross-contamination and mix-up. Furthermore, there may be incomplete
knowledge of the potency and toxicity of the product and a lack of full process
validation. Moreover, authorised products may be used which have been re-
packaged or modified in some way. These challenges require personnel with a
thorough understanding of and training in the application of good manufacturing
practice to investigational medicinal products. The increased complexity in
manufacturing operations requires a highly effective quality system.
For manufacturers to be able to apply and comply with good manufacturing

practice for investigational medicinal products, co-operation between
manufacturers and sponsors of clinical trials is required. This co-operation should
be described in a technical agreement between the sponsor and manufacturer.
1. SCOPE
These guidelines apply to manufacture or import of investigational medicinal
products for human use.
Reconstitution of investigational medicinal products is not considered

manufacturing, unless otherwise subject to national law, and therefore is not
covered by this guideline.
The reconstitution is understood as the simple process of dissolving or dispersing

the investigational medicinal product for administration of the product to a trial
subject, or diluting or mixing the investigation medicinal product with some other
substance(s) used as a vehicle for the purpose of administering it to a trial
subject.
Reconstitution is not mixing several ingredients, including the active substance,

together to produce the investigational medicinal product. An investigational
medicinal product must exist before a process can be defined as reconstitution.
The process of reconstitution has to be undertaken as close in time as possible

to administration and has to be defined in the clinical trial application dossier and
document available at the clinical trial site.
While these guidelines do not apply to the activities listed below, PIC/S
Participating Authorities should, in accordance with national law, make those
processes subject to appropriate and proportionate requirements to ensure
subject safety and reliability and robustness of the data generated in the clinical
trial:
 Re-labelling or re-packaging, where those processes are carried out in

hospitals, health centres or clinics, by pharmacists or other persons legally
authorised in the country concerned to carry out such processes, and if
the investigational medicinal products are intended to be used exclusively
in hospitals, health centres or clinics taking part in the same clinical trial
in the same country;

 The preparation of radiopharmaceuticals used as diagnostic

investigational medicinal products where this process is carried out in
hospitals, health centres or clinics, by pharmacists or other persons legally
authorised in the country concerned to carry out such processes, and
where the investigational medicinal products are intended to be used
exclusively in hospitals, health centres or clinics taking part in the same
clinical trial in the same country;
 The preparation of medicinal products for use as investigational medicinal

products, where this process is carried out in hospitals, health centres or
clinics legally authorised in the country concerned to carry out such
process and where the investigational medicinal products are intended to
be used exclusively in hospitals, health centres or clinics taking part in the
same clinical trial in the same country.
2. PHARMACEUTICAL QUALITY SYSTEM

The pharmaceutical quality system which is designed, set-up and verified by the
manufacturer should be described in written procedures, taking into account the
guidance in Chapter 1 of Part 1 of the PIC/S GMP Guide, as applicable, to
investigational medicinal products.
The product specifications and manufacturing instructions may be changed

during development, but full control and traceability of the changes should be
documented and maintained. Deviations from any predefined specifications and
instructions should be registered, investigated and corrective and preventive
action measures initiated as appropriate.
The selection, qualification, approval and maintenance of suppliers of starting

materials, together with their purchase and acceptance, should be documented
as part of the pharmaceutical quality system to ensure the integrity of the supply
chain and protect against falsified products. The level of supervision should be
proportionate to the risks posed by the individual materials, taking into account
their source, manufacturing process, supply chain complexity and the final use to
which the material is put in the investigational medicinal product. The supporting
evidence for each supplier approval and material approval should be documented
and maintained.
2.1. Product specification file

1. The product specification file brings together and contains all of the essential
reference documents to ensure that investigational medicinal products are
manufactured according to good manufacturing practice for investigational
medicinal products and the clinical trial authorisation. The product
specification file is one of the essential elements of the pharmaceutical quality
system.
2. Applicable sections of the product specification file should be available at the

start of manufacturing of the first batch of the investigational medicinal
product for use in a clinical trial.

3. The product specification file should be continually updated as development

of the product proceeds, ensuring appropriate traceability to the previous
versions. It should include, or refer to, at least the following documents:
i. specifications and analytical methods for starting materials,

packaging materials, intermediate product, bulk product and finished
product;
ii. manufacturing methods;
iii. in-process testing and methods;
iv. approved label copy;
v. relevant clinical trial authorisations and amendments thereof, clinical
trial protocol and randomisation codes, as appropriate;
vi. relevant technical agreements with contract givers and acceptors,
as appropriate;
vii. stability plan and reports;
viii. details of plans and arrangements for reference and retention
samples;
ix. storage and transport conditions; and
x. details of the supply chain including manufacturing, packaging,
labelling and testing sites for the investigational medicinal products,
preferably in the format of a comprehensive diagram.
4. This list of documents is neither exhaustive nor exclusive.
5. The contents of the product specification file will vary depending on the
product and the stage of development.
6. Where different manufacturing steps are carried out at different locations

under the responsibility of different Authorised Persons, it is acceptable to
maintain separate files limited to information of relevance to the activities at
the respective locations. The manufacturing site should have access to the
necessary documentation of the product specification file, including changes,
to enable the relevant activities to be performed.
3. PERSONNEL
1. The guidance in Chapter 2 of Part 1 of the PIC/S GMP Guide should be taken
into account, as appropriate, in relation to the manufacture of investigational
medicinal products.
2. All personnel involved with the manufacture, import, storage or handling of

investigational medicinal products should be appropriately trained in the
requirements specific to these types of product.
3. Even where the number of staff involved in the manufacturing or import of

investigational medicinal products is small, there should be, for each batch,
separate people responsible for production and quality control.
4. The Authorised Person who certifies the finished batch of investigational

medicinal products for use in the clinical trial should ensure that there are
systems in place that meet the requirements of good manufacturing practice
and should have a broad knowledge of pharmaceutical development, clinical
trial processes and supply chain of the batch concerned.
4. PREMISES AND EQUIPMENT

1. The toxicity, potency or sensitising potential may not be fully understood for
investigational medicinal products and this reinforces the need to minimise all
risks of cross-contamination. The design of equipment and premises,
inspection/test methods and acceptance limits to be used after cleaning
should reflect the nature of these risks and take account of the quality risk
management principles detailed in Chapters 3 and 5 of Part 1 of the PIC/S
GMP Guide.
2. Consideration should be given to campaign manufacturing, where

appropriate. Account should be taken of the solubility of the product in
decisions about the choice of cleaning solvent.
3. A quality risk management process, which includes a potency and

toxicological evaluation, should be used to assess and control the cross-
contamination risks presented by the investigational medicinal products
manufactured. Factors that should be taken into account include:
i. facility/equipment design and use;

ii. personnel and material flow;
iii. microbiological controls;
iv. physio-chemical characteristics of the active substance;
v. process characteristics;
vi. cleaning processes;
vii. analytical capabilities relative to the relevant limits established from
the evaluation of the investigational medicinal products.
4. Premises and equipment are expected to be qualified in accordance with

Annex 15 to the PIC/S GMP Guide.
5. DOCUMENTATION
1. Documentation should be generated and controlled in line with the principles
detailed in the PIC/S GMP Guide, Part I, Chapter 4. The retention period for
instructions and records required to demonstrate compliance with good
manufacturing practice should be defined according to the type of document
while complying with any relevant national laws. The documentation shall be
consistent with the Product Specification File. Documents which are part of
the Product Specification File shall be retained for the period of at least 5
years, unless otherwise specified in relevant national laws.
2. The sponsor may have specific responsibilities for document retention of the
clinical trial master file according to relevant national laws but unless

otherwise specified in national laws, should retain such documentation for at

least 25 years after the end of the trial. If the sponsor and the manufacturer
are not the same entity, the sponsor has to make appropriate arrangements
with the manufacturer to fulfil the sponsor’s requirement to retain the clinical
trial master file. Arrangement for retention of such documents and the type of
documents to be retained should be defined in an agreement between the
sponsor and manufacturer.
5.1 Specification and instructions

1. Specifications for starting materials, immediate packaging materials,
intermediate products, bulk products and finished products, manufacturing
formulae and processing and packing instructions should be as
comprehensive as possible given the current state of knowledge. They should
be re-assessed during development and updated as necessary. Each new
version should take into account the latest data, current technology used,
regulatory and pharmacopoeial developments and should allow traceability
to the previous document. Any changes should be carried out according to a
written procedure which should address any implications for product quality
such as stability and bioequivalence. The approval process for instructions
and changes thereof shall include responsible personnel at the manufacturing
site.
2. Rationales for changes should be recorded and the consequences of a

change on product quality and on any on-going clinical trials should be
investigated and fully documented.
5.2 Order
The manufacturer should retain the order for the investigational medicinal product
as part of the batch documentation. The order should request the processing
and/or packaging of a certain number of units and/or their distribution and be
given by or on behalf of the sponsor to the manufacturer. The order should be in
writing, though it may be transmitted by electronic means, and be precise enough
to avoid any ambiguity. It should be formally authorised by the sponsor or his
representative and refer to the product specification file and the relevant clinical
trial protocol as appropriate.
5.3 Manufacturing formulae and processing instructions

1. For every manufacturing operation or supply there should be clear and
adequate written instructions and written records which are prepared using
the specific clinical study information detailed in the product specification file.
Records are particularly important for the preparation of the final version of
the documents to be used in routine manufacture once the marketing
authorisation is granted.
2. The relevant information in the product specification file should be used to

draft the detailed written instructions on processing, packaging, quality control
testing, and storage, including storage conditions.

5.4 Packaging instructions

1. Investigational medicinal products are normally packed in an individual way
for each subject included in the clinical trial. The number of units to be
packaged should be specified prior to the start of the packaging operations,
including units necessary for carrying out quality control and for any retention
samples to be kept. Sufficient reconciliations should take place to ensure that
the correct quantity of each product required has been accounted for at each
stage of processing.
2. Procedures should describe the specification, generation, testing, security,

distribution, handling and retention of any randomisation code used for
packaging investigational medicinal products as well as code-break
mechanism. Appropriate records should be maintained.
5.5 Batch records

1. Batch records should be kept in sufficient detail for the sequence of
operations to be accurately determined. These records should contain any
relevant remarks which justify procedures used and any changes made,
enhance knowledge of the product, develop the manufacturing operations
and document deviations from predefined requirements.
2. Batch manufacturing records should be retained by the manufacturer for at

least 5 years after the completion or formal discontinuation of the last clinical
trial in which the batch was used, or in accordance with the requirements of
national laws.
6. PRODUCTION
6.1. Packaging materials

Specifications and quality control checks should include measures to guard
against unintentional unblinding due to changes in appearance between different
batches of packaging materials.
6.2. Manufacturing operations

1. During development critical parameters should be identified and in-process
controls primarily used to control the process. Provisional production
parameters and in-process controls may be deduced from prior experience,
including that gained from earlier development work. Careful consideration by
key personnel is called for in order to formulate the necessary instructions
and to adapt them continually to the experience gained in production.
Parameters identified and controlled should be justifiable based on
knowledge available at the time.
2. The manufacturing process is not required to be validated to the extent

necessary for routine production but shall be validated in its entirety, as far
as is appropriate, taking into account the stage of product development. The
validation should be documented in accordance with the requirements

detailed in Annex 15 of the PIC/S GMP Guide. The manufacturer shall identify
the process steps that safeguard the safety of the subject and the reliability
and robustness of the clinical trial data generated in the clinical study.
3. To avoid cross-contamination, written cleaning procedures and analytical

methods to verify the cleaning process should be available.
4. For sterile products, the validation of controls and processes related to

assurance of sterility should be of the same standards as for authorised
medicinal products and take account of the principles for the manufacture of
sterile medicinal products as detailed in Annex 1 to the PIC/S GMP Guide.
Likewise, when required, virus inactivation/removal and removal of other
impurities of biological origin should be demonstrated, to assure the safety of
biotechnologically derived and biological products by following the scientific
principles and techniques defined in the available guidance in this area.
5. Validation of aseptic processes presents special problems where the batch

size is small; in these cases, the number of units filled may be the maximum
number filled in production. If practicable, and otherwise consistent with
simulating the process, a larger number of units should be filled with media
to provide greater confidence in the results obtained. Filling and sealing is
often a manual or semi-automated operation presenting great challenges to
sterility, so enhanced attention should be given to operator training and
validating the aseptic technique of individual operators.
6.3. Modification of comparator products

1. If a product is modified, data should be available (e.g. stability, comparative
dissolution or bioavailability) to demonstrate that these changes do not
significantly alter the original quality characteristics of the product.
2. The expiry date stated for the comparator product in its original packaging
might not be applicable to the product where it has been repackaged in a
different container that may not offer equivalent protection, or be compatible
with the product. A suitable retest date, taking into account the nature of the
product, the characteristics of the container and the storage conditions to
which the product may be subjected, should be determined by or on behalf of
the sponsor. Such a date should be justified and must not be later than the
expiry date of the original package. There should be compatibility of expiry
dating and clinical trial duration.
3. A reference sample of comparator product, which has been repackaged or

over encapsulated for blinding purposes, should be taken at a point
representative of the additional processing and retained, as the additional
processing step could have an impact on stability or be needed for
identification purposes in the event of a quality defect investigation, which
would not be covered by the commercial retained sample.
6.4 Blinding operations

1. Where products are blinded, systems should be in place to ensure that the
blind is achieved and maintained while allowing for identification of "blinded"

products, when necessary, including batch numbers of the products before

the blinding operation. Rapid identification of product should also be possible
in an emergency. Where the manufacturer has been delegated the
responsibility for generation of randomisation codes, the manufacturer should
enable that unblinding information is available to the appropriate responsible
investigator site personnel before investigational medicinal products are
supplied.
2. Where products are blinded, the expiry date assigned to all products should
be stated at the expiry of the shortest dated product so that the blinding is
maintained.
6.5 Packaging
1. During packaging of investigational medicinal products, it may be necessary
to handle different products on the same packaging line at the same time.
The risk of product unintentional mixing (mix-ups) must be minimised by using
appropriate procedures and/or specialised equipment as appropriate and
relevant staff training. Documentation must be sufficient to demonstrate that
appropriate segregation has been maintained during any packaging
operations.
2. Packaging and labelling of investigational medicinal products are likely to be

more complex and more liable to errors which are also harder to detect than
for authorised medicinal products, particularly when blinded products with
similar appearance are used. Precautions against mislabelling such as
reconciliation, line clearance, in- process control checks by appropriately
trained staff should accordingly be intensified.
3. The packaging must ensure that the investigational medicinal product

remains in good condition during transport and storage at intermediate
destinations. Any opening or tampering of the outer packaging during
transport should be readily discernible.
4. Re-packaging operations may be performed by authorised personnel at a

hospital, health centre or clinic that meet the requirements of relevant national
laws or requirements (i.e. in healthcare establishments that are not otherwise
subject to good manufacturing practices).
6.6 Labelling
1. The labelling of investigational medicinal products shall comply with the
requirements of relevant national laws or requirements, and where no such
requirements exist, it should address at least the following elements, unless
their absence can be justified, e.g. use of a centralised electronic
randomisation system:
i. name, address and telephone number of the sponsor, contract

research organisation or investigator (the main contact for information
on the product, clinical trial and emergency unblinding);
ii. the name/identifier and strength/potency, and in the case of blinded
trials, all product labelling should indicate “placebo/comparator or

[name/identifier] + [strength/potency]”
iii. pharmaceutical dosage form, route of administration, and quantity of
dosage units;
iv. the batch and/or code number to identify the contents and packaging
operation;
v. a trial reference code allowing identification of the trial, site,
investigator and sponsor if not given elsewhere;
vi. the trial subject identification number/treatment number and where
relevant, the visit number;
vii. the name of the investigator (if not included in (i) or (v));
viii. directions for use (reference may be made to a leaflet or other
explanatory document intended for the trial subject or person
administering the product);
ix. “For clinical trial use only” or similar wording;
x. the storage conditions;
xi. period of use (use-by date, expiry date or re-test date as applicable),
in month/year format and in a manner that avoids any ambiguity; and
xii. “keep out of reach of children” except when the product is for use in
trials where the product is not taken home by subjects.
2. The information which shall appear on the labelling should comply with any
relevant national laws or requirements. The labelling operation should be
performed at an authorised manufacturing site in accordance with relevant
national laws or requirements.
3. If it becomes necessary to change the expiry date, an additional label should

be affixed to the investigational medicinal product. This additional label
should state the new expiry date and repeat the batch number and clinical
trial reference number. It may be superimposed on the old expiry date, but for
quality control reasons, not on the original batch number.
4. The re-labelling operation should be performed by appropriately trained staff

in accordance with good manufacturing practice principles and specific
standard operating procedures and should be checked by a second person.
This additional labelling should be properly documented in the batch records.
To avoid mistakes the additional labelling activity should be carried out in an
area which is partitioned or separated from other activities. A line clearance
at the start and end of activity should be carried out and label reconciliation
performed. Any discrepancies observed during reconciliation should be
investigated and accounted for before release.
5. The re-labelling operation may be performed by authorised personnel at a

hospital, health centre or clinic that meet the requirements of relevant national
laws or requirements (i.e. in healthcare establishments that are not subject to
good manufacturing practices).

7. QUALITY CONTROL
1. The manufacturer should establish and maintain a quality control system
placed under the authority of a person who has the requisite qualifications
and is independent of production.
2. As processes may not be standardised or fully validated, testing takes on

more importance in ensuring that each batch meets the approved
specification at the time of testing.
3. Quality control of the investigational medicinal product, including that of the

comparator product, should be performed in accordance with the information
submitted in the application for the clinical trial, as authorised by the relevant
country.
4. Verification of the effectiveness of blinding should be performed and

recorded.
5. Retention periods for samples of investigational medicinal products should

comply with the relevant national laws or other requirements.
6. Samples are retained to fulfil two purposes: firstly, to provide a sample for
future analytical testing, and secondly, to provide a specimen of the finished
investigational medicinal product which may be used in the investigation of a
product quality defect.
7. Samples may therefore fall into two categories:
 Reference sample: a sample of a batch of starting material, packaging

material or finished product which is stored for the purpose of being
analysed should the need arise. Where stability permits, reference
samples from critical intermediate stages, e.g. those requiring analytical
testing and release, or intermediates which are transported outside of the
manufacturer's control, should be kept.
 Retention sample: a sample of a fully packaged unit from a batch of

finished product. It is stored for identification purposes. For example,
presentation, packaging, labelling, package leaflet, batch number, expiry
date should the need arise during the shelf life of the batch concerned.
8. There may be exceptional circumstances where this requirement can be met

without retention of duplicate samples, e.g. where small amounts of a batch
are packaged for different markets or in the production of very expensive
medicinal products.
9. For retention samples it is acceptable to store information related to the final

packaging as written, photographic or electronic records, if such records
provide sufficient information, e.g. examples of packaging, labelling and any
accompanying documentation to permit investigations associated with the
use of the product. In case of electronic records, the system should comply
with the requirements of Annex 11 of the PIC/S GMP Guide.

10. Where reference samples and retention samples are presented identically,
i.e. as fully packaged units, the samples may be regarded as interchangeable.
11. Samples are not expected of an investigational medicinal product which is an

unblinded comparator in its original packaging and sourced from the
authorised supply chain in the country in which the clinical trial is intended to
occur or of a product which holds a marketing authorisation granted by the
national competent authority of the country in which the clinical trial occurs.
(Note: In the EU, it might be the European Commission that has granted the
marketing authorisation.)
12. The storage location of samples should be defined in a technical agreement

between the sponsor and the manufacturer(s) and should allow timely access
by the competent authorities.
13. Reference samples of finished product should be stored under defined

storage conditions in the country in which the manufacturer is located or in
another country where appropriate arrangements have been made between
(or on behalf of) the two countries to ensure that the manufacturer of the
investigational medicinal product applies standards of good manufacturing
practice at least equivalent to those laid down by the PIC/S GMP Guide. In
exceptional circumstances, the reference samples of the finished product
may be stored by the manufacturer in another country, in which case this
should be justified and documented in a technical agreement between the
sponsor, the manufacturer and the storage site.
14. The reference sample should be of sufficient size to perform, on at least two
occasions, all critical quality attribute tests as defined in the investigational
medicinal product dossier authorised by the relevant country. Any exception
to this should be justified to, and agreed with, the national competent
authority.
8. RELEASE OF BATCHES
1. Release of investigational medicinal products should not occur until after the
Authorised Person has certified that the relevant requirements have been
met. The Authorised Person should take into account the elements listed
below, as appropriate.
2. The scope of the certification can be limited to assuring that the products are
in accordance with the authorisation of the clinical trial and any subsequent
processing carried out by the manufacturer for the purpose of blinding, trial-
specific packaging and labelling.
3. The information in the product specification file should form the basis for
assessment of the suitability for certification and release of a particular batch
by the Authorised Person and should therefore be accessible to him or her.
4. Assessment by the Authorised Person of each batch for certification prior to

release should take account of the principles detailed in Annex 16 of the
PIC/S GMP Guide and may include as appropriate;

i. batch records, including control reports, in-process test reports and

release reports demonstrating compliance with the product
specification file, the order, protocol and randomisation code. These
records should include all deviations or planned changes, and any
consequent additional checks and tests, and should be completed
and endorsed by the staff authorised to do so according to the quality
system;
ii. production conditions;
iii. cleaning records;
iv. the qualification status of facilities, validation status of processes and
methods;
v. examination of finished packs;
vi. the results of any analyses or tests performed after importation,
where relevant;
vii. stability plan and reports;
viii. the source and verification of conditions of storage and shipment;
ix. audit reports concerning the quality system of the manufacturer;
x. documents certifying that the manufacturer is authorised to
manufacture investigational medicinal product for export (as
applicable under national law); by the appropriate authorities in the
relevant country;
xi. where relevant, regulatory requirements for marketing authorisation,
good manufacturing practice standards applicable and any official
verification of compliance with good manufacturing practice;
xii. verification of the supply chain including manufacturing, packaging,
labelling and testing sites for the investigational medicinal products;
and
xiii. all factors of which the Authorised Person is aware that are relevant
to the quality of the batch.
5. The relevance of the above elements is affected by the country of origin of

the product, the manufacturer, the status of the product, i.e. with or without a
marketing authorisation granted by the relevant competent authority, and the
phase of development of the product.
6. Where investigational medicinal products are produced and packaged at

different sites under the supervision of different Authorised Persons, sharing
of responsibilities amongst the Authorised Persons in relation to compliance
of a batch must be defined in a document formally agreed by all parties.
7. Where required to support certification, the Authorised Person has to ensure

that the investigational medicinal product has been stored and transported
under conditions that maintain product quality and supply chain security.
Relevant situations may include short expiry date products released prior to
final Authorised Person certification, or where return of investigational
medicinal products to an authorised manufacturer for re-labelling and re-
packaging remains a possibility.
8. Where the manufacturer is delegated by the sponsor to perform the regulatory

release in addition to certification by the Authorised Person, the

arrangements should be defined in an agreement between the sponsor and

the manufacturer. Relevant clinical trial authorisation and amendment
information should be available for reference in the product specification file
and the manufacturer should ensure the necessary clinical trial authorisations
are in place and prior to shipping product for use in the trial.
9. After certification by the Authorised Person, the investigational medicinal

product should be stored and transported under conditions that maintain
product quality and supply chain security.
10. The Authorised Person is not required to certify re-packaging (section 6.5) or
re-labelling (section 6.6) performed by authorised personnel at a hospital,
health centre or clinic that meet the requirements of relevant national laws or
requirements.
9. OUTSOURCED OPERATIONS
Activities which are outsourced should be defined, agreed and controlled by
written contracts between the contract giver and the party to whom the operations
are outsourced in accordance with the principles detailed in Part I, Chapter 7 of
the PIC/S GMP Guide.
10. COMPLAINTS
1. There should be written procedures describing the actions to be taken upon
receipt of a complaint at the manufacturing, storage or importation site. All
complaints should be documented and assessed to establish if they represent
a potential quality defect or other issue. The procedures should ensure that
the sponsor is able to assess the complaints to determine if they justify the
reporting of a serious breach to the relevant competent authority.
2. The investigation of quality defect should be performed in accordance with

the principles detailed in Part I, Chapter 8 of the PIC/S GMP Guide.
3. The conclusions of the investigation should be discussed between the

manufacturer and the sponsor, if different, in a timely manner. This should
involve the Authorised Person and those responsible for the relevant clinical
trial in order to asses any potential impact on the trial, product development
and on subjects.
11. RECALLS AND RETURNS
11.1 Recalls
1. Procedures for retrieving investigational medicinal products and documenting
such retrievals should be in line with relevant national laws and guidelines,
and be agreed by the sponsor in cooperation with the manufacturer, where
different. The manufacturer, investigator and the sponsor's representative
need to understand their obligations under the retrieval procedure. The

procedures for retrieval of investigational medicinal products should be in

accordance with the principles detailed in Chapter 8 of the PIC/S GMP Guide.
2. To facilitate recall, a detailed inventory of the shipments made by the

manufacturer should be maintained.
11.2 Returns
Returned investigational medicinal products should be clearly identified and
stored in an appropriately controlled, dedicated area. Inventory records of
returned products should be kept.
11.3 Destruction
1. The manufacturer or sponsor’s representative should destroy investigational
medicinal products only with prior written authorisation by the sponsor. The
arrangements for destruction of investigational medicinal products have to be
described in the protocol. Any arrangement between sponsor and
manufacturer in this regard should be defined in their technical agreement.
2. Destruction of unused investigational medicinal products should be carried

out only after reconciliation of delivered, used and recovered products and
after investigation and satisfactory explanation of any discrepancies upon
which the reconciliation has been accepted.
3. Records of destruction operations should be retained, including a dated

certificate of destruction or a receipt for destruction to the sponsor. These
documents should clearly identify or allow traceability to the batches and/or
patient numbers involved and the actual quantities destroyed.
GLOSSARY TO ANNEX 13
Blinding
A procedure in which one or more parties to the trial are kept unaware of the treatment
assignment(s). Single-blinding usually refers to the subject(s) being unaware, and
double-blinding usually refers to the subject(s), investigator(s), monitor, and, in some
cases, data analyst(s) being unaware of the treatment assignment(s). In relation to an
investigational medicinal product, blinding shall mean the deliberate disguising of the
identity of the product in accordance with the instructions of the sponsor. Unblinding shall
mean the disclosure of the identity of blinded products.
Campaign manufacturing
Manufacturing a series of batches of the same product in sequence in a given period of
time followed by an appropriate (validated) cleaning procedure.
Clinical trial
Any investigation in human subjects intended to discover or verify the clinical,
pharmacological and/or other pharmacodynamic effects of an investigational product(s)
and/or to identify any adverse reactions to an investigational product(s), and/or to study
absorption, distribution, metabolism, and excretion of one or more investigational
medicinal product(s) with the object of ascertaining its/their safety and/or efficacy.

Comparator product
An investigational medicinal product used as a reference, including as a placebo, in a
clinical trial.
Expiry date
The date placed on the container/labels of an investigational medicinal products
designating the time during which the investigational medicinal products is expected to
remain within established shelf life specifications if stored under defined conditions,
and after which it should not be used.
Investigational medicinal product

A pharmaceutical form of an active substance or placebo being tested or used as a
reference in a clinical trial, including a product with a marketing authorisation when used
or assembled (formulated or packaged) in a way different from the authorised form, or
when used for an unauthorised indication, or when used to gain further information about
the authorised form.
Investigator
A person responsible for the conduct of the clinical trial at a trial site. If a trial is conducted
by a team of individuals at a trial site, the investigator is the responsible leader of the
team and may be called the principal investigator.
Manufacturer/importer of Investigational Medicinal Products

Any holder of the authorisation to manufacture/import.
Manufacture
All operations of purchase of materials and products, production, quality control, release,
storage, distribution of investigational medicinal products and the related controls. Note
that the word 'preparation' as used in this Annex should be taken as synonymous with
the word ‘manufacture’.
Order
The order should request the processing and/or packaging of a certain number of units
and/or their shipment and be given by or on behalf of the sponsor to the manufacturer.
Preparation
See ‘Manufacture’ above.
Product Specification File

A reference file containing, or referring to files containing, all the information necessary
to draft the detailed written instructions on processing, packaging, quality control testing,
batch release and shipping of an investigational medicinal product.
Randomisation
The process of assigning trial subjects to treatment or control groups using an element
of chance to determine the assignments in order to reduce bias.
Randomisation Code
A listing in which the treatment assigned to each subject from the randomisation process
is identified.

Retest date
The date when a material should be re-examined to ensure that it is still suitable for
use.
Regulatory Release
The verification of batch certification and that the clinical trial site is trained, qualified
and has the necessary approvals, thus is ready to receive investigational medicinal
product.
Shipping
The operation of packaging for shipment and sending of ordered medicinal products for
clinical trials.
Sponsor
An individual, company, institution or organisation which takes responsibility for the
initiation, management and/or financing of a clinical trial.

Annex 14 Manufacture of medicinal products derived from human blood or plasma
ANNEX 14
MANUFACTURE OF MEDICINAL PRODUCTS DERIVED

FROM HUMAN BLOOD OR PLASMA
CONTENTS
Glossary
1. Scope
2. Principles
3. Quality Management
4. Traceability and Post Collection Measures
5. Premises and equipment
6. Manufacturing
7. Quality Control
8. Release of intermediate and finished products
9. Retention of plasma pool samples
10. Disposal of waste
GLOSSARY
Blood
Blood1 means whole blood collected from a single (human) donor and processed either
for transfusion or for further manufacturing.
Blood component
A blood component2 means a therapeutic constituent of blood (red cells, white cells,
platelets and plasma) that can be prepared by various methods, using conventional
blood bank methodology (e.g. centrifugation, filtration, freezing). This does not include
haematopoietic progenitor cells.
Blood establishment
A blood establishment3 is any structure or body that is responsible for any aspect of the
collection and testing of human blood and blood components, whatever their intended
purpose, and their processing, storage and distribution when intended for transfusion.
Blood products
A blood product4 means any therapeutic product derived from human blood or plasma.
Fractionation, fractionation plant

Fractionation is the manufacturing process in a plant (fractionation plant) during which
plasma components are separated/purified by various physical and chemical methods
such as e.g. precipitation, chromatography.
1 For EU/EEA as referred to in Directive 2002/98/EC (Art. 3a)

2 For EU/EEA as referred to in Directive 2002/98/EC (Art. 3b)
3 For EU/EEA as referred to in Directive 2002/98/EC (Art. 3e)
4 For EU/EEA as referred to in Directive 2002/98/EC (Art. 3c)

Annex 14 Manufacture of products derived from human blood or plasma
Good Practice guidelines

Good practice guidelines give interpretation on the national standards and specifications
defined for quality systems in blood establishments5.
Medicinal products derived from human blood or human plasma

Medicinal products derived from human blood or human plasma6 are medicinal products
based on blood constituents which are prepared industrially by public or private
establishments.
Plasma for fractionation

Plasma for fractionation is the liquid part of human blood remaining after separation of
the cellular elements from blood collected in a container containing an anticoagulant, or
separated by continuous filtration or centrifugation of anti-coagulated blood in an
apheresis procedure; it is intended for the manufacture of plasma derived medicinal
products, in particular albumin, coagulation factors and immunoglobulins of human origin
and specified in the European (or other relevant) Pharmacopoeia (Ph. Eur.) monograph
“Human Plasma for fractionation” (0853).
Plasma Master File (PMF)

A Plasma Master File7 is a stand-alone document, which is separate from the dossier for
marketing authorisation. It provides all relevant detailed information on the
characteristics of the entire human plasma used as a starting material and/or a raw
material for the manufacture of sub/intermediate fractions, constituents of the excipients
and active substances, which are part of plasma, derived medicinal products or medical
devices.
Processing
Processing8 means any step in the preparation of blood component that is carried out
between the collection of blood and the issuing of a blood component, e.g. separation
and freezing of blood components. In this Annex, processing in addition refers to those
operations performed at the blood establishment that are specific to plasma to be used
for fractionation.
Responsible Person (RP)

A person responsible for securing that each batch of (biological) active substance or
medicinal product has been manufactured and checked in compliance with the laws in
force and in accordance with the specifications and/or requirements of the marketing
authorisation. The RP is equivalent to the EU term “Qualified Person” 9.
Responsible Person (RP) for blood establishment

A person responsible for ensuring that every unit of blood or blood components has been
collected and tested, processed, stored and distributed in compliance with the laws in
force. This term is equivalent to the EU term “Responsible Person”10.
5 For EU/EEA as established in the Annex of Directive 2005/62/EC

6 For EU/EEA as referred to as referred to in Directive 2001/83/EC (Art. 1 No. 10)
7 For EU/EEA as referred to in Directive 2001/83/EC (Annex I, Part III, No. 1.1.a)
8 For EU/EEA as according to the terminology of directive 2005/62/EC
9 For EU/EEA, see Article 48 of Directive 2001/83/EC and Article 52 of Directive 2001/82/EC.
10 For EU/EEA, see Article 9 of Directive 2002/98/EC.

Contract fractionation program

This is a contract fractionation in a national plant of a fractionator/manufacturer, using
starting material from other countries and manufacturing products not intended for the
national market.
1. SCOPE
1.1 The provisions of this Annex apply to medicinal products derived from human
blood or plasma, fractionated in or imported into the country. The Annex applies
also to the starting material (e.g. human plasma) for these products. In line with
national legislation11 the requirements may apply also for stable derivatives of
human blood or human plasma (e.g. Albumin) incorporated into medical devices.
1.2 This Annex defines specific Good Manufacturing Practices (GMP) requirements
for collection, processing, storage and transport of human plasma used for
fractionation and for the manufacture of medicinal products derived from human
blood or plasma.
1.3 The Annex addresses specific provisions for when starting material is imported
from other countries and for contract fractionation programs for other countries.
1.4 The Annex does not apply to blood components intended for transfusion.
2. PRINCIPLES
2.1 Medicinal products derived from human blood or plasma (and their active
substances which are used as starting materials) must comply with the principles
and guidelines of Good Manufacturing Practice12 as well as the relevant
marketing authorisation. They are considered to be biological medicinal products
and the starting materials include biological substances, such as cells or fluids
(including blood or plasma) of human origin. Certain special features arise from
the biological nature of the source material. For example, disease- transmitting
agents, especially viruses, may contaminate the source material. The quality and
safety of these products relies therefore on the control of source materials and
their origin as well as on the subsequent manufacturing procedures, including
infectious marker testing, virus removal and virus inactivation.
2.2 In principle active substances used as starting material for medicinal products
must comply with the principles and guidelines of Good Manufacturing Practice
(see 2.1). For starting materials derived from human blood and plasma national13
or international requirements for blood establishments involved in the collection,
preparation and testing are to be followed. Collection, preparation and testing
11 For EU/EEA as set out in Directive 2003/63/EC

12 For EU/EEA this is laid down in Commission Directive 2003/94/EC and the EU Guidelines on GMP
published by the European Commission.
13 For EU/EEA requirement for the collection and testing are defined in Directive 2002/98/EC.

must be performed in accordance with an appropriate quality system14 and for

which standards and specifications are defined. Furthermore, the national15 or
international requirements on traceability and serious adverse reactions and
serious adverse event notifications from the donor to the recipient should be
applied. Reference is hereby made to international guidelines as defined in the
addendum. In addition the monographs of the relevant Pharmacopoeia16 are to
be observed.
2.3 Starting material for the manufacture of medicinal products derived from human
blood or plasma imported from other countries and intended for use or distribution
within the country must meet the national17 standards.
2.4 In the case of contract fractionation programs the starting material imported from
other countries must comply with the national or equivalent18 quality and safety
requirements for blood components. The activities conducted within the country
must fully comply with GMP. Consideration should be given to national 19
standards and specifications relating to a quality system for blood
establishments, the traceability requirements and notification of serious adverse
reactions and events and the relevant WHO guidelines and recommendations as
listed in the addendum.
2.5 All subsequent steps after collection and testing (e.g. processing (including
separation), freezing, storage and transport to the manufacturer) must therefore
be done in accordance with the principles and guidelines of Good Manufacturing
Practice20. Normally, these activities would be carried out under the responsibility
of a Responsible Person in an establishment with a manufacturing authorisation.
Where specific processing steps in relation to plasma for fractionation take place
in a blood establishment, the specific appointment of a Responsible Person may,
however, not be proportionate given the presence and responsibility of a
Responsible Person of the blood establishment. To address this particular
situation and to ensure the legal responsibilities of the Responsible Person are
properly addressed, the fractionation plant/manufacturer should establish a
contract in accordance with Chapter 7 of the GMP Guide with the blood
establishment that defines respective responsibilities and the detailed
14 For EU/EEA standards and specifications for quality systems are defined in the Annex of Directive
2005/62/EC and interpreted in the Good Practice guidelines referred to in Article 2 (2) of Directive
2005/62/EC.
15 For EU/EEA requirements on traceability and serious adverse reactions and serious adverse event
notifications are defined in Directive 2005/61/EC.
16 For EU/EEA this is the European Pharmacopoeia as defined in Directive 2002/98/EC.
17 For EU/EEA these standards are equivalent to Community Standards and specifications relating to a
quality system for blood establishments as set out in Commission Directive 2005/62/EC (Recital 6; Article
2(3)), the traceability and serious adverse reaction and serious adverse event notification requirements
as set out in Commission Directive 2005/61/EC (Recital 5; Article 7), and the technical requirements for
blood and blood components as set out in Commission Directive 2004/33/EC (Recital 4; point 2.3 of
Annex V).
18 For EU/EEA reference is made to the quality and safety requirements as laid down in Directive
2002/98/EC and in Annex V of Directive 2004/33/EC.
19 For EU/EEA considerations should be given to the Community standards and specifications relating to
a quality system for blood establishments set out in Commission Directive 2005/62/EC and the
traceability requirements and notification of serious adverse reactions and events as set out in
Commission Directive 2005/61/EC.
20 For EU/EEA the requirements of Directive 2001/83/EC apply.

requirements in order to ensure compliance. The Responsible Person of the

blood establishment and the Responsible Person of the
fractionation/manufacturing plant (see 3.5) should be involved in drawing up this
contract. The Responsible Person should ensure that audits are performed to
confirm that the blood establishment complies with the contract.
2.6 Depending on national legislation, specific requirements for documentation and

other arrangements relating to the starting material of plasma-derived medicinal
products are defined in the Plasma Master File.
3. QUALITY MANAGEMENT
3.1 Quality management should govern all stages from donor selection in the blood
establishment up to delivery of the finished product by the finished product
manufacturer. Traceability of each donation up to and including the delivery of
plasma to the fractionation plant should be ensured by the blood establishment
through accurate identification procedures, record maintenance and an
appropriate labelling system according to national21 or international
requirements, and should be maintained during further manufacturing and
distribution of final products by the manufacturer.
3.2 Blood or plasma used as source material for the manufacture of medicinal
products must be collected and processed by blood establishments and be tested
in laboratories which apply quality systems in accordance with national22 or
international standards. Reference is made to documents listed in the addendum.
The blood establishments have to be authorised and subject to regular
inspections by a national competent authority23. Contract fractionation programs
have to be notified to the competent authority by the manufacturer24.
3.3 If plasma is imported from other countries it should only be purchased from
approved suppliers (e.g. blood establishments, including external warehouses).
They should be named in the specifications for starting materials as defined by
the fractionation plant/manufacturer, and be accepted by the competent authority
(e.g. following an inspection) of the importing country and by the Responsible
Person of the importing fractionation plant. Certification and release of plasma
(plasma for fractionation) as starting material is mentioned in section 6.8.
3.4 Supplier qualification, including audits, should be performed by the fractionation

plant/manufacturer of the finished product including test laboratory according to
written procedures. Re-qualification of suppliers should be performed at regular
intervals taking a risk-based approach into account.
3.5 The fractionation plant/manufacturer of the finished product should establish

written contracts with the supplying blood establishments. As a minimum the
following key aspects should be addressed:
- definition of duties and respective responsibilities
21 For EU/EEA reference is made to Directive 2005/61/EC and to Directive 2005/62/EC.

22 For EU/EEA reference is made to Directive 2005/62/EC.
23 For EU/EEA as referred to in Directive 2002/98/EC
24 For EU/EEA it is the competent authority as referred to in Directive 2001/83/EC.

- quality system and documentation requirements

- donor selection criteria and testing
- requirements for the separation of blood into blood components/plasma
- freezing of plasma
- storage and transport of plasma
- traceability and post donation / collection information (including adverse
events).
The test results of all units supplied by the blood establishment should be
available to the fractionation plant/manufacturer of the medicinal product. In
addition, any fractionation step subcontracted should be defined in a written
contract.
3.6 A formal change control system should be in place to plan, evaluate and
document all changes that may affect the quality or safety of the products, or
traceability. The potential impact of proposed changes should be evaluated. The
need for additional testing and validation, especially viral inactivation and removal
steps, should be determined.
3.7 An adequate safety strategy should be in place to minimise the risk from
infectious agents and emerging infectious agents. This strategy should involve a
risk assessment that:
- defines an inventory holding time (internal quarantine time) before
processing the plasma i.e. to remove look back units25.
- considers all aspects of virus reduction and/or testing for infectious agents
or surrogates.
- considers the virus reduction capabilities, the pool size and other relevant
aspects of the manufacturing processes.
4. TRACEABILITY AND POST COLLECTION MEASURES

4.1 There must be a system in place that enables each donation to be traced, from
the donor and the donation via the blood establishment through to the batch of
medicinal product and vice versa.
4.2 Responsibilities for traceability of the product should be defined (there should be
no gaps):
- from the donor and the donation in the blood establishment to the
fractionation plant (this is the responsibility of the RP of the blood
establishment);
- from the fractionation plant to the manufacturer of the medicinal product and
any secondary facility, whether a manufacturer of a medicinal product or of
a medical device (this is the responsibility of the RP).
25 Plasma units donated by donors during a defined period (as defined on a national / EU basis) before it
is found that a donation from a high-risk donor should have been excluded from processing, e.g. due to
a positive test result.

4.3 Data needed for full traceability must be stored according to national legislation 26.
4.4 The contracts (as mentioned in 3.5) between the blood establishments (including
testing laboratories) and the fractionation plant/manufacturer should ensure that
traceability and post collection measures cover the complete chain from the
collection of the plasma to all manufacturers responsible for release of the final
products.
4.5 The blood establishments should notify the fractionating plant/manufacturer of

any event which may affect the quality or safety of the product including serious
adverse events and reactions27 and other relevant information found subsequent
to donor acceptance or release of the plasma, e.g. look back information28 (post-
collection information). Where the fractionation plant/manufacturer is located in
another country, the information should be forwarded to the manufacturer
responsible for release in the country of any product manufactured from the
plasma concerned. In both cases, if relevant for the quality or safety of the final
product, this information should be forwarded to the competent authority29
responsible for the fractionation plant/manufacturer as required by national
legislation.
4.6 The notification procedure as described in 4.5 also applies when an inspection of
a blood establishment by a competent authority leads to a withdrawal of an
existing licence/certificate/ approval.
4.7 The management of post-collection information should be described in standard

operating procedures and taking into account obligations and procedures for
informing the competent authorities. Post-collection measures should be
available as defined in national or relevant international recommendations30.
The blood establishment and the fractionation/manufacturer should inform each
other if, following donation:
- It is found that the donor did not meet the relevant donor health criteria;
- A subsequent donation from a donor previously found negative for viral
markers is found positive for any of the viral markers;
- It is discovered that testing for viral markers has not been carried out according
to agreed procedures;
- The donor has developed an infectious disease caused by an agent potentially
transmissible by plasma-derived products (HBV, HCV, HAV and other non-A,
non-B, non-C hepatitis viruses, HIV-1 and 2 and other agents in the light of
current knowledge);
26 For EU/EEA this is for at least 30 years according to Article 4 of Directive 2005/61/EC and Article 14 of
Directive 2002/98/EC. Both Directives are linked to Article 109 of Directive 2001/83/EC by defining
specific rules for medicinal products derived from human blood or plasma.
27 For EU/EEA reference is made to in Annex II part A and Annex III part A of Directive 2005/61/EC.
28 Information that appears if a subsequent donation from a donor previously found negative for viral
markers is found positive for any of the viral markers or any other risk factors which may induce a viral
infection.
29 For EU/EEA this is the competent authority as referred to in Directive 2001/83/EC.
30 For EU/EEA referene is made to the “Note for Guidance on Plasma Derived Medicinal Products" in its
current version as adopted by the Committee for Medicinal Products for Human Use (CHMP) and
published by the European Medicines Agency. Current version at date of publication:
CPMP/BWP/269/95.

- The donor develops Creutzfeldt-Jakob disease (CJD or vCJD);

- The recipient of blood or a blood component develops post-transfusion
infection which implicates or can be traced back to the donor.
In the event of any of the above, a re-assessment of the batch documentation
should always be carried out. The need for withdrawal of the given batch should
be carefully considered, taking into account criteria such as the transmissible
agent involved, the size of the pool, the time period between donation and
seroconversion, the nature of the product and its manufacturing method.
5. PREMISES AND EQUIPMENT

5.1 In order to minimise microbiological contamination or the introduction of foreign
material into the plasma pool, thawing and pooling of plasma units should be
performed in an area conforming at least to the Grade D requirements defined in
Annex 1 of the PIC/S GMP Guide. Appropriate clothing should be worn including
face masks and gloves. All other open manipulations during the manufacturing
process should be done under conditions conforming to the appropriate
requirements of Annex 1 of the PIC/S GMP Guide.
5.2 Environmental monitoring should be performed regularly, especially during the

‘opening’ of plasma containers, and during subsequent thawing and pooling
processes in accordance with Annex 1 of the PIC/S GMP Guide.
5.3 In the production of plasma-derived medicinal products, appropriate viral

inactivation or removal procedures are used and steps should be taken to prevent
cross contamination of treated with untreated products. Dedicated and distinct
premises and equipment should be used for manufacturing steps before and after
viral inactivation treatment.
5.4 To avoid placing routine manufacture at risk of contamination from viruses used
during validation studies, the validation of methods for virus reduction should not
be conducted in production facilities. Validation should be performed according
to international recommendations31.
6. MANUFACTURING
Starting material
6.1 The starting material should comply with the requirements of all relevant
monographs of the relevant Pharmacopoeia and of the conditions laid down in
the respective marketing authorisation dossier (including the Plasma Master File
if applicable). These requirements should be defined in the written contract (see
3.5) between the blood establishment and the fractionating plant/manufacturer
and controlled through the quality system.
31 For EU/EEA reference is made to the "Note for Guidance on Virus Validation Studies: The Design,
Contribution and Interpretation of Studies validating the Inactivation and Removal of Viruses" in its
current version as adopted by the Committee for Medicinal Products for Human Use (CHMP) and
published by the European Medicines Agency. Current version at date of publication:
CHMP/BWP/268/95.

6.2. Starting material imported for contract fractionation programs should comply with
the requirements as specified in 2.4.
6.3 Depending on the type of collection (i.e. either whole blood collection or
automated apheresis) different processing steps may be required. All processing
steps (e.g. centrifugation and/or separation, sampling, labelling, freezing) should
be defined in written procedures.
6.4 Any mix-ups of units and of samples, especially during labelling, as well as any
contamination, e.g. when cutting the tube segments/sealing the containers, must
be avoided.
6.5 Freezing is a critical step for the recovery of proteins that are labile in plasma,
e.g. clotting factors. Freezing should therefore be performed as soon as possible
after collection (see the European Pharmacopoeia monograph No 0853 "Human
Plasma for Fractionation" and where relevant, monograph No 1646 "Human
Plasma pooled and treated for virus inactivation", or other relevant
Pharmacopoeia), following a validated method.
6.6 The storage and transport of blood or plasma at any stage in the transport chain
to the fractionation plant should be defined and recorded. Any deviation from the
defined temperature should be notified to the fractionation plant. Qualified
equipment and validated procedures should be used.
Certification/release of plasma for fractionation as starting material

6.7 Plasma for fractionation should only be released, i.e. from a quarantine status,
through systems and procedures that assure the quality needed for the
manufacture of the finished product. It should only be distributed to the plasma
fractionation plant/manufacturer after it has been documented by the
Responsible Person of the blood establishment (or in case of blood/plasma
collection in other countries by a person with equivalent responsibilities and
qualifications) that the plasma for fractionation does comply with the
requirements and specifications defined in the respective written contracts and
that all steps have been performed in accordance with Good Practice and GMP
Guidelines, as appropriate.
6.8 On entering the fractionation plant, the plasma units should be released for
fractionation under the responsibility of the Responsible Person. The
Responsible Person should confirm that the plasma complies with the
requirements of all relevant monographs and the conditions laid down in the
respective marketing authorisation dossier (including the Plasma Master File if
applicable) or, in case of plasma to be used for contract fractionation programs,
with the requirements as specified in 2.4.
Processing of plasma for fractionation

6.9 The steps used in the fractionation process vary according to product and
manufacturer and usually include several fractionation/purification procedures,
some of which may contribute to the inactivation and/or removal of potential
contamination.

6.10 Requirements for the processes of pooling, pool sampling and

fractionation/purification and virus inactivation/removal should be defined and
followed thoroughly.
6.11 The methods used in the viral inactivation process should be undertaken with
strict adherence to validated procedures and in compliance with the methods
used in the virus validation studies. Detailed investigation of failures in virus
inactivation procedures should be performed. Adherence to the validated
production process is especially important in the virus reduction procedures as
any deviation could result in a safety risk for the final product. Procedures which
take this risk into consideration should be in place.
6.12 Any reprocessing or reworking may only be performed after a quality risk
management exercise has been performed and using processing steps as
defined in the relevant marketing authorisation.
6.13 A system for clearly segregating/distinguishing between products or

intermediates which have undergone a process of virus reduction, from those
which have not, should be in place.
6.14 Depending on the outcome of a thorough risk management process (taking into
consideration possible differences in epidemiology) production in campaigns
including clear segregation and defined validated cleaning procedures should be
adopted when plasma/intermediates of different origins is processed at the same
plant. The requirement for such measures should be based on international
recommendations32. The risk management process should consider whether it is
necessary to use dedicated equipment in the case of contract fractionation
programs.
6.15 For intermediate products intended to be stored, a shelf-life should be defined

based on stability data.
6.16 The storage and transport of intermediate and finished medicinal products at any
stage of the transport chain should be specified and recorded. Qualified
equipment and validated procedures should be used.
7. QUALITY CONTROL
7.1 Testing requirements for viruses or other infectious agents should be considered
in the light of knowledge emerging on infectious agents and on the availability of
appropriate, validated test methods.
7.2 The first homogeneous plasma pool (e.g. after separation of the cryoprecipitate
from the plasma pool) should be tested using validated test methods of suitable
sensitivity and specificity, according to the relevant Pharmacopoeia
monographs33.
32 For EU/EEA, see Guideline on Epidemiological Data on Blood Transmissible Infections,

EMEA/CPMP/BWP/125/04.
33 For EU/EEA reference is made to the relevant European Pharmacopoeia monographs (e.g. No 0853).

8. RELEASE OF INTERMEDIATE AND FINISHED PRODUCTS

8.1 Only batches derived from plasma pools tested and found negative for virus
markers / antibodies and found in compliance with the relevant Pharmacopoeia
monographs, including any specific virus cut-off limits, and with the approved
specifications (e.g. Plasma Master File if applicable), should be released.
8.2 The release of intermediates intended for further in-house processing or delivery
to a different site and the release of finished products should be performed by the
Responsible Person and in accordance with the approved marketing
authorisation.
8.3. The release of intermediates and final products used in contract fractionation
programs should be performed by the Responsible Person on the basis of
standards agreed with the contract giver and compliance with PIC/S GMP
standards.
9. RETENTION OF PLASMA POOL SAMPLES

One plasma pool may be used to manufacture more than one batch and/or
product. Retention samples and corresponding records from every pool should
be kept for at least one year after the expiry date of the finished medicinal product
with the longest shelf-life derived from the pool.
10. DISPOSAL OF WASTE

There should be written procedures for the safe and documented storage and
disposal of waste, disposable and rejected items (e.g. contaminated units, units
from infected donors, out of date blood, plasma, intermediate or finished
products).
ADDENDUM
The Addendum lists EU-specific directives and guidelines which give further
guidance on specific topics or must be implemented by EU/EEA Member States.

Addendum
A) EU/EEA Member States have been obliged to implement the following Directives and
guidelines:
1. for collection and testing of blood and blood components:
Directive/Guidelines Title Scope
Directive 2002/98/EC Setting standards of quality and Art.2 Defines standards of quality
of the European safety for the collection, testing, and safety for the collection and
Parliament and of the processing, storage and distribution testing of human blood and blood
Council of human blood and blood components, whatever their
components, amending Directive intended purpose, and for their
2001/83/EC. processing, storage and distribution
when intended for transfusion.
Commission Directive Implementing Directive 2002/98/EC Defines the provision of information

2004/33/EC of the European Parliament and of to prospective donors and
the Council as regards certain information required from donors
technical requirements for blood and (Part A and B, Annex II), eligibility of
blood components donors (Annex III), storage,
transport and distribution conditions
for blood and blood components
(Annex IV), as well as quality and
safety requirements for blood and
blood components (Annex V).
Commission Directive Implementing Directive 2002/98/EC Defines traceability requirements

2005/61/EC of the European Parliament and of for blood establishments, donors,
the Council as regards traceability blood and blood components, and
requirements and notification of for the final destination of each unit,
serious adverse reactions and whatever the intended purpose. It
events. further defines the reporting
requirements in the event of serious
adverse events and reactions.
Commission Directive Implementing Directive 2002/98/EC Defines the implementation of

2005/62/EC of the European Parliament and of quality system standards and
the Council as regards Community specifications as referred to in
standards and specifications relating article 47 of Directive 2001/83/EC.
to a quality system for blood
establishments.

2. for collection and regulatory submission of data/information for plasma for

fractionation:
Directive/ Guidelines Title Scope

Directive 2001/83/EC On the Community Code relating to Art. 2 Medicinal products for human
of the European medicinal products for human use. use intended to be placed on the
Parliament and the market in Member States and either
Council prepared industrially or
manufactured by a method
involving an industrial process,
covering medicinal products
derived from human blood or
human plasma.
Commission Directive Amending Directive 2001/83/EC of

2003/63/EC the European Parliament and of the
Council on the Community code
relating to medicinal products for
human use; Amending the Annex on
documentation of medicinal products
Commission Directive Laying down the principles and Art. 1 Principles and guidelines of
2003/94/EC guidelines of good manufacturing good manufacturing practice in
practice in respect of medicinal respect of medicinal products for
products for human use and human use and investigational
investigational medicinal products for medicinal products for human use
human use
EU Guidelines to Giving interpretation on the principles

Good Manufacturing and guidelines on GMP
Practice
EMEA/CHMP/BWP/37 Guideline on the Scientific data
94/03 Rev.1, 15. Nov. requirements for a Plasma Master
2006 File (PMF) Revision 1
EMEA/CPMP/BWP/12 Guideline on Epidemiological Data

5/04 EMEA Guideline on Blood Transmissible Infections

B. Other relevant documents:

Document Title Scope
PE 005 PIC/S GMP Guide for blood Guidance for GMP for blood
establishments establishments
Recommendation No. Guide to the Preparation, use and

R (95) 15 (Council of quality assurance of blood components
Europe)
World Health WHO Recommendations for the Guidance on the production,
Organization production, control and regulation of control and regulation of human
WHO Technical human plasma for fractionation plasma for fractionation, adopted
Report Series No 941, by the 56th meeting of the WHO
2007; Annex 4 Expert Committee on Biological
Standardization, 24-28 October
2005
World Health WHO guidelines on Good

Organization, Manufacturing Practices for blood
WHO Technical establishments
Report Series, No.
961, 2011; Annex 4
Reference should be made to the latest revisions of these documents for current
guidance.

Annex 15 Qualification and validation
ANNEX 15
QUALIFICATION AND VALIDATION
PRINCIPLE
This Annex describes the principles of qualification and validation which are
applicable to the facilities, equipment, utilities and processes used for the
manufacture of medicinal products and may also be used as supplementary
optional guidance for active substances without introduction of additional
requirements to Part II. It is a GMP requirement that manufacturers control the
critical aspects of their particular operations through qualification and validation
over the life cycle of the product and process. Any planned changes to the
facilities, equipment, utilities and processes, which may affect the quality of the
product, should be formally documented and the impact on the validated status
or control strategy assessed. Computerised systems used for the manufacture of
medicinal products should also be validated according to the requirements of
Annex 11. The relevant concepts and guidance presented in ICH Q8, Q9, Q10
and Q11 should also be taken into account.
GENERAL
A quality risk management approach should be applied throughout the lifecycle
of a medicinal product. As part of a quality risk management system, decisions
on the scope and extent of qualification and validation should be based on a
justified and documented risk assessment of the facilities, equipment, utilities and
processes. Retrospective validation is no longer considered an acceptable
approach.
Data supporting qualification and/or validation studies which were obtained from
sources outside of the manufacturers own programmes may be used provided
that this approach has been justified and that there is adequate assurance that
controls were in place throughout the acquisition of such data.
1. ORGANISING AND PLANNING FOR QUALIFICATION AND

VALIDATION
1.1 All qualification and validation activities should be planned and take the life cycle
of facilities, equipment, utilities, process and product into consideration.
1.2 Qualification and validation activities should only be performed by suitably trained
personnel who follow approved procedures.
1.3 Qualification/validation personnel should report as defined in the pharmaceutical

quality system although this may not necessarily be to a quality management or
a quality assurance function. However, there should be appropriate quality
oversight over the whole validation life cycle.

1.4 The key elements of the site qualification and validation programme should be
clearly defined and documented in a validation master plan (VMP) or equivalent
document.
1.5 The VMP or equivalent document should define the qualification/validation

system and include or reference information on at least the following:
i. Qualification and Validation policy;

ii. The organisational structure including roles and responsibilities for
qualification and validation activities;
iii. Summary of the facilities, equipment, systems, processes on site and the
qualification and validation status;
iv. Change control and deviation management for qualification and validation ;
v. Guidance on developing acceptance criteria;
vi. References to existing documents;
vii. The qualification and validation strategy, including requalification, where
applicable.
1.6 For large and complex projects, planning takes on added importance and
separate validation plans may enhance clarity
1.7 A quality risk management approach should be used for qualification and
validation activities. In light of increased knowledge and understanding from any
changes during the project phase or during commercial production, the risk
assessments should be repeated, as required. The way in which risk
assessments are used to support qualification and validation activities should be
clearly documented.
1.8 Appropriate checks should be incorporated into qualification and validation work
to ensure the integrity of all data obtained.
2. DOCUMENTATION, INCLUDING VMP

2.1 Good documentation practices are important to support knowledge management
throughout the product lifecycle.
2.2 All documents generated during qualification and validation should be approved
and authorised by appropriate personnel as defined in the pharmaceutical quality
system.
2.3 The inter-relationship between documents in complex validation projects should

be clearly defined.
2.4 Validation protocols should be prepared which defines the critical systems,
attributes and parameters and the associated acceptance criteria.

2.5 Qualification documents may be combined together, where appropriate, e.g.

installation qualification (IQ) and operational qualification (OQ).
2.6 Where validation protocols and other documentation are supplied by a third party
providing validation services, appropriate personnel at the manufacturing site
should confirm suitability and compliance with internal procedures before
approval. Vendor protocols may be supplemented by additional
documentation/test protocols before use.
2.7 Any significant changes to the approved protocol during execution, e.g.
acceptance criteria, operating parameters etc., should be documented as a
deviation and be scientifically justified.
2.8 Results which fail to meet the pre-defined acceptance criteria should be recorded
as a deviation, and be fully investigated according to local procedures. Any
implications for the validation should be discussed in the report.
2.9 The review and conclusions of the validation should be reported and the results
obtained summarised against the acceptance criteria. Any subsequent changes
to acceptance criteria should be scientifically justified and a final recommendation
made as to the outcome of the validation.
2.10 A formal release for the next stage in the qualification and validation process
should be authorised by the relevant responsible personnel either as part of the
validation report approval or as a separate summary document. Conditional
approval to proceed to the next qualification stage can be given where certain
acceptance criteria or deviations have not been fully addressed and there is a
documented assessment that there is no significant impact on the next activity.
3. QUALIFICATION STAGES FOR EQUIPMENT, FACILITIES,

UTILITIES AND SYSTEMS.
3.1 Qualification activities should consider all stages from initial development of the
user requirements specification through to the end of use of the equipment,
facility, utility or system. The main stages and some suggested criteria (although
this depends on individual project circumstances and may be different) which
could be included in each stage are indicated below:
User requirements specification (URS)
3.2 The specification for equipment, facilities, utilities or systems should be defined
in a URS and/or a functional specification. The essential elements of quality need
to be built in at this stage and any GMP risks mitigated to an acceptable level.
The URS should be a point of reference throughout the validation life cycle.
Design qualification (DQ)
3.3 The next element in the qualification of equipment, facilities, utilities, or systems
is DQ where the compliance of the design with GMP should be demonstrated
and documented. The requirements of the user requirements specification should
be verified during the design qualification.

Factory acceptance testing (FAT) /Site acceptance testing (SAT)
3.4 Equipment, especially if incorporating novel or complex technology, may be

evaluated, if applicable, at the vendor prior to delivery.
3.5 Prior to installation, equipment should be confirmed to comply with the URS/
functional specification at the vendor site, if applicable.
3.6 Where appropriate and justified, documentation review and some tests could be
performed at the FAT or other stages without the need to repeat on site at IQ/OQ
if it can be shown that the functionality is not affected by the transport and
installation.
3.7 FAT may be supplemented by the execution of a SAT following the receipt of
equipment at the manufacturing site.
Installation qualification (IQ)
3.8 IQ should be performed on equipment, facilities, utilities, or systems.
3.9 IQ should include, but is not limited to the following:
i. Verification of the correct installation of components, instrumentation,

equipment, pipe work and services against the engineering drawings and
specifications;
ii. Verification of the correct installation against pre-defined criteria;
iii. Collection and collation of supplier operating and working instructions and
maintenance requirements;
iv. Calibration of instrumentation;
v. Verification of the materials of construction.
Operational qualification (OQ)
3.10 OQ normally follows IQ but depending on the complexity of the equipment, it may
be performed as a combined Installation/Operation Qualification (IOQ).
3.11 OQ should include but is not limited to the following:
i. Tests that have been developed from the knowledge of processes, systems
and equipment to ensure the system is operating as designed;
ii. Tests to confirm upper and lower operating limits, and/or “worst case”
conditions.
3.12 The completion of a successful OQ should allow the finalisation of standard

operating and cleaning procedures, operator training and preventative
maintenance requirements.

Performance qualification (PQ)
3.13 PQ should normally follow the successful completion of IQ and OQ. However, it
may in some cases be appropriate to perform it in conjunction with OQ or Process
Validation.
3.14 PQ should include, but is not limited to the following:
i. Tests, using production materials, qualified substitutes or simulated product

proven to have equivalent behaviour under normal operating conditions with
worst case batch sizes. The frequency of sampling used to confirm process
control should be justified;
ii. Tests should cover the operating range of the intended process, unless
documented evidence from the development phases confirming the
operational ranges is available.
4. RE-QUALIFICATION
4.1 Equipment, facilities, utilities and systems should be evaluated at an appropriate
frequency to confirm that they remain in a state of control.
4.2 Where re-qualification is necessary and performed at a specific time period, the
period should be justified and the criteria for evaluation defined. Furthermore,
the possibility of small changes over time should be assessed.
5. PROCESS VALIDATION
General
5.1 The requirements and principles outlined in this section are applicable to the
manufacture of all pharmaceutical dosage forms. They cover the initial validation
of new processes, subsequent validation of modified processes, site transfers
and ongoing process verification. It is implicit in this annex that a robust product
development process is in place to enable successful process validation.
5.2 Section 5 should be used in conjunction with relevant guidelines on Process

Validation1.
5.2.1 A guideline on Process Validation is intended to provide guidance on the

information and data to be provided in the regulatory submission only. However
GMP requirements for process validation continue throughout the lifecycle of the
process
5.2.2 This approach should be applied to link product and process development. It will
ensure validation of the commercial manufacturing process and maintenance of
the process in a state of control during routine commercial production.
1 In the EU/EEA, see EMA/CHMP/CVMP/QWP/BWP/70278/2012

5.3 Manufacturing processes may be developed using a traditional approach or a

continuous verification approach. However, irrespective of the approach used,
processes must be shown to be robust and ensure consistent product quality
before any product is released to the market. Manufacturing processes using the
traditional approach should undergo a prospective validation programme
wherever possible prior to certification of the product. Retrospective validation is
no longer an acceptable approach.
5.4 Process validation of new products should cover all intended marketed strengths
and sites of manufacture. Bracketing could be justified for new products based
on extensive process knowledge from the development stage in conjunction with
an appropriate ongoing verification programme.
5.5 For the process validation of products, which are transferred from one site to
another or within the same site, the number of validation batches could be
reduced by the use of a bracketing approach. However, existing product
knowledge, including the content of the previous validation, should be available.
Different strengths, batch sizes and pack sizes/ container types may also use a
bracketing approach if justified.
5.6 For the site transfer of legacy products, the manufacturing process and controls
must comply with the marketing authorisation and meet current standards for
marketing authorisation for that product type. If necessary, variations to the
marketing authorisation should be submitted.
5.7 Process validation should establish whether all quality attributes and process
parameters, which are considered important for ensuring the validated state and
acceptable product quality, can be consistently met by the process. The basis
by which process parameters and quality attributes were identified as being
critical or non-critical should be clearly documented, taking into account the
results of any risk assessment activities.
5.8 Normally batches manufactured for process validation should be the same size
as the intended commercial scale batches and the use of any other batch sizes
should be justified or specified in other sections of the GMP guide.
5.9 Equipment, facilities, utilities and systems used for process validation should be
qualified. Test methods should be validated for their intended use.
5.10 For all products irrespective of the approach used, process knowledge from
development studies or other sources should be accessible to the manufacturing
site, unless otherwise justified, and be the basis for validation activities.
5.11 For process validation batches, production, development, or other site transfer
personnel may be involved. Batches should only be manufactured by trained
personnel in accordance with GMP using approved documentation. It is expected
that production personnel are involved in the manufacture of validation batches
to facilitate product understanding.
5.12 The suppliers of critical starting and packaging materials should be qualified prior
to the manufacture of validation batches; otherwise a justification based on the
application of quality risk management principles should be documented.

5.13 It is especially important that the underlying process knowledge for the design
space justification (if used) and for development of any mathematical models (if
used) to confirm a process control strategy should be available.
5.14 Where validation batches are released to the market this should be pre-defined.
The conditions under which they are produced should fully comply with GMP,
with the validation acceptance criteria, with any continuous process verification
criteria (if used) and with the marketing authorisation or clinical trial authorisation.
5.15 For the process validation of investigational medicinal products (IMP), please
refer to Annex 13.
Concurrent validation
5.16 In exceptional circumstances, where there is a strong benefit-risk ratio for the
patient, it may be acceptable not to complete a validation programme before
routine production starts and concurrent validation could be used. However, the
decision to carry out concurrent validation must be justified, documented in the
VMP for visibility and approved by authorised personnel.
5.17 Where a concurrent validation approach has been adopted, there should be
sufficient data to support a conclusion that any given batch of product is uniform
and meets the defined acceptance criteria. The results and conclusion should
be formally documented and available to the Authorised Person prior to
certification of the batch.
Traditional process validation

5.18 In the traditional approach, a number of batches of the finished product are
manufactured under routine conditions to confirm reproducibility.
5.19 The number of batches manufactured and the number of samples taken should
be based on quality risk management principles, allow the normal range of
variation and trends to be established and provide sufficient data for evaluation.
Each manufacturer must determine and justify the number of batches necessary
to demonstrate a high level of assurance that the process is capable of
consistently delivering quality product.
5.20 Without prejudice to 5.19, it is generally considered acceptable that a minimum

of three consecutive batches manufactured under routine conditions could
constitute a validation of the process. An alternative number of batches may be
justified taking into account whether standard methods of manufacture are used
and whether similar products or processes are already used at the site. An initial
validation exercise with three batches may need to be supplemented with further
data obtained from subsequent batches as part of an on-going process
verification exercise.
5.21 A process validation protocol should be prepared which defines the critical
process parameters (CPP), critical quality attributes (CQA) and the associated
acceptance criteria which should be based on development data or documented
process knowledge.
5.22 Process validation protocols should include, but are not limited to the following:

i. A short description of the process and a reference to the respective Master

Batch Record;
ii. Functions and responsibilities;
iii. Summary of the CQAs to be investigated;
iv. Summary of CPPs and their associated limits;
v. Summary of other (non-critical) attributes and parameters which will be
investigated or monitored during the validation activity, and the reasons for
their inclusion;
vi. List of the equipment/facilities to be used (including
measuring/monitoring/recording equipment) together with the calibration
status;
vii. List of analytical methods and method validation, as appropriate;
viii. Proposed in-process controls with acceptance criteria and the reason(s) why
each in-process control is selected;
ix. Additional testing to be carried out, with acceptance criteria;
x. Sampling plan and the rationale behind it;
xi. Methods for recording and evaluating results;
xii. Process for release and certification of batches (if applicable).
Continuous process verification
5.23 For products developed by a quality by design approach, where it has been
scientifically established during development that the established control strategy
provides a high degree of assurance of product quality, then continuous process
verification can be used as an alternative to traditional process validation.
5.24 The method by which the process will be verified should be defined. There should
be a science based control strategy for the required attributes for incoming
materials, critical quality attributes and critical process parameters to confirm
product realisation. This should also include regular evaluation of the control
strategy. Process Analytical Technology and multivariate statistical process
control may be used as tools. Each manufacturer must determine and justify the
number of batches necessary to demonstrate a high level of assurance that the
process is capable of consistently delivering quality product.
5.25 The general principles laid down in 5.1 – 5.14 above still apply.
Hybrid approach
5.26 A hybrid of the traditional approach and continuous process verification could be
used where there is a substantial amount of product and process knowledge and
understanding which has been gained from manufacturing experience and
historical batch data.

5.27 This approach may also be used for any validation activities after changes or
during ongoing process verification even though the product was initially
validated using a traditional approach.
Ongoing Process Verification during Lifecycle
5.28 Paragraphs 5.28-5.32 are applicable to all three approaches to process validation
mentioned above, i.e. traditional, continuous and hybrid.
5.29 Manufacturers should monitor product quality to ensure that a state of control is
maintained throughout the product lifecycle with the relevant process trends
evaluated.
5.30 The extent and frequency of ongoing process verification should be reviewed
periodically. At any point throughout the product lifecycle, it may be appropriate
to modify the requirements taking into account the current level of process
understanding and process performance.
5.31 Ongoing process verification should be conducted under an approved protocol or

equivalent documents and a corresponding report should be prepared to
document the results obtained. Statistical tools should be used, where
appropriate, to support any conclusions with regard to the variability and
capability of a given process and ensure a state of control.
5.32 Ongoing process verification should be used throughout the product lifecycle to
support the validated status of the product as documented in the Product Quality
Review. Incremental changes over time should also be considered and the need
for any additional actions, e.g. enhanced sampling, should be assessed.
6. VERIFICATION OF TRANSPORTATION
6.1 Finished medicinal products, investigational medicinal products, bulk product and
samples should be transported from manufacturing sites in accordance with the
conditions defined in the marketing authorisation, the approved label, product
specification file or as justified by the manufacturer.
6.2 It is recognised that verification of transportation may be challenging due to the

variable factors involved however, transportation routes should be clearly
defined. Seasonal and other variations should also be considered during
verification of transport
6.3 A risk assessment should be performed to consider the impact of variables in the
transportation process other than those conditions which are continuously
controlled or monitored, e.g. delays during transportation, failure of monitoring
devices, topping up liquid nitrogen, product susceptibility and any other relevant
factors.
6.4 Due to the variable conditions expected during transportation, continuous

monitoring and recording of any critical environmental conditions to which the
product may be subjected should be performed, unless otherwise justified.

7. VALIDATION OF PACKAGING
7.1 Variation in equipment processing parameters especially during primary
packaging may have a significant impact on the integrity and correct functioning
of the pack, e.g. blister strips, sachets and sterile components; therefore primary
and secondary packaging equipment for finished and bulk products should be
qualified.
7.2 Qualification of the equipment used for primary packing should be carried out at
the minimum and maximum operating ranges defined for the critical process
parameters such as temperature, machine speed and sealing pressure or for any
other factors.
8. QUALIFICATION OF UTILITIES
8.1 The quality of steam, water, air, other gases etc. should be confirmed following
installation using the qualification steps described in section 3 above.
8.2 The period and extent of qualification should reflect any seasonal variations, if
applicable, and the intended use of the utility.
8.3 A risk assessment should be carried out where there may be direct contact with
the product, e.g. heating, ventilation and air-conditioning (HVAC) systems, or
indirect contact such as through heat exchangers to mitigate any risks of failure.
9. VALIDATION OF TEST METHODS

9.1 All analytical test methods used in qualification, validation or cleaning exercises
should be validated with an appropriate detection and quantification limit, where
necessary, as defined in Chapter 6 of the PIC/S GMP guide Part I.
9.2 Where microbial testing of product is carried out, the method should be validated
to confirm that the product does not influence the recovery of microorganisms.
9.3 Where microbial testing of surfaces in clean rooms is carried out, validation
should be performed on the test method to confirm that sanitising agents do not
influence the recovery of microorganisms.
10. CLEANING VALIDATION

10.1 Cleaning validation should be performed in order to confirm the effectiveness of
any cleaning procedure for all product contact equipment. Simulating agents may
be used with appropriate scientific justification. Where similar types of equipment
are grouped together, a justification of the specific equipment selected for
cleaning validation is expected.
10.2 A visual check for cleanliness is an important part of the acceptance criteria for
cleaning validation. It is not generally acceptable for this criterion alone to be

used. Repeated cleaning and retesting until acceptable residue results are
obtained is not considered an acceptable approach.
10.3 It is recognised that a cleaning validation programme may take some time to
complete and validation with verification after each batch may be required for
some products e.g. investigational medicinal products. There should be sufficient
data from the verification to support a conclusion that the equipment is clean and
available for further use.
10.4 Validation should consider the level of automation in the cleaning process. Where
an automatic process is used, the specified normal operating range of the utilities
and equipment should be validated.
10.5 For all cleaning processes an assessment should be performed to determine the
variable factors which influence cleaning effectiveness and performance, e.g.
operators, the level of detail in procedures such as rinsing times etc. If variable
factors have been identified, the worst case situations should be used as the
basis for cleaning validation studies.
10.6 Limits for the carryover of product residues should be based on a toxicological
evaluation2. The justification for the selected limits should be documented in a
risk assessment which includes all the supporting references. Limits should be
established for the removal of any cleaning agents used. Acceptance criteria
should consider the potential cumulative effect of multiple items of equipment in
the process equipment train.
10.6.1 Therapeutic macromolecules and peptides are known to degrade and denature
when exposed to pH extremes and/or heat, and may become pharmacologically
inactive. A toxicological evaluation may therefore not be applicable in these
circumstances.
10.6.2 If it is not feasible to test for specific product residues, other representative
parameters may be selected, e.g. total organic carbon (TOC) and conductivity.
10.7 The risk presented by microbial and endotoxin contamination should be

considered during the development of cleaning validation protocols.
10.8 The influence of the time between manufacture and cleaning and the time
between cleaning and use should be taken into account to define dirty and clean
hold times for the cleaning process.
10.9 Where campaign manufacture is carried out, the impact on the ease of cleaning
at the end of the campaign should be considered and the maximum length of a
campaign (in time and/or number of batches) should be the basis for cleaning
validation exercises.
10.10 Where a worst case product approach is used as a cleaning validation model, a
scientific rationale should be provided for the selection of the worst case product
and the impact of new products to the site assessed. Criteria for determining the
worst case may include solubility, cleanability, toxicity, and potency.
2 In the EU/EEA, this is the EMA Guideline on setting health based exposure limits for use in risk
identification in the manufacture of different medicinal products in shared facilities

10.11 Cleaning validation protocols should specify or reference the locations to be

sampled, the rationale for the selection of these locations and define the
acceptance criteria.
10.12 Sampling should be carried out by swabbing and/or rinsing or by other means
depending on the production equipment. The sampling materials and method
should not influence the result. Recovery should be shown to be possible from
all product contact materials sampled in the equipment with all the sampling
methods used.
10.13 The cleaning procedure should be performed an appropriate number of times

based on a risk assessment and meet the acceptance criteria in order to prove
that the cleaning method is validated.
10.14 Where a cleaning process is ineffective or is not appropriate for some equipment,
dedicated equipment or other appropriate measures should be used for each
product as indicated in chapters 3 and 5 of the PIC/S GMP Guide.
10.15 Where manual cleaning of equipment is performed, it is especially important that

the effectiveness of the manual process should be confirmed at a justified
frequency.
11. CHANGE CONTROL

11.1 The control of change is an important part of knowledge management and should
be handled within the pharmaceutical quality system.
11.2 Written procedures should be in place to describe the actions to be taken if a

planned change is proposed to a starting material, product component, process,
equipment, premises, product range, method of production or testing, batch size,
design space or any other change during the lifecycle that may affect product
quality or reproducibility.
11.3 Where design space is used, the impact on changes to the design space should
be considered against the registered design space within the marketing
authorisation and the need for any regulatory actions assessed.
11.4 Quality risk management should be used to evaluate planned changes to

determine the potential impact on product quality, pharmaceutical quality
systems, documentation, validation, regulatory status, calibration, maintenance
and on any other system to avoid unintended consequences and to plan for any
necessary process validation, verification or requalification efforts.
11.5 Changes should be authorised and approved by the responsible persons or

relevant functional personnel in accordance with the pharmaceutical quality
system.
11.6 Supporting data, e.g. copies of documents, should be reviewed to confirm that
the impact of the change has been demonstrated prior to final approval.

11.7 Following implementation, and where appropriate, an evaluation of the

effectiveness of change should be carried out to confirm that the change has
been successful.
12. GLOSSARY
Definitions of terms relating to qualification and validation which are not given in other
sections of the current PIC/S Guide to GMP are given below.
Bracketing approach:
A science and risk based validation approach such that only batches on the
extremes of certain predetermined and justified design factors, e.g. strength,
batch size, and/or pack size, are tested during process validation. The design
assumes that validation of any intermediate levels is represented by validation of
the extremes. Where a range of strengths is to be validated, bracketing could be
applicable if the strengths are identical or very closely related in composition, e.g.
for a tablet range made with different compression weights of a similar basic
granulation, or a capsule range made by filling different plug fill weights of the
same basic composition into different size capsule shells. Bracketing can be
applied to different container sizes or different fills in the same container closure
system.
Change Control
A formal system by which qualified representatives of appropriate disciplines
review proposed or actual changes that might affect the validated status of
facilities, systems, equipment or processes. The intent is to determine the need
for action to ensure and document that the system is maintained in a validated
state.
Cleaning Validation
Cleaning validation is documented evidence that an approved cleaning procedure
will reproducibly remove the previous product or cleaning agents used in the
equipment below the scientifically set maximum allowable carryover level.
Cleaning verification
The gathering of evidence through chemical analysis after each batch/campaign
to show that the residues of the previous product or cleaning agents have been
reduced below the scientifically set maximum allowable carryover level.
Concurrent Validation
Validation carried out in exceptional circumstances, justified on the basis of
significant patient benefit, where the validation protocol is executed concurrently
with commercialisation of the validation batches.
Continuous process verification
An alternative approach to process validation in which manufacturing process
performance is continuously monitored and evaluated. (ICH Q8)

Control Strategy:
A planned set of controls, derived from current product and process
understanding that ensures process performance and product quality. The
controls can include parameters and attributes related to drug substance and
drug product materials and components, facility and equipment operating
conditions, in-process controls, finished product specifications, and the
associated methods and frequency of monitoring and control. (ICH Q10)
Critical process parameter (CPP)
A process parameter whose variability has an impact on a critical quality attribute
and therefore should be monitored or controlled to ensure the process produces
the desired quality. (ICH Q8)
Critical quality attribute (CQA)
A physical, chemical, biological or microbiological property or characteristic that
should be within an approved limit, range or distribution to ensure the desired
product quality. (ICH Q8)
Design qualification (DQ)
The documented verification that the proposed design of the facilities, systems
and equipment is suitable for the intended purpose.
Design Space
The multidimensional combination and interaction of input variables, e.g. material
attributes, and process parameters that have been demonstrated to provide
assurance of quality. Working within the design space is not considered as a
change. Movement out of the design space is considered to be a change and
would normally initiate a regulatory post approval change process. Design space
is proposed by the applicant and is subject to regulatory assessment and
approval. (ICH Q8)
Installation Qualification (IQ)
The documented verification that the facilities, systems and equipment, as
installed or modified, comply with the approved design and the manufacturer’s
recommendations.
Knowledge management
A systematic approach to acquire, analyse, store and disseminate information.
(ICH Q10)
Lifecycle
All phases in the life of a product, equipment or facility from initial development
or use through to discontinuation of use.
Ongoing Process Verification (also known as continued process verification)
Documented evidence that the process remains in a state of control during
commercial manufacture.
Operational Qualification (OQ)
The documented verification that the facilities, systems and equipment, as
installed or modified, perform as intended throughout the anticipated operating
ranges.

Performance Qualification (PQ)

The documented verification that systems and equipment can perform effectively
and reproducibly based on the approved process method and product
specification.
Process Validation
The documented evidence that the process, operated within established
parameters, can perform effectively and reproducibly to produce a medicinal
product meeting its predetermined specifications and quality attributes.
Product realisation
Achievement of a product with the quality attributes to meet the needs of patients,
health care professionals and regulatory authorities and internal customer
requirements. (ICH Q10)
Prospective Validation
Validation carried out before routine production of products intended for sale.
Quality by design
A systematic approach that begins with predefined objectives and emphasises
product and process understanding and process control, based on sound science
and quality risk management.
Quality risk management
A systematic process for the assessment, control, communication and review of
risks to quality across the lifecycle. (ICH Q9)
Simulated agents
A material that closely approximates the physical and, where practical, the
chemical characteristics, e.g. viscosity, particle size, pH etc., of the product under
validation.
State of control
A condition in which the set of controls consistently provides assurance of
acceptable process performance and product quality.
Traditional approach
A product development approach where set points and operating ranges for
process parameters are defined to ensure reproducibility.
User requirements Specification (URS)
The set of owner, user, and engineering requirements necessary and sufficient
to create a feasible design meeting the intended purpose of the system.
Worst Case
A condition or set of conditions encompassing upper and lower processing limits
and circumstances, within standard operating procedures, which pose the
greatest chance of product or process failure when compared to ideal conditions.
Such conditions do not necessarily induce product or process failure.

Annex 16 Authorised person and batch release
ANNEX 16
CERTIFICATION BY THE AUTHORISED PERSON AND

BATCH RELEASE
SCOPE
This Annex provides guidance on the certification by an Authorised Person and
on batch release of medicinal products for human or veterinary use within a
Pharmaceutical Inspection Co-operation Scheme (PIC/S) Participating Authority
or made for export. The principles of this guidance also apply to investigational
medicinal products (IMP) for human use, subject to any difference in the legal
provisions and more specific guidance published by PIC/S Participating
Authorities under national law.
Guidance in this Annex on the certification of batches by a manufacturer of a

medicinal product is within the scope of the Pharmaceutical Inspection Co-
operation Scheme. However, each PIC/S Participating Authority may decide
whether guidance expressed in this annex should become a legally-binding
standard in relation to imported medicinal products.
This Annex does not address any controls on release of medicinal products by a
National Competent Authority under national law (e.g. certain blood and
immunological products); however, this Annex does apply to the Authorised
Person certification and subsequent release of such batches.
The basic arrangements for batch release for a medicinal product are defined by
its marketing authorisation (MA). Nothing in this Annex should be taken as
overriding those arrangements.
GENERAL PRINCIPLES
The ultimate responsibility for the performance of a medicinal product over its
lifetime, its safety, quality and efficacy, lies with the marketing authorisation
holder (MAH).
However, the Authorised Person is responsible for ensuring that each individual
batch has been manufactured and checked in compliance with national
requirements in accordance with the requirements of the marketing authorisation
(MA) and with Good Manufacturing Practice (GMP).
The process of batch release comprises of:
i. The checking of the manufacture and testing of the batch in accordance

with defined release procedures.

ii. The certification of the finished product batch performed by an Authorised

Person signifying that the batch is in compliance with GMP and the
requirements of its MA. This represents the quality release of the batch.
iii. The transfer to saleable stock, and/or export of the finished batch of
product which should take into account the certification performed by the
Authorised Person. If this transfer is performed at a site other than that
where certification takes place, then the arrangement should be
documented in a written agreement between the sites.
The purpose of controlling batch release is notably to ensure that:
i. The batch has been manufactured and checked in accordance with the
requirements of its MA.
ii. The batch has been manufactured and checked in accordance with the
principles and guidelines of GMP.
iii. Any other relevant legal requirements are taken into account.
iv. In the event that a quality defect as referred to in Chapter 8 of PIC/S GMP
Guide, Part I, needs to be investigated or a batch recalled, to ensure that
any Authorised Persons involved in the certification or confirmation1 and
any relevant records are readily identifiable.
1. THE PROCESS OF CERTIFICATION

1.1. Each batch of finished product must be certified2 by an Authorised Person before
being released for sale, supply or export. Certification can only be performed by
an Authorised Person of the manufacturer and/or importer which are described
in the MA.
1.2. Any Authorised Person involved in the certification or confirmation of a batch

must have detailed knowledge of the steps for which they are taking
responsibility. The Authorised Persons should be able to prove their continuous
training regarding the product type, production processes, technical advances
and changes to GMP.
1.3. There may be several sites involved in the various stages of manufacture,
importation, testing and storage of a batch before it undergoes certification.
Regardless of how many sites are involved, the Authorised Person performing
certification of the finished product must ensure that all necessary steps have
been completed under accepted pharmaceutical quality systems to assure
compliance of the batch with GMP, the MA and any other national requirements
where certification is taking place.
1 Information required for the confirmation, where Authorised Person responsibilities for the
batch are being transferred between sites, is recommended in Appendix I to this Annex.
2 The contents of a batch certificate for medicinal products are recommended in Appendix
II to this Annex. The content of a batch certificate may differ from Appendix II as required
under national law or as required to facilitate arrangements between National Competent
Authorities.

1.4. Each manufacturing site must have at least one Authorised Person.
1.4.1 Where the site only undertakes partial manufacturing operations in relation to a
batch, then an Authorised Person at that site must at least confirm that the
operations undertaken by the site have been performed in accordance with GMP
and the terms of the written agreement detailing the operations for which the site
is responsible. If the Authorised Person is responsible for providing confirmation
of compliance for those operations with the relevant MA, then the Authorised
Person should have access to the necessary details of the MA.
1.4.2 The Authorised Person who performs certification of the finished product batch
should assume full responsibility for all stages of manufacture of the batch or this
responsibility may be shared with other Authorised Persons who have provided
confirmation for specified steps in the manufacture and control of a batch. These
could be other Authorised Persons who are operating under the same
manufacturing authorisation holder or operating under different manufacturing
authorisation holders
1.4.3 Any sharing of responsibilities amongst Authorised Persons in relation to

compliance of a batch must be defined in a written agreement. This document
should detail responsibility for assessment of the impact any deviation(s)
has/have on compliance of the batch with GMP and the MA.
1.5 For medicinal products manufactured outside the jurisdiction of a National

Competent Authority, physical importation and certification are the final stages of
manufacturing which precede the transfer to saleable stock of the batch,
depending on national law.
1.5.1 The process of certification as described in Section 1 of this Annex, applies to all
medicinal products intended to be released within domestic markets, or for
export, irrespective of the complexity of the supply chain and the global locations
of manufacturing sites involved.
1.5.2 In accordance with the principles described in Section 1.4 of this Annex and the
law in each jurisdiction, the Authorised Person certifying the finished medicinal
product batch may take account of the confirmation by, and share defined
responsibilities with, other Authorised Persons in relation to any manufacturing
or importation operations taking place at other sites in the same jurisdiction and
other manufacturing authorisation holders defined in the relevant MA.
1.5.3 Conditions of storage and transport for the batch and the sample, if sent
separately, should be taken into account by the Authorised Person before
certification of a batch.
1.5.4 The Authorised Person certifying the finished product is responsible for ensuring
that each finished medicinal product batch has been manufactured in accordance
with GMP and the MA. The Authorised Person is also responsible for ensuring
that the finished medicinal product batch has undergone testing required upon
importation in accordance with national law.
1.5.5 If sampling of imported product is necessary, it should be fully representative of

the batch. Samples may either be taken after arrival in the jurisdiction of the
National Competent Authority, or be taken at the manufacturing site located in

another jurisdiction in accordance with national law and a technically justified

approach which is documented within the company’s quality system.
Responsibilities in relation to the sampling should be defined in a written
agreement between the sites. Any samples taken outside the National
Competent Authority jurisdiction should be shipped under equivalent transport
conditions as the batch that they represent.
1.5.6 Where sampling is performed at a manufacturing site located in another

jurisdiction, the technical justification should include a formal Quality Risk
Management process to identify and manage any risks associated with this
approach. This should be fully documented and include at least the following
elements:
i. Audit of the manufacturing activity including any sampling activity in the

other jurisdiction and evaluation of subsequent transportation steps of
both the batch and samples to ensure that the samples are representative
of the imported batch.
ii. A comprehensive scientific study, including data to support any
conclusions that samples taken in the other jurisdiction are representative
of the batch after importation. This study should at least include:
 description of the sampling process in the other jurisdiction;
 description of the transported conditions of the sample and the
imported batch. Any differences should be justified;
 comparative analysis of samples taken in the other jurisdiction and
samples taken after importation; and
 consideration of the time interval between sampling and importation
of the batch and generation of data to support appropriate defined
limits.
iii. Provision for random periodic analysis of samples taken after importation
to justify ongoing reliance on samples taken in another jurisdiction.
iv. A review of any unexpected result or confirmed out of specification result.
These may have implications for reliance on sampling performed at a
manufacturing site located in another jurisdiction and should be notified to
the National Competent Authority for the site where certification is
performed. Such an occurrence should be regarded as a potential quality
defect and investigated in line with the guidance in Chapter 8 of the PIC/S
GMP Guide, Part I.
1.5.7 Different imported finished product batches may originate from the same bulk
product batch. If testing upon importation is required (see 1.5.4), the Authorised
Person(s) certifying the different finished product batches may base their decision
on the quality control testing of the first imported finished batch provided that a
justification has been documented based on Quality Risk Management
principles. This should take into account the provisions of paragraph 1.5.6 in
relation to reliance on any samples taken in another jurisdiction. Evidence should
be available to ensure that the integrity and identity of the imported finished
product batch has been established through documented verification of at least
the following:
i. relevant requirements for storage of the bulk product prior to packaging

have been satisfied;

ii. the finished product batch has been stored and transported under the
required conditions;
iii. the consignment has remained secure and there is no evidence of
tampering during storage or transportation;
iv. correct identification of the product has been established; and
v. the sample(s) tested are representative of all finished product batches
derived from the bulk batch.
1.6 The Authorised Person must ensure that the following operational responsibilities
are fulfilled prior to certification of a batch:
i. Certification is permitted under the terms of any authorisation by the

national competent authority.
ii. Any additional duties and requirements of national law are complied with.
iii. Certification is recorded in accordance with this Annex and in accordance
to national law.
1.7 In addition, the Authorised Person has responsibility for ensuring points 1.7.1 to
1.7.21 are secured. These tasks may be delegated to appropriately trained
personnel or third parties. It is recognised that the Authorised Person will need to
rely on the pharmaceutical quality system and the Authorised Person should have
on-going assurance that this reliance is well founded.
1.7.1 All activities associated with manufacture and testing of the medicinal product
have been conducted in accordance with the principles and guidelines of GMP.
1.7.2 The entire supply chain of the active substance and medicinal product up to the
stage of certification is documented and available for the Authorised Person. This
should include the manufacturing sites of the starting materials and packaging
materials for the medicinal product and any other materials deemed critical
through a risk assessment of the manufacturing process. The document should
preferably be in the format of a comprehensive diagram, where each party,
including subcontractors of critical steps such as the sterilisation of components
and equipment for aseptic processing, are included.
1.7.3 All audits of sites involved in the manufacture and the testing of the medicinal
products and in the manufacture of the active substance have been carried out
and that the audit reports are available to the Authorised Person performing the
certification.
1.7.4 All sites of manufacture, analysis and certification are compliant with the terms of
the MA for the intended jurisdiction.
1.7.5 All manufacturing activities and testing activities are consistent with those
described in the MA.
1.7.6 The source and specifications of starting materials and packaging materials used
in the batch are compliant with the MA. Supplier quality management systems
are in place that ensures only materials of the required quality have been
supplied.

1.7.7 For medicinal products, the active substances have been manufactured in
accordance with GMP and, where required, distributed in accordance with Good
Distribution Practice (GDP) for Active Substances.
1.7.8 Active substances used in the manufacture of medicinal products for human use
shall only be imported if the active substances comply with the following
requirements:
i. the active substances have been manufactured in accordance with

standards of GMP and, where applicable, distributed in accordance with
Good Distribution Practice according to national law; and
ii. there is evidence of GMP compliance of the manufacturer of the active
substance in accordance to national law.
1.7.9 The excipients used to manufacture a medicinal product have been

manufactured with an appropriate good manufacturing practice. Where
applicable, this shall be in accordance with PI 045-1: Guidelines on the formalised
risk assessment for ascertaining the appropriate good manufacturing practice for
excipients of medicinal products for human use.
1.7.10 When relevant, the TSE (Transmissible Spongiform Encephalopathy) status of

all materials used in batch manufacture is compliant with the terms of the MA.
1.7.11 All records are complete and endorsed by appropriate personnel. All required in-
process controls and checks have been made.
1.7.12 All manufacturing and testing processes remain in the validated state. Personnel
are trained and qualified as appropriate.
1.7.13 Finished product quality control (QC) test data complies with the Finished Product
Specification described in the MA, or where authorised, the Real Time Release
Testing programme.
1.7.14 Any regulatory post-marketing commitments relating to manufacture or testing of

the product have been addressed. On-going stability data continues to support
certification.
1.7.15 The impact of any change to product manufacturing or testing has been
evaluated and any additional checks and tests are complete.
1.7.16 All investigations pertaining to the batch being certified (including out of
specification and out of trend investigations) have been completed to a sufficient
level to support certification.
1.7.17 A batch should not be certified if there are any on-going complaints,
investigations or recalls that may have impact on the batch.
1.7.18 The required technical agreements are in place.
1.7.19 The self-inspection programme is active and current.
1.7.20 The appropriate arrangements for distribution and shipment are in place.

1.7.21 Where required in national law, safety features have been affixed to the
packaging enabling wholesale distributors and persons authorised or entitled to
supply medicinal products to the public to:
i. verify the authenticity of the medicinal product;

ii. identify individual packs; and
iii. verify, via a device, of whether the outer packaging has been tampered
with.
1.8 For certain products, special guidance may apply, such as PIC/S GMP Guide
Annex 2: Manufacture of Biological active substances and Medicinal Products for
Human Use, and Annex 3: Manufacture of Radiopharmaceuticals.
1.9 In the case of parallel importation and parallel distribution, any repackaging
operation carried out on a batch which has already been released must be
approved by the competent authority of the intended market, as applicable under
national law.
1.9.1 Prior to certification of a repacked batch the Authorised Person should confirm
compliance with national requirements for parallel importation and rules for
parallel distribution.
1.9.2 The Authorised Person, who is responsible for the certification of the batch in the
MA of the repackaged finished product, certifies that the repackaging has been
performed in accordance with the relevant authorisation pertaining to the
repackaged product and GMP.
1.10 Recording of Authorised Person certification:
1.10.1 The certification of a medicinal product is recorded by the Authorised Person in

the document provided for that purpose. The record should show that each
production batch satisfies the following provisions:
i. Each batch of medicinal products has been manufactured and checked in

compliance with national law and in accordance with the requirements of
the marketing authorisation.
ii. In the case of medicinal products coming from another jurisdiction each
production batch has a full qualitative analysis, a quantitative analysis of
at least all the active substances and all the other tests or checks
necessary to ensure the quality of medicinal products in accordance with
the requirements of the marketing authorisation. Such testing is also
performed in the importing country where required in national law.
iii. In the case of medicinal products imported from another jurisdiction,
where appropriate arrangements have been made with the exporting
jurisdiction to ensure that the manufacturer of the medicinal product
applies standards of good manufacturing practice at least equivalent to
those laid down by the national competent authority, and to ensure that
the controls referred to under point (ii) have been carried out in the
exporting country, the authorised person may be relieved of responsibility
for carrying out those controls.

iv. The record must be kept up to date as operations are carried out and must
remain at the disposal of the agents of the National Competent Authority
the longer of one year after expiry of the batch or five years unless
otherwise specified in national law.
1.10.2 The control report referred to in 1.10.1 or another proof for release for sale,
supply, or export, based on an equivalent system, should be made available for
the batch in order to be exempted from further controls when entering another
National Competent Authority jurisdiction.
2. RELYING ON GMP ASSESSMENTS BY THIRD PARTIES, E.G.

AUDITS
In some cases the Authorised Person will rely on the correct functioning of the
pharmaceutical quality system of sites involved in the manufacture of the product
and this may be derived from audits conducted by third parties.
2.1 Relying on assessment by third parties, e.g. audits should be in accordance with
Chapter 7 of the PIC/S GMP Guide in order to appropriately define, agree and
control any outsourced activity.
2.2 Special focus should be given to the approval of audit reports:
i. The audit report should address general GMP requirements, as for

example the quality management system, all relevant production and
quality control procedures related to the supplied product, e.g. active
substance manufacturing, quality control testing, primary packaging, etc.
All audited areas should be accurately described resulting in a detailed
report of the audit.
ii. It should be determined whether the manufacture and quality control of
the active substance and medicinal product complies with GMP or in case
of manufacture in another jurisdiction, GMP at least equivalent to that of
each National Competent Authority.
iii. In case of outsourced activities compliance with the MA should be verified.
iv. The Authorised Person should ensure that a written final assessment and
approval of third party audit reports have been made. The Authorised
Person should have access to all documentation which facilitates review
of the audit outcome and continued reliance on the outsourced activity.
v. Outsourced activities with critical impact on product quality should be
defined in accordance with the principles of Quality Risk Management as
described in Annex 20 of the PIC/S GMP Guide. According to this, the
Authorised Person should be aware of the outcome of an audit with critical
impact on the product quality before certifying the relevant batches.
vi. Repeated audits should be performed in accordance with the principles of
Quality Risk Management.

3. HANDLING OF UNEXPECTED DEVIATIONS

Provided registered specifications for active substances, excipients, packaging
materials and medicinal products are met, an Authorised Person may consider
confirming compliance or certifying a batch where an unexpected deviation
concerning the manufacturing process and/or the analytical control methods from
details contained within the MA and/or GMP has occurred. The deviation should
be thoroughly investigated and the root cause corrected. This may require the
submission of a variation to the MA for the continued manufacture of the product.
3.1 The impact of the deviation should be assessed in accordance with a quality risk
management process using an appropriate approach such as described in Annex
20 of the PIC/S GMP Guide. The quality risk management process should include
the following;
i. Evaluation of the potential impact of the deviation on quality, safety or

efficacy of the batch(es) concerned and conclusion that the impact is
negligible.
ii. Consideration of the need to include the affected batch(es) in the ongoing
stability programme.
iii. In the case of biological medicinal products, consideration that any
deviations from the approved process can have an unexpected impact on
safety and efficacy.
Taking account that responsibilities may be shared between more than one
Authorised Person involved in the manufacture and control of a batch, the
Authorised Person performing certification of a batch of medicinal product should
be aware of and take into consideration any deviations which have the potential
to impact compliance with GMP and/or compliance with the MA.
4. THE RELEASE OF A BATCH

4.1 Batches of medicinal products should only be released for sale or supply to the
market after certification by an Authorised Person as described above. Until a
batch is certified, it should remain at the site of manufacture or be shipped under
quarantine to another site which has been approved for that purpose by the
relevant National Competent Authority.
4.2 Safeguards to ensure that uncertified batches are not transferred to saleable
stock should be in place and may be physical in nature, e.g. the use of
segregation and labelling or electronic in nature, e.g. the use of validated
computerised systems. When uncertified batches are moved from one authorised
site to another, the safeguards to prevent premature release should remain.
4.3 The steps necessary to notify Authorised Person certification to the site where
the transfer to saleable stock is to take place should be defined within a technical
agreement. Such notification by an Authorised Person to the site should be formal
and unambiguous and should be subject to the requirements of Chapter 4 of the
PIC/S GMP Guide, Part I.

4.4 National law may require a specific release for the local market (market release)
by the MAH which takes into consideration the certification of the finished product
by the manufacturer.
GLOSSARY TO ANNEX 16
Certain words and phrases in this annex are used with the particular meanings defined
below. Reference should also be made to the Glossary in the main part of the PIC/S
GMP Guide.
Certification of the finished product batch

The certification in a document by an Authorised Person, as defined in this annex, and
represents the quality release of the batch before the batch is released for sale or
distribution.
Confirmation (Confirm and confirmed have equivalent meanings)

A signed statement by an Authorised Person that a process or test has been conducted
in accordance with GMP and the relevant marketing authorisation or clinical trial
authorisation, product specification file and/or technical agreement, as applicable, as
agreed in writing with the Authorised Person responsible for certifying the finished
product batch before release. The Authorised Person providing a confirmation takes
responsibility for those activities being confirmed.
Finished product batch

With reference to the control or test of the finished product, a finished medicinal product
batch is an entity which comprises all the units of a pharmaceutical form which are made
from the same initial quantity of material and have undergone the same series of
manufacturing and/or sterilisation operations or, in the case of a continuous production
process, all the units manufactured in a given period of time. In the context of this annex
the term in particular denotes the batch of product in its final pack for release to the
market.
Importer
Any holder of the authorisation to import as required by national law.
Jurisdiction
A jurisdiction is a territory within which a court or government agency is exercising its
power. A jurisdiction can be e.g. a State (whether internationally recognised or not) or a
region.

APPENDIX I
Recommended content of the confirmation of the partial
manufacturing of a medicinal product
[LETTER HEAD OF MANUFACTURER WHO CARRIED OUT THE MANUFACTURING
ACTIVITY]
1. Name of the product and description of the manufacturing stage (e.g.

paracetamol 500 mg tablets, primary packaging into blister packs).
2. Batch number.
3. Name and address of the site carrying out the partial manufacturing.
4. Reference to the Technical Quality Agreement (in accordance with Chapter 7 of

the PIC/S GMP Guide).
5. Confirmation statement.
I hereby confirm that the manufacturing stages referred to in the Technical Quality
Agreement have been carried out in full compliance with the GMP requirements
of the [insert jurisdiction] and the terms described in the Agreement for ensuring
compliance with the requirements of the Marketing Authorisation(s) as provided
by [Contract Giver/manufacturer certifying and releasing the batch].
6. Name of the Authorised Person confirming the partial manufacturing.
7. Signature of Authorised Person confirming the partial manufacturing.
8. Date of signature.

APPENDIX II
Recommended content of the Batch Certificate for Medicinal
Products
[LETTER HEAD OF THE BATCH CERTIFYING AND RELEASING MANUFACTURER]
1. Name, strength/potency, dosage form and package size

(identical to the text on the finished product package).
2. Batch number of the finished product.
3. Name of the destination country/countries of the batch.
4. Certification statement.
I hereby certify that all the manufacturing stages of this batch of finished product
have been carried out in full compliance with the GMP requirements of the [insert
jurisdiction] and [as applicable] with the requirements of the Marketing
Authorisation(s) of the destination country/countries.
5. Name of the Authorised Person certifying the batch.
6. Signature of the Authorised Person certifying the batch.
7. Date of signature.

Annex 17 Real Time Release & Parametric Release
ANNEX 17
REAL TIME RELEASE TESTING AND

PARAMETRIC RELEASE
1. PRINCIPLE
1.1 Medicinal products must comply with their approved specifications and subject to
compliance with GMP, can normally be released to market by performing a
complete set of tests on active substances and/or finished products as defined in
the relevant marketing authorisation or clinical trial authorisation. In specific
circumstances, where authorised, based on product knowledge and process
understanding, information collected during the manufacturing process can be
used instead of end-product testing for batch release. Any separate activities
required for this form of batch release should be integrated into the
Pharmaceutical Quality System (PQS).
2. SCOPE
2.1 This document is intended to outline the requirements for application of Real
Time Release Testing (RTRT) and parametric release, where the control of
critical parameters and relevant material attributes are authorised as an
alternative to routine end-product testing of active substances and/or finished
products. A specific aim of this guideline is to incorporate the application of RTRT
to any stage in the manufacturing process and to any type of finished products or
active substances, including their intermediates.
3. REAL TIME RELEASE TESTING (RTRT)

3.1 Under RTRT, a combination of in-process monitoring and controls may provide,
when authorised, a substitute for end-product testing as part of the batch release
decision. Interaction with all relevant regulatory authorities prior and during the
assessment process preceding regulatory approval is required. The level of
interaction will depend on the level of complexity of the RTRT control procedure
applied on site.
3.2 When designing the RTRT strategy, the following minimum criteria are expected
to be established and met:
(i) Real time measurement and control of relevant in-process material

attributes and process parameters should be accurate predictors of the
corresponding finished product attributes.
(ii) The valid combination of relevant assessed material attributes and
process controls to replace finished product attributes should be
established with scientific evidence based on material, product and
process knowledge.

(iii) The combined process measurements (process parameters and material

attributes) and any other test data generated during the manufacturing
process should provide a robust foundation for RTRT and the batch
release decision.
3.3 A RTRT strategy should be integrated and controlled through the PQS. This
should include or reference information at least of the following:
- quality risk management, including a full process related risk
assessment, in accordance with the principles described in the PIC/S
Guide to Good Manufacturing Practice for Medicinal Products, Part I
Chapter 1 and Part II Chapter 2,
- change control program,
- control strategy,
- specific personnel training program,
- qualification and validation policy,
- deviation/CAPA system,
- contingency procedure in case of a process sensor/equipment failure,
- periodic review/assessment program to measure the effectiveness of the
RTRT plan for continued assurance of product quality.
3.4 In accordance with the principles described in the PIC/S Guide to Good
Manufacturing Practice for Medicinal Products, Part I Chapter 1, Part II Chapter
13 and Annex 15, the change control program is an important part of the real time
release testing approach. Any change that could potentially impact product
manufacturing and testing, or the validated status of facilities, systems,
equipment, analytical methods or processes, should be assessed for risk to
product quality and impact on reproducibility of the manufacturing process. Any
change should be justified by the sound application of quality risk management
principles, and fully documented. After change implementation, an evaluation
should be undertaken to demonstrate that there are no unintended or deleterious
impact on product quality.
3.5 A control strategy should be designed not only to monitor the process, but also
to maintain a state of control and ensure that a product of the required quality will
be consistently produced. The control strategy should describe and justify the
selected in-process controls, material attributes and process parameters which
require to be routinely monitored and should be based on product, formulation
and process understanding. The control strategy is dynamic and may change
throughout the lifecycle of the product requiring the use of a quality risk
management approach and of knowledge management. The control strategy
should also describe the sampling plan and acceptance/rejection criteria.
3.6 Personnel should be given specific training on RTRT technologies, principles and
procedures. Key personnel should demonstrate adequate experience, product
and process knowledge and understanding. Successful implementation of RTRT
requires input from a cross-functional/multi-disciplinary team with relevant
experience on specific topics, such as engineering, analytics, chemometric
modeling or statistics.
3.7 Important parts of the RTRT strategy are validation and qualification policy, with
particular reference to advanced analytical methods. Particular attention should
be focused on the qualification, validation and management of in-line and on-line

analytical methods, where the sampling probe is placed within the manufacturing
equipment.
3.8 Any deviation or process failure should be thoroughly investigated and any
adverse trending indicating a change in the state of control should be followed up
appropriately.
3.9 Continuous learning through data collection and analysis over the life cycle of a
product is important and should be part of the PQS. With advances in technology,
certain data trends, intrinsic to a currently acceptable process, may be observed.
Manufacturers should scientifically evaluate the data, in consultation if
appropriate, with the regulatory authorities, to determine how or if such trends
indicate opportunities to improve quality and/or consistency.
3.10 When RTRT has been approved, this approach should be routinely used for
batch release. In the event that the results from RTRT fail or are trending toward
failure, a RTRT approach may not be substituted by end-product testing. Any
failure should be thoroughly investigated and considered in the batch release
decision depending on the results of these investigations, and must comply with
the content of the marketing authorisation and GMP requirements. Trends should
be followed up appropriately.
3.11 Attributes (e.g. uniformity of content) that are indirectly controlled by approved
RTRT should still appear in the Certificate of Analysis for batches. The approved
method for testing the end-product should be mentioned and the results given as
“Complies if tested” with a footnote: “Controlled by approved Real Time Release
Testing”.
4. PARAMETRIC RELEASE AND STERILISATION
4.1 This section provides guidance on parametric release which is defined as the
release of a batch of terminally sterilised product based on a review of critical
process control parameters rather than requiring an end-product testing for
sterility.
4.2 An end-product test for sterility is limited in its ability to detect contamination as it
utilises only a small number of samples in relation to the overall batch size, and
secondly, culture media may only stimulate growth of some, but not all,
microorganisms. Therefore, an end-product testing for sterility only provides an
opportunity to detect major failures in the sterility assurance system (i.e. a failure
that results in contamination of a large number of product units and/or that result
in contamination by the specific microorganisms whose growth is supported by
the prescribed media). In contrast, data derived from in-process controls (e.g.
pre-sterilisation product bioburden or environmental monitoring) and by
monitoring relevant sterilisation parameters can provide more accurate and
relevant information to support sterility assurance of the product.
4.3 Parametric release can only be applied to products sterilised in their final
container using either moist heat, dry heat or ionising radiation (dosimetric
release).

4.4 To utilise this approach, the manufacturer should have a history of acceptable
GMP compliance and a robust sterility assurance program in place to
demonstrate consistent process control and process understanding.
4.5 The sterility assurance program should be documented and include, at least, the
identification and monitoring of the critical process parameters, steriliser cycle
development and validation, container/packaging integrity validation, bioburden
control, environmental monitoring program, product segregation plan, equipment,
services and facility design and qualification program, maintenance and
calibration program, change control program, personnel training, and incorporate
a quality risk management approach.
4.6 Risk management is an essential requirement for parametric release and should
focus on mitigating the factors which increase the risk of failure to achieve and
maintain sterility in each unit of every batch. If a new product or process is being
considered for parametric release, then a risk assessment should be conducted
during process development including an evaluation of production data from
existing products if applicable. If an existing product or process is being
considered, the risk assessment should include an evaluation of any historical
data generated.
4.7 Personnel involved in the parametric release process should have experience in
the following areas: microbiology, sterility assurance, engineering, production
and sterilisation. The qualifications, experience, competency and training of all
personnel involved in parametric release should be documented.
4.8 Any proposed change which may impact on sterility assurance should be
recorded in the change control system and reviewed by appropriate personnel
who are qualified and experienced in sterility assurance.
4.9 A pre-sterilisation bio-burden monitoring program for the product and

components should be developed to support parametric release. The bioburden
should be performed for each batch. The sampling locations of filled units before
sterilization should be based on a worst-case scenario and be representative of
the batch. Any organisms found during bioburden testing should be identified to
confirm that they are not spore forming which may be more resistant to the
sterilising process.
4.10 Product bio-burden should be minimised by appropriate design of the

manufacturing environment and the process by:
- good equipment and facility design to allow effective cleaning,
disinfection and sanitisation;
- availability of detailed and effective procedures for cleaning, disinfection
and sanitisation;
- use of microbial retentive filters where possible;
- availability of operating practices and procedures which promote
personnel hygiene and enforce appropriate garment control;
- appropriate microbiological specifications for raw materials,
intermediates and process aids (e.g. gases)
4.11 For aqueous or otherwise microbiologically unstable products, the time lag
between dissolving the starting materials, product fluid filtration, and sterilisation

should be defined in order to minimise the development of bioburden and an

increase in endotoxins (if applicable).
Sterilisation Process
4.12 Qualification and validation are critical activities to assure that sterilisation
equipment can consistently meet cycle operational parameters and that the
monitoring devices provide verification of the sterilisation process.
4.13 Periodic requalification of equipment and revalidation of processes should be

planned and justified in accordance with the requirements of the PIC/S Guide to
Good Manufacturing Practice for Medicinal Products Annexes 1 and 15.
4.14 Appropriate measurement of critical process parameters during sterilisation is a

critical requirement in a parametric release program. The standards used for
process measuring devices should be specified and the calibration should be
traceable to national or international standards.
4.15 Critical process parameters should be established, defined and undergo periodic
re-evaluation. The operating ranges should be developed based on sterilisation
process, process capability, calibration tolerance limits and parameter criticality.
4.16 Routine monitoring of the steriliser should demonstrate that the validated
conditions necessary to achieve the specified process is achieved in each cycle.
Critical processes should be specifically monitored during the sterilisation phase.
4.17 The sterilisation record should include all the critical process parameters. The
sterilisation records should be checked for compliance to specification by at least
two independent systems. These systems may consist of two people or a
validated computer system plus a person.
4.18 Once parametric release has been approved by the regulatory authorities,
decisions for release or rejection of a batch should be based on the approved
specifications and the review of critical process control data. Routine checks of
the steriliser, changes, deviations, unplanned and routine planned maintenance
activities should be recorded, assessed and approved before releasing the
products to the market. Non-compliance with the specification for parametric
release cannot be overruled by a finished product passing the test for sterility.
5. GLOSSARY
Control strategy
A planned set of controls, derived from current product and process
understanding that ensures process performance and product quality. The
controls can include parameters and attributes related to drug substance and
drug product materials and components, facility and equipment operating
conditions, in-process controls, finished product specifications, and the
associated methods and frequency of monitoring and control.

Critical Process Parameters:

A process parameter whose variability has an impact on a critical quality attribute
and therefore should be monitored or controlled to ensure the process produces
the desired quality [ICH Q8 (R2)].
Critical Quality Attributes

A physical, chemical, biological, or microbiological property or characteristic that
should be within an appropriate limit, range, or distribution to ensure the desired
product quality. [ICH Q8 (R2)]
Parametric release
One form of RTRT. Parametric release for terminally sterilised product is based
on the review of documentation on process monitoring (e.g. temperature,
pressure, time for terminal sterilisation) rather than the testing of a sample for a
specific attribute (ICH Q8 Q&A).
Real time release testing

The ability to evaluate and ensure the quality of in-process and/or final product
based on process data, which typically include a valid combination of measured
material attributes and process controls. (ICH Q8)
State of Control
A condition in which the set of controls consistently provides assurance of
continued process performance and product quality. (ICH Q10)

Annex 18 GMP Guide for active pharmaceutical ingredients
[ANNEX 18]
[GMP GUIDE FOR ACTIVE PHARMACEUTICAL

INGREDIENTS] 1
1
The EU first adopted the ICH GMP Guide on APIs as Annex 18 to the EU GMP Guide while PIC/S
adopted it as a stand-alone GMP Guide (PE 007). The Guide has now been adopted as Part II of
the PIC/S GMP Guide (see PE 009 (Part II)).

Annex 19 Reference and Retention Samples
ANNEX 19
REFERENCE AND RETENTION SAMPLES
1. SCOPE
1.1 This Annex to the Guide to Good Manufacturing Practice for Medicinal Products
(“the GMP Guide”) gives guidance on the taking and holding of reference
samples of starting materials, packaging materials or finished products and
retention samples of finished products.
1.2 Specific requirements for investigational medicinal products are given in Annex
13 to the Guide.
1.3 This annex also includes guidance on the taking of retention samples for parallel
imported / distributed medicinal products.
2. PRINCIPLE
2.1 Samples are retained to fulfil two purposes; firstly to provide a sample for
analytical testing and secondly to provide a specimen of the fully finished product.
Samples may therefore fall into two categories:
Reference sample: a sample of a batch of starting material, packaging material

or finished product which is stored for the purpose of being analyzed should the
need arise during the shelf life of the batch concerned. Where stability permits,
reference samples from critical intermediate stages (e.g. those requiring
analytical testing and release) or intermediates that are transported outside of the
manufacturer’s control should be kept.
Retention sample: a sample of a fully packaged unit from a batch of finished

product. It is stored for identification purposes. For example, presentation,
packaging, labelling, patient information leaflet, batch number, expiry date should
the need arise during the shelf life of the batch concerned. There may be
exceptional circumstances where this requirement can be met without retention
of duplicate samples e.g. where small amounts of a batch are packaged for
different markets or in the production of very expensive medicinal products.
For finished products, in many instances the reference and retention samples will
be presented identically, i.e. as fully packaged units. In such circumstances,
reference and retention samples may be regarded as interchangeable.
2.2 It is necessary for the manufacturer, importer or site of batch release, as specified
under section 7 and 8, to keep reference and/or retention samples from each
batch of finished product and, for the manufacturer to keep a reference sample
from a batch of starting material (subject to certain exceptions – see 3.2 below)
and/or intermediate product. Each packaging site should keep reference samples
of each batch of primary and printed packaging materials. Availability of printed

materials as part of the reference and/or retention sample of the finished product
can be accepted.
2.3 The reference and/or retention samples serve as a record of the batch of finished
product or starting material and can be assessed in the event of, for example, a
dosage form quality complaint, a query relating to compliance with the marketing
authorisation, a labelling/packaging query or a pharmacovigilance report.
2.4 Records of traceability of samples should be maintained and be available for

review by competent authorities.
3. DURATION OF STORAGE
3.1 Reference and retention samples from each batch of finished product should be
retained for at least one year after the expiry date. The reference sample should
be contained in its finished primary packaging or in packaging composed of the
same material as the primary container in which the product is marketed (for
veterinary medicinal products other than immunologicals, see also Annex 4,
paragraphs 8 and 9).
3.2 Unless a longer period is required under the law of the country of manufacture
(whose competent authority is a PIC/S Member), samples of starting materials
(other than solvents, gases or water used in the manufacturing process) should
be retained for at least two years after the release of product. That period may
be shortened if the period of stability of the material, as indicated in the relevant
specification, is shorter. Packaging materials should be retained for the duration
of the shelf life of the finished product concerned.
4. SIZE OF REFERENCE AND RETENTION SAMPLES

4.1 The reference sample should be of sufficient size to permit the carrying out, on,
at least, two occasions, of the full analytical controls on the batch in accordance
with the Marketing Authorisation File which has been assessed and approved by
the relevant Competent Authority / Authorities. Where it is necessary to do so,
unopened packs should be used when carrying out each set of analytical
controls. Any proposed exception to this should be justified to, and agreed with,
the relevant competent authority.
4.2 Where applicable, national requirements relating to the size of reference samples
and, if necessary, retention samples, should be followed.
4.3 Reference samples should be representative of the batch of starting material,

intermediate product or finished product from which they are taken. Other
samples may also be taken to monitor the most stressed part of a process (e.g.
beginning or end of a process). Where a batch is packaged in two, or more,
distinct packaging operations, at least one retention sample should be taken from
each individual packaging operation. Any proposed exception to this should be
justified to, and agreed with, the relevant competent authority.

4.4 It should be ensured that all necessary analytical materials and equipment are
still available, or are readily obtainable, in order to carry out all tests given in the
specification until one year after expiry of the last batch manufactured.
5. STORAGE CONDITIONS
5.1 […] *
5.2 Storage conditions should be in accordance with the marketing authorisation (e.g.
refrigerated storage where relevant).
6. WRITTEN AGREEMENTS
6.1 Where the marketing authorisation holder is not the same legal entity as the
site(s) responsible for batch release, the responsibility for taking and storage of
reference/retention samples should be defined in a written agreement between
the two parties in accordance with Chapter 7 of the PIC/S Guide to Good
Manufacturing Practice. This applies also where any manufacturing or batch
release activity is carried out at a site other than that with overall responsibility for
the batch and the arrangements between each different site for the taking and
keeping of reference and retention samples should be defined in a written
agreement.
6.2 The Authorised Person who certifies a batch for sale should ensure that all
relevant reference and retention samples are accessible at all reasonable times.
Where necessary, the arrangements for such access should be defined in a
written agreement.
6.3 Where more than one site is involved in the manufacture of a finished product,
the availability of written agreements is key to controlling the taking and location
of reference and retention samples.
7. REFERENCE SAMPLES – GENERAL POINTS

7.1 Reference samples are for the purpose of analysis and, therefore, should be
conveniently available to a laboratory with validated methodology. For starting
materials and packaging materials used for medicinal products, this is the original
site of manufacture of the finished product. For finished products, this is the
original site of manufacture.
7.2 […] *
* This Section is specific to the EU GMP Guide and has not been adopted by PIC/S.

8. RETENTION SAMPLES – GENERAL POINTS

8.1 A retention sample should represent a batch of finished products as distributed
and may need to be examined in order to confirm non-technical attributes for
compliance with the marketing authorisation or national legislation. The retention
samples should preferably be stored at the site where the Authorised Person (AP)
certifying the finished product batch is located.
8.2 […] *
8.3 Retention samples should be stored at the premises of an authorised

manufacturer in order to permit ready access by the Competent Authority.
8.4 Where more than one manufacturing site is involved in the manufacture
importation/packaging/testing/batch release, as appropriate of a product, the
responsibility for taking and storage of retention samples should be defined in a
written agreement(s) between the parties concerned.
9. REFERENCE AND RETENTION SAMPLES FOR PARALLEL

IMPORTED / PARALLEL DISTRIBUTED PRODUCTS
Note: This section is only applicable if the national legislation deals with parallel
imported / parallel distributed products.
9.1 Where the secondary packaging is not opened, only the packaging material used
needs to be retained, as there is no, or little, risk of product mix up.
9.2 Where the secondary packaging is opened, for example, to replace the carton or
patient information leaflet, then one retention sample, per packaging operation,
containing the product should be taken, as there is a risk of product mix-up during
the assembly process. It is important to be able to identify quickly who is
responsible in the event of a mix-up (original manufacturer or parallel import
assembler), as it would affect the extent of any resulting recall.
10. REFERENCE AND RETENTION SAMPLES IN THE CASE

OF CLOSEDOWN OF A MANUFACTURER
10.1 Where a manufacturer closes down and the manufacturing authorisation is
surrendered, revoked, or ceases to exist, it is probable that many unexpired
batches of medicinal products manufactured by that manufacturer remain on the
market. In order for those batches to remain on the market, the manufacturer
should make detailed arrangements for transfer of reference and retention
samples (and relevant GMP documentation) to an authorised storage site. The
manufacturer should satisfy the Competent Authority that the arrangements for
storage are satisfactory and that the samples can, if necessary, be readily
accessed and analysed.

10.2 If the manufacturer is not in a position to make the necessary arrangements this
may be delegated to another manufacturer. The Marketing Authorisation holder
(MAH) is responsible for such delegation and for the provision of all necessary
information to the Competent Authority. In addition, the MAH should, in relation
to the suitability of the proposed arrangements for storage of reference and
retention samples, consult with the competent authority of each country in which
any unexpired batch has been placed on the market.
10.3 […] *
______________

Annex 20 Quality Risk Management
ANNEX 20*
QUALITY RISK MANAGEMENT
FOREWORD AND SCOPE OF APPLICATION

1. The new GMP Annex 20 corresponds to ICH Q9 guideline on Quality Risk
Management. It provides guidance on a systematic approach to quality risk
management facilitating compliance with GMP and other quality requirements. It
includes principles to be used and options for processes, methods and tools
which may be used when applying a formal quality risk management approach.
2. To ensure coherence, GMP Part I, Chapter 1 on Quality Management, has been

revised to include aspects of quality risk management within the quality system
framework. A similar revision is planned for Part II of the Guide. Other sections
of the GMP Guide may be adjusted to include aspects of quality risk management
in future broader revisions of those sections.
3. With the revision of the chapters on quality management in GMP Parts I and II
quality risk management becomes an integral part of a manufacturer’s quality
system. Annex 20 itself is not intended, however, to create any new regulatory
expectations; it provides an inventory of internationally acknowledged risk
management methods and tools together with a list of potential applications at
the discretion of manufacturers.
4. It is understood that the ICH Q9 guideline was primarily developed for quality risk
management of medicinal products for human use. With the implementation in
Annex 20 benefits of the guideline, such as processes, methods and tools for
quality risk management are also made available to the veterinary sector.
5. While the GMP guide is primarily addressed to manufacturers, the ICH Q9

guideline, has relevance for other quality guidelines and includes specific
sections for regulatory agencies.
6. However, for reasons of coherence and completeness, the ICH Q9 guideline has
been transferred completely into GMP Annex 20.
INTRODUCTION
7. Risk management principles are effectively utilized in many areas of business
and government including finance, insurance, occupational safety, public health,
pharmacovigilance, and by agencies regulating these industries. Although there
are some examples of the use of quality risk management in the pharmaceutical
industry today, they are limited and do not represent the full contributions that risk
management has to offer. In addition, the importance of quality systems has been
* This Annex is voluntary.

recognized in the pharmaceutical industry and it is becoming evident that quality

risk management is a valuable component of an effective quality system.
8. It is commonly understood that risk is defined as the combination of the probability

of occurrence of harm and the severity of that harm. However, achieving a shared
understanding of the application of risk management among diverse stakeholders
is difficult because each stakeholder might perceive different potential harms,
place a different probability on each harm occurring and attribute different
severities to each harm. In relation to pharmaceuticals, although there are a
variety of stakeholders, including patients and medical practitioners as well as
government and industry, the protection of the patient by managing the risk to
quality should be considered of prime importance.
9. The manufacturing and use of a drug (medicinal) product, including its

components, necessarily entail some degree of risk. The risk to its quality is just
one component of the overall risk. It is important to understand that product
quality should be maintained throughout the product lifecycle such that the
attributes that are important to the quality of the drug (medicinal) product remain
consistent with those used in the clinical studies. An effective quality risk
management approach can further ensure the high quality of the drug (medicinal)
product to the patient by providing a proactive means to identify and control
potential quality issues during development and manufacturing. Additionally, use
of quality risk management can improve the decision making if a quality problem
arises. Effective quality risk management can facilitate better and more informed
decisions, can provide regulators with greater assurance of a company’s ability
to deal with potential risks and can beneficially affect the extent and level of direct
regulatory oversight.
10. The purpose of this document is to offer a systematic approach to quality risk
management. It serves as a foundation or resource document that is independent
of, yet supports, other ICH Quality documents and complements existing quality
practices, requirements, standards, and guidelines within the pharmaceutical
industry and regulatory environment. It specifically provides guidance on the
principles and some of the tools of quality risk management that can enable more
effective and consistent risk based decisions, both by regulators and industry,
regarding the quality of drug substances and drug (medicinal) products across
the product lifecycle. It is not intended to create any new expectations beyond
the current regulatory requirements.
11. It is neither always appropriate nor always necessary to use a formal risk
management process (using recognized tools and/ or internal procedures e.g.
standard operating procedures). The use of informal risk management processes
(using empirical tools and/ or internal procedures) can also be considered
acceptable.
12. Appropriate use of quality risk management can facilitate but does not obviate
industry’s obligation to comply with regulatory requirements and does not replace
appropriate communications between industry and regulators.

SCOPE
13. This guideline provides principles and examples of tools for quality risk
management that can be applied to different aspects of pharmaceutical quality.
These aspects include development, manufacturing, distribution, and the
inspection and submission/review processes throughout the lifecycle of drug
substances, drug (medicinal) products, biological and biotechnological products
(including the use of raw materials, solvents, excipients, packaging and labeling
materials in drug (medicinal) products, biological and biotechnological products).
PRINCIPLES OF QUALITY RISK MANAGEMENT

14. Two primary principles of quality risk management are:
 The evaluation of the risk to quality should be based on scientific
knowledge and ultimately link to the protection of the patient; and
 The level of effort, formality and documentation of the quality risk
management process should be commensurate with the level of risk.
GENERAL QUALITY RISK MANAGEMENT PROCESS

15. Quality risk management is a systematic process for the assessment, control,
communication and review of risks to the quality of the drug (medicinal) product
across the product lifecycle. A model for quality risk management is outlined in
the diagram (Figure 1). Other models could be used. The emphasis on each
component of the framework might differ from case to case but a robust process
will incorporate consideration of all the elements at a level of detail that is
commensurate with the specific risk.

Figure 1: Overview of a typical quality risk management process
Initiate
Quality Risk Management Process
Risk Assessment
Risk Identification
Risk Analysis
Risk Evaluation
unacceptable
Risk Management tools

Risk Communication
Risk Control
Risk Reduction
Risk Acceptance
Output / Result of the

Quality Risk Management Process
Risk Review
Review Events
16. Decision nodes are not shown in the diagram above because decisions can occur
at any point in the process. These decisions might be to return to the previous
step and seek further information, to adjust the risk models or even to terminate
the risk management process based upon information that supports such a
decision. Note: “unacceptable” in the flowchart does not only refer to statutory,
legislative or regulatory requirements, but also to the need to revisit the risk
assessment process.
Responsibilities
17. Quality risk management activities are usually, but not always, undertaken by
interdisciplinary teams. When teams are formed, they should include experts
from the appropriate areas (e.g. quality unit, business development, engineering,
regulatory affairs, production operations, sales and marketing, legal, statistics
and clinical) in addition to individuals who are knowledgeable about the quality
risk management process.
18. Decision makers should:

 take responsibility for coordinating quality risk management across various
functions and departments of their organization; and
 assure that a quality risk management process is defined, deployed and
reviewed and that adequate resources are available.

Initiating a Quality Risk Management Process
19. Quality risk management should include systematic processes designed to

coordinate, facilitate and improve science-based decision making with respect to
risk. Possible steps used to initiate and plan a quality risk management process
might include the following:
 Define the problem and/or risk question, including pertinent assumptions
identifying the potential for risk
 Assemble background information and/ or data on the potential hazard,
harm or human health impact relevant to the risk assessment
 Identify a leader and necessary resources
 Specify a timeline, deliverables and appropriate level of decision making
for the risk management process
Risk Assessment
20. Risk assessment consists of the identification of hazards and the analysis and
evaluation of risks associated with exposure to those hazards (as defined below).
Quality risk assessments begin with a well-defined problem description or risk
question. When the risk in question is well defined, an appropriate risk
management tool (see examples in section 5) and the types of information
needed to address the risk question will be more readily identifiable. As an aid to
clearly defining the risk(s) for risk assessment purposes, three fundamental
questions are often helpful:
1. What might go wrong?

2. What is the likelihood (probability) it will go wrong?
3. What are the consequences (severity)?
Risk identification is a systematic use of information to identify hazards referring

to the risk question or problem description. Information can include historical
data, theoretical analysis, informed opinions, and the concerns of stakeholders.
Risk identification addresses the “What might go wrong?” question, including
identifying the possible consequences. This provides the basis for further steps
in the quality risk management process.
22. Risk analysis is the estimation of the risk associated with the identified hazards.
It is the qualitative or quantitative process of linking the likelihood of occurrence
and severity of harms. In some risk management tools, the ability to detect the
harm (detectability) also factors in the estimation of risk.
23. Risk evaluation compares the identified and analyzed risk against given risk
criteria. Risk evaluations consider the strength of evidence for all three of the
fundamental questions.
24. In doing an effective risk assessment, the robustness of the data set is important
because it determines the quality of the output. Revealing assumptions and
reasonable sources of uncertainty will enhance confidence in this output and/or
help identify its limitations. Uncertainty is due to combination of incomplete
knowledge about a process and its expected or unexpected variability. Typical

sources of uncertainty include gaps in knowledge gaps in pharmaceutical science

and process understanding, sources of harm (e.g., failure modes of a process,
sources of variability), and probability of detection of problems.
25. The output of a risk assessment is either a quantitative estimate of risk or a

qualitative description of a range of risk. When risk is expressed quantitatively,
a numerical probability is used. Alternatively, risk can be expressed using
qualitative descriptors, such as “high”, “medium”, or “low”, which should be
defined in as much detail as possible. Sometimes a "risk score" is used to further
define descriptors in risk ranking. In quantitative risk assessments, a risk estimate
provides the likelihood of a specific consequence, given a set of risk-generating
circumstances. Thus, quantitative risk estimation is useful for one particular
consequence at a time. Alternatively, some risk management tools use a relative
risk measure to combine multiple levels of severity and probability into an overall
estimate of relative risk. The intermediate steps within a scoring process can
sometimes employ quantitative risk estimation.
Risk Control
26. Risk control includes decision making to reduce and/or accept risks. The purpose
of risk control is to reduce the risk to an acceptable level. The amount of effort
used for risk control should be proportional to the significance of the risk. Decision
makers might use different processes, including benefit-cost analysis, for
understanding the optimal level of risk control.
27. Risk control might focus on the following questions:

 Is the risk above an acceptable level?
 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?
28. Risk reduction focuses on processes for mitigation or avoidance of quality risk
when it exceeds a specified (acceptable) level (see Fig. 1). Risk reduction might
include actions taken to mitigate the severity and probability of harm. Processes
that improve the detectability of hazards and quality risks might also be used as
part of a risk control strategy. The implementation of risk reduction measures can
introduce new risks into the system or increase the significance of other existing
risks. Hence, it might be appropriate to revisit the risk assessment to identify and
evaluate any possible change in risk after implementing a risk reduction process.
29. Risk acceptance is a decision to accept risk. Risk acceptance can be a formal
decision to accept the residual risk or it can be a passive decision in which
residual risks are not specified. For some types of harms, even the best quality
risk management practices might not entirely eliminate risk. In these
circumstances, it might be agreed that an appropriate quality risk management
strategy has been applied and that quality risk is reduced to a specified
(acceptable) level. This (specified) acceptable level will depend on many
parameters and should be decided on a case-by-case basis.

Risk Communication
30. Risk communication is the sharing of information about risk and risk
management between the decision makers and others. Parties can communicate
at any stage of the risk management process (see Fig. 1: dashed arrows). The
output/result of the quality risk management process should be appropriately
communicated and documented (see Fig. 1: solid arrows). Communications
might include those among interested parties; e.g., regulators and industry,
industry and the patient, within a company, industry or regulatory authority, etc.
The included information might relate to the existence, nature, form, probability,
severity, acceptability, control, treatment, detectability or other aspects of risks to
quality. Communication need not be carried out for each and every risk
acceptance. Between the industry and regulatory authorities, communication
concerning quality risk management decisions might be effected through existing
channels as specified in regulations and guidances.
Risk Review
31. Risk management should be an ongoing part of the quality management process.
A mechanism to review or monitor events should be implemented.
32. The output/results of the risk management process should be reviewed to take
into account new knowledge and experience. Once a quality risk management
process has been initiated, that process should continue to be utilized for events
that might impact the original quality risk management decision, whether these
events are planned (e.g. results of product review, inspections, audits, change
control) or unplanned (e.g. root cause from failure investigations, recall). The
frequency of any review should be based upon the level of risk. Risk review might
include reconsideration of risk acceptance decisions (section 4.4).
RISK MANAGEMENT METHODOLOGY

33. Quality risk management supports a scientific and practical approach to decision-
making. It provides documented, transparent and reproducible methods to
accomplish steps of the quality risk management process based on current
knowledge about assessing the probability, severity and sometimes detectability
of the risk.
34. Traditionally, risks to quality have been assessed and managed in a variety of
informal ways (empirical and/ or internal procedures) based on, for example,
compilation of observations, trends and other information. Such approaches
continue to provide useful information that might support topics such as handling
of complaints, quality defects, deviations and allocation of resources.
35. Additionally, the pharmaceutical industry and regulators can assess and manage
risk using recognized risk management tools and/ or internal procedures (e.g.,
standard operating procedures). Below is a non-exhaustive list of some of these
tools (further details in Annex 1 and Chapter 8):
 Basic risk management facilitation methods (flowcharts, check sheets etc.)
 Failure Mode Effects Analysis (FMEA)

 Failure Mode, Effects and Criticality Analysis (FMECA)

 Fault Tree Analysis (FTA)
 Hazard Analysis and Critical Control Points (HACCP)
 Hazard Operability Analysis (HAZOP)
 Preliminary Hazard Analysis (PHA)
 Risk ranking and filtering
 Supporting statistical tools
36. It might be appropriate to adapt these tools for use in specific areas pertaining to
drug substance and drug (medicinal) product quality. Quality risk management
methods and the supporting statistical tools can be used in combination (e.g.
Probabilistic Risk Assessment). Combined use provides flexibility that can
facilitate the application of quality risk management principles.
37. The degree of rigor and formality of quality risk management should reflect
available knowledge and be commensurate with the complexity and/ or criticality
of the issue to be addressed.
INTEGRATION OF QUALITY RISK MANAGEMENT INTO

INDUSTRY AND REGULATORY OPERATIONS
38. Quality risk management is a process that supports science-based and practical
decisions when integrated into quality systems (see Annex II). As outlined in the
introduction, appropriate use of quality risk management does not obviate
industry’s obligation to comply with regulatory requirements. However, effective
quality risk management can facilitate better and more informed decisions, can
provide regulators with greater assurance of a company’s ability to deal with
potential risks, and might affect the extent and level of direct regulatory oversight.
In addition, quality risk management can facilitate better use of resources by all
parties.
39. Training of both industry and regulatory personnel in quality risk management
processes provides for greater understanding of decision-making processes and
builds confidence in quality risk management outcomes.
40. Quality risk management should be integrated into existing operations and
documented appropriately. Annex II provides examples of situations in which the
use of the quality risk management process might provide information that could
then be used in a variety of pharmaceutical operations. These examples are
provided for illustrative purposes only and should not be considered a definitive
or exhaustive list. These examples are not intended to create any new
expectations beyond the requirements laid out in the current regulations.

41. Examples for industry and regulatory operations (see Annex II):
 Quality management
42. Examples for industry operations and activities (see Annex II):
 Development
 Facility, equipment and utilities
 Materials management
 Production
 Laboratory control and stability testing
 Packaging and labelling
43. Examples for regulatory operations (see Annex II):

 Inspection and assessment activities
44. While regulatory decisions will continue to be taken on a regional basis, a

common understanding and application of quality risk management principles
could facilitate mutual confidence and promote more consistent decisions among
regulators on the basis of the same information. This collaboration could be
important in the development of policies and guidelines that integrate and support
quality risk management practices.
DEFINITIONS
Decision maker(s) – Person(s) with the competence and authority to make
appropriate and timely quality risk management decisions
Detectability - the ability to discover or determine the existence, presence, or fact

of a hazard
Harm – damage to health, including the damage that can occur from loss of
product quality or availability
Hazard - the potential source of harm (ISO/IEC Guide 51)
Product Lifecycle – all phases in the life of the product from the initial
development through marketing until the product’s discontinuation
Quality – the degree to which a set of inherent properties of a product, system or

process fulfils requirements (see ICH Q6a definition specifically for "quality" of
drug substance and drug (medicinal) products.)
Quality risk management – a systematic process for the assessment, control,

communication and review of risks to the quality of the drug (medicinal) product
across the product lifecycle
Quality system – the sum of all aspects of a system that implements quality policy
and ensures that quality objectives are met

Requirements – the explicit or implicit needs or expectations of the patients or

their surrogates (e.g. health care professionals, regulators and legislators). In this
document, “requirements” refers not only to statutory, legislative, or regulatory
requirements, but also to such needs and expectations.
Risk – the combination of the probability of occurrence of harm and the severity
of that harm (ISO/IEC Guide 51)
Risk acceptance – the decision to accept risk (ISO Guide 73)
Risk analysis – the estimation of the risk associated with the identified hazards
Risk assessment – a systematic process of organizing information to support a

risk decision to be made within a risk management process. It consists of the
identification of hazards and the analysis and evaluation of risks associated with
exposure to those hazards.
Risk communication – the sharing of information about risk and risk management
between the decision maker and other stakeholders
Risk control – actions implementing risk management decisions (ISO Guide 73)
Risk evaluation – the comparison of the estimated risk to given risk criteria using
a quantitative or qualitative scale to determine the significance of the risk
Risk identification – the systematic use of information to identify potential sources

of harm (hazards) referring to the risk question or problem description
Risk management – the systematic application of quality management policies,

procedures, and practices to the tasks of assessing, controlling, communicating
and reviewing risk
Risk reduction – actions taken to lessen the probability of occurrence of harm and
the severity of that harm
Risk review – review or monitoring of output/results of the risk management

process considering (if appropriate) new knowledge and experience about the
risk
Severity – a measure of the possible consequences of a hazard
Stakeholder – any individual, group or organization that can affect, be affected

by, or perceive itself to be affected by a risk. Decision makers might also be
stakeholders. For the purposes of this guideline, the primary stakeholders are
the patient, healthcare professional, regulatory authority, and industry
Trend – a statistical term referring to the direction or rate of change of a

variable(s)

REFERENCES
ICH Q8 Pharmaceutical development
ISO/IEC Guide 73:2002 - Risk Management - Vocabulary - Guidelines for use in

Standards
ISO/IEC Guide 51:1999 - Safety Aspects - Guideline for their inclusion in

standards
Process Mapping by the American Productivity & Quality Center 2002, ISBN
1928593739
IEC 61025 - Fault Tree Analysis (FTA)
IEC 60812 Analysis Techniques for system reliability—Procedures for failure

mode and effects analysis (FMEA)
Failure Mode and Effect Analysis, FMEA from Theory to Execution, 2nd Edition
2003, D. H. Stamatis, ISBN 0873895983
Guidelines for Failure Modes and Effects Analysis (FMEA) for Medical Devices,
2003 Dyadem Press ISBN 0849319102
The Basics of FMEA, Robin McDermott, Raymond J. Mikulak, Michael R.

Beauregard 1996 ISBN 0527763209
WHO Technical Report Series No 908, 2003 Annex 7 Application of Hazard

Analysis and Critical Control Point (HACCP) methodology to pharmaceuticals
IEC 61882 - Hazard Operability Analysis (HAZOP)
ISO 14971:2000 - Application of Risk Management to Medical Devices
ISO 7870:1993 - Control Charts
ISO 7871:1997 - Cumulative Sum Charts
ISO 7966:1993 - Acceptance Control Charts
ISO 8258:1991 - Shewhart Control Charts
What is Total Quality Control?; The Japanese Way, Kaoru Ishikawa (Translated
by David J. Liu), 1985, ISBN 0139524339

APPENDIX I: RISK MANAGEMENT METHODS AND TOOLS

The purpose of this appendix is to provide a general overview of and references
for some of the primary tools that might be used in quality risk management by
industry and regulators. The references are included as an aid to gain more
knowledge and detail about the particular tool. This is not an exhaustive list. It is
important to note that no one tool or set of tools is applicable to every situation in
which a quality risk management procedure is used.
I.1 Basic Risk Management Facilitation Methods
Some of the simple techniques that are commonly used to structure risk
management by organizing data and facilitating decision-making are:
 Flowcharts
 Check Sheets
 Process Mapping
 Cause and Effect Diagrams (also called an Ishikawa diagram or fish bone
diagram)
I.2 Failure Mode Effects Analysis (FMEA)
FMEA (see IEC 60812) provides for an evaluation of potential failure modes for
processes and their likely effect on outcomes and/or product performance. Once
failure modes are established, risk reduction can be used to eliminate, contain,
reduce or control the potential failures. FMEA relies on product and process
understanding. FMEA methodically breaks down the analysis of complex
processes into manageable steps. It is a powerful tool for summarizing the
important modes of failure, factors causing these failures and the likely effects of
these failures.
Potential Areas of Use(s)
FMEA can be used to prioritize risks and monitor the effectiveness of risk control
activities.
FMEA can be applied to equipment and facilities and might be used to analyze a
manufacturing operation and its effect on product or process. It identifies
elements/operations within the system that render it vulnerable. The output/
results of FMEA can be used as a basis for design or further analysis or to guide
resource deployment.
I.3 Failure Mode, Effects and Criticality Analysis (FMECA)
FMEA might be extended to incorporate an investigation of the degree of severity

of the consequences, their respective probabilities of occurrence, and their
detectability, thereby becoming a Failure Mode Effect and Criticality Analysis
(FMECA; see IEC 60812). In order for such an analysis to be performed, the
product or process specifications should be established.
FMECA can identify places where additional preventive actions might be

appropriate to minimize risks.

FMECA application in the pharmaceutical industry should mostly be utilized for

failures and risks associated with manufacturing processes; however, it is not
limited to this application. The output of an FMECA is a relative risk “score” for
each failure mode, which is used to rank the modes on a relative risk basis.
I.4 Fault Tree Analysis (FTA)
The FTA tool (see IEC 61025) is an approach that assumes failure of the
functionality of a product or process. This tool evaluates system (or subsystem)
failures one at a time but can combine multiple causes of failure by identifying
causal chains. The results are represented pictorially in the form of a tree of fault
modes. At each level in the tree, combinations of fault modes are described with
logical operators (AND, OR, etc.). FTA relies on the experts’ process
understanding to identify causal factors.
FTA can be used to establish the pathway to the root cause of the failure. FTA
can be used to investigate complaints or deviations in order to fully understand
their root cause and to ensure that intended improvements will fully resolve the
issue and not lead to other issues (i.e. solve one problem yet cause a different
problem). Fault Tree Analysis is an effective tool for evaluating how multiple
factors affect a given issue. The output of an FTA includes a visual representation
of failure modes. It is useful both for risk assessment and in developing
monitoring programs.
I.5 Hazard Analysis and Critical Control Points (HACCP)
HACCP is a systematic, proactive, and preventive tool for assuring product

quality, reliability, and safety (see WHO Technical Report Series No 908, 2003
Annex 7). It is a structured approach that applies technical and scientific
principles to analyze, evaluate, prevent, and control the risk or adverse
consequence(s) of hazard(s) due to the design, development, production, and
use of products.
HACCP consists of the following seven steps:
1. conduct a hazard analysis and identify preventive measures for each step
of the process;
2. determine the critical control points;
3. establish critical limits;
4. establish a system to monitor the critical control points;
5. establish the corrective action to be taken when monitoring indicates that
the critical control points are not in a state of control;
6. establish system to verify that the HACCP system is working effectively;
7. establish a record-keeping system.

HACCP might be used to identify and manage risks associated with physical,
chemical and biological hazards (including microbiological contamination).
HACCP is most useful when product and process understanding is sufficiently
comprehensive to support identification of critical control points. The output of a
HACCP analysis is risk management information that facilitates monitoring of
critical points not only in the manufacturing process but also in other life cycle
phases.
I.6 Hazard Operability Analysis (HAZOP)
HAZOP (see IEC 61882) is based on a theory that assumes that risk events are
caused by deviations from the design or operating intentions. It is a systematic
brainstorming technique for identifying hazards using so-called “guide-words”.
“Guide-words” (e.g., No, More, Other Than, Part of, etc.) are applied to relevant
parameters (e.g., contamination, temperature) to help identify potential
deviations from normal use or design intentions. It often uses a team of people
with expertise covering the design of the process or product and its application.
HAZOP can be applied to manufacturing processes, including outsourced

production and formulation as well as the upstream suppliers, equipment and
facilities for drug substances and drug (medicinal) products. It has also been used
primarily in the pharmaceutical industry for evaluating process safety hazards. As
is the case with HACCP, the output of a HAZOP analysis is a list of critical
operations for risk management. This facilitates regular monitoring of critical
points in the manufacturing process.
I.7 Preliminary Hazard Analysis (PHA)
PHA is a tool of analysis based on applying prior experience or knowledge of a

hazard or failure to identify future hazards, hazardous situations and events that
might cause harm, as well as to estimate their probability of occurrence for a
given activity, facility, product or system. The tool consists of: 1) the identification
of the possibilities that the risk event happens, 2) the qualitative evaluation of the
extent of possible injury or damage to health that could result and 3) a relative
ranking of the hazard using a combination of severity and likelihood of
occurrence, and 4) the identification of possible remedial measures.
PHA might be useful when analyzing existing systems or prioritizing hazards

where circumstances prevent a more extensive technique from being used. It can
be used for product, process and facility design as well as to evaluate the types
of hazards for the general product type, then the product class, and finally the
specific product. PHA is most commonly used early in the development of a
project when there is little information on design details or operating procedures;
thus, it will often be a precursor to further studies. Typically, hazards identified in
the PHA are further assessed with other risk management tools such as those in
this section.

I.8 Risk Ranking and Filtering
Risk ranking and filtering is a tool for comparing and ranking risks. Risk ranking
of complex systems typically requires evaluation of multiple diverse quantitative
and qualitative factors for each risk. The tool involves breaking down a basic risk
question into as many components as needed to capture factors involved in the
risk. These factors are combined into a single relative risk score that can then be
used for ranking risks. “Filters,” in the form of weighting factors or cut-offs for risk
scores, can be used to scale or fit the risk ranking to management or policy
objectives.
Risk ranking and filtering can be used to prioritize manufacturing sites for
inspection/audit by regulators or industry. Risk ranking methods are particularly
helpful in situations in which the portfolio of risks and the underlying
consequences to be managed are diverse and difficult to compare using a single
tool. Risk ranking is useful when management needs to evaluate both
quantitatively-assessed and qualitatively-assessed risks within the same
organizational framework.
I.9 Supporting Statistical Tools
Statistical tools can support and facilitate quality risk management. They can
enable effective data assessment, aid in determining the significance of the data
set(s), and facilitate more reliable decision making. A listing of some of the
principal statistical tools commonly used in the pharmaceutical industry is
provided:
(i) Control Charts, for example:

- Acceptance Control Charts (see ISO 7966)
- Control Charts with Arithmetic Average and Warning Limits (see ISO
7873)
- Cumulative Sum Charts (see ISO 7871)
- Shewhart Control Charts (see ISO 8258)
- Weighted Moving Average
(ii) Design of Experiments (DOE)
(iii) Histograms
(iv) Pareto Charts
(v) Process Capability Analysis

APPENDIX II: POTENTIAL APPLICATIONS FOR QUALITY

RISK MANAGEMENT
This Appendix is intended to identify potential uses of quality risk management
principles and tools by industry and regulators. However, the selection of
particular risk management tools is completely dependent upon specific facts and
circumstances. These examples are provided for illustrative purposes and only
suggest potential uses of quality risk management. This Annex is not intended to
create any new expectations beyond the current regulatory requirements.
II.1 Quality Risk Management as Part of Integrated Quality Management
Documentation
To review current interpretations and application of regulatory expectations
To determine the desirability of and/or develop the content for SOPs, guidelines,
etc.
Training and education
To determine the appropriateness of initial and/or ongoing training sessions

based on education, experience and working habits of staff, as well as on a
periodic assessment of previous training (e.g., its effectiveness)
To identify the training, experience, qualifications and physical abilities that allow
personnel to perform an operation reliably and with no adverse impact on the
quality of the product
Quality defects
To provide the basis for identifying, evaluating, and communicating the potential
quality impact of a suspected quality defect, complaint, trend, deviation,
investigation, out of specification result, etc.
To facilitate risk communications and determine appropriate action to address

significant product defects, in conjunction with regulatory authorities (e.g., recall)
Auditing/Inspection
To define the frequency and scope of audits, both internal and external, taking
into account factors such as:
 Existing legal requirements
 Overall compliance status and history of the company or facility
 Robustness of a company’s quality risk management activities
 Complexity of the site
 Complexity of the manufacturing process
 Complexity of the product and its therapeutic significance
 Number and significance of quality defects (e.g. recall)
 Results of previous audits/inspections

 Major changes of building, equipment, processes, key personnel

 Experience with manufacturing of a product (e.g. frequency, volume,
number of batches)
 Test results of official control laboratories
Periodic review
To select, evaluate and interpret trend results of data within the product quality
review
To interpret monitoring data (e.g., to support an assessment of the

appropriateness of revalidation or changes in sampling)
Change management / change control
To manage changes based on knowledge and information accumulated in

pharmaceutical development and during manufacturing
To evaluate the impact of the changes on the availability of the final product
To evaluate the impact on product quality of changes to the facility, equipment,

material, manufacturing process or technical transfers
To determine appropriate actions preceding the implementation of a change, e.g.,

additional testing, (re)qualification, (re)validation or communication with
regulators
Continual improvement
To facilitate continual improvement in processes throughout the product lifecycle
II.2 Quality Risk Management as Part of Regulatory Operations
Inspection and assessment activities
To assist with resource allocation including, for example, inspection planning and
frequency, and inspection and assessment intensity (see "Auditing" section in
Annex II.1)
To evaluate the significance of, for example, quality defects, potential recalls and
inspectional findings
To determine the appropriateness and type of post-inspection regulatory follow-

up
To evaluate information submitted by industry including pharmaceutical

development information
To evaluate impact of proposed variations or changes

To identify risks which should be communicated between inspectors and

assessors to facilitate better understanding of how risks can be or are controlled
(e.g. parametric release, Process Analytical Technology (PAT)).
II.3 Quality Risk Management as Part of Development
To design a quality product and its manufacturing process to consistently deliver

the intended performance of the product (see ICH Q8)
To enhance knowledge of product performance over a wide range of material

attributes (e.g. particle size distribution, moisture content, flow properties),
processing options and process parameters
To assess the critical attributes of raw materials, solvents, Active Pharmaceutical

Ingredient (API) starting materials, APIs, excipients, or packaging materials
To establish appropriate specifications, identify critical process parameters and

establish manufacturing controls (e.g., using information from pharmaceutical
development studies regarding the clinical significance of quality attributes and
the ability to control them during processing)
To decrease variability of quality attributes:

 reduce product and material defects
 reduce manufacturing defects
To assess the need for additional studies (e.g., bioequivalence, stability) relating
to scale up and technology transfer
To make use of the “design space” concept (see ICH Q8)
II.4 Quality Risk Management for Facilities, Equipment and Utilities
Design of facility / equipment
To determine appropriate zones when designing buildings and facilities, e.g.,

 flow of material and personnel
 minimize contamination
 pest control measures
 prevention of mix-ups
 open versus closed equipment
 clean rooms versus isolator technologies
 dedicated or segregated facilities / equipment
To determine appropriate product contact materials for equipment and containers

(e.g., selection of stainless steel grade, gaskets, lubricants)
To determine appropriate utilities (e.g., steam, gases, power source, compressed

air, heating, ventilation and air conditioning (HVAC), water)

To determine appropriate preventive maintenance for associated equipment

(e.g., inventory of necessary spare parts)
Hygiene aspects in facilities
To protect the product from environmental hazards, including chemical,

microbiological, and physical hazards (e.g., determining appropriate clothing and
gowning, hygiene concerns)
To protect the environment (e.g., personnel, potential for cross-contamination)

from hazards related to the product being manufactured
Qualification of facility/equipment/utilities
To determine the scope and extent of qualification of facilities, buildings, and

production equipment and/or laboratory instruments (including proper calibration
methods)
Cleaning of equipment and environmental control
To differentiate efforts and decisions based on the intended use (e.g. multi-versus
single-purpose, batch versus continuous production)
To determine acceptable (specified) cleaning validation limits
Calibration/preventive maintenance
To set appropriate calibration and maintenance schedules
Computer systems and computer controlled equipment
To select the design of computer hardware and software (e.g., modular,

structured, fault tolerance)
To determine the extent of validation, e.g.:

 identification of critical performance parameters
 selection of the requirements and design
 code review
 the extent of testing and test methods
 reliability of electronic records and signatures
II.5 Quality Risk Management as Part of Materials Management
Assessment and evaluation of suppliers and contract manufacturers
To provide a comprehensive evaluation of suppliers and contract manufacturers

(e.g., auditing, supplier quality agreements)

Starting material
To assess differences and possible quality risks associated with variability in

starting materials (e.g., age, route of synthesis).
Use of materials
To determine whether it is appropriate to use material under quarantine (e.g., for

further internal processing)
To determine appropriateness of reprocessing, reworking, use of returned goods
Storage, logistics and distribution conditions
To assess the adequacy of arrangements to ensure maintenance of appropriate

storage and transport conditions (e.g., temperature, humidity, container design)
To determine the effect on product quality of discrepancies in storage or transport

conditions (e.g. cold chain management) in conjunction with other ICH guidelines
To maintain infrastructure (e.g. capacity to ensure proper shipping conditions,

interim storage, handling of hazardous materials and controlled substances,
customs clearance)
To provide information for ensuring the availability of pharmaceuticals (e.g.

ranking risks to the supply chain)
II.6 Quality Risk Management as Part of Production
Validation
To identify the scope and extent of verification, qualification and validation

activities (e.g., analytical methods, processes, equipment and cleaning methods
To determine the extent for follow-up activities (e.g., sampling, monitoring and re-
validation)
To distinguish between critical and non-critical process steps to facilitate design

of a validation study
In-process sampling & testing
To evaluate the frequency and extent of in-process control testing (e.g., to justify
reduced testing under conditions of proven control)
To evaluate and justify the use of process analytical technologies (PAT) in

conjunction with parametric and real time release
Production planning
To determine appropriate production planning (e.g. dedicated, campaign and

concurrent production process sequences)

II.7 Quality Risk Management as Part of Laboratory Control and

Stability Studies
Out of specification results
To identify potential root causes and corrective actions during the investigation of
out of specification results
Retest period / expiration date
To evaluate adequacy of storage and testing of intermediates, excipients and

starting materials
II.8 Quality Risk Management as Part of Packaging and Labelling
Design of packages
To design the secondary package for the protection of primary packaged product
(e.g., to ensure product authenticity, label legibility)
Selection of container closure system
To determine the critical parameters of the container closure system
Label controls
To design label control procedures based on the potential for mix-ups involving
different product labels, including different versions of the same label
_______________

Glossary
GLOSSARY
Definitions given below apply to the words as used in this Guide. They may have
different meanings in other contexts.
Action limit
Established criteria, requiring immediate follow-up and corrective action if
exceeded.
Air lock
An enclosed space with two or more doors, and which is interposed between two
or more rooms, e.g. of differing class of cleanliness, for the purpose of controlling
the air-flow between those rooms when they need to be entered. An air-lock is
designed for and used by either people or goods.
Alert limit
Established criteria giving early warning of potential drift from normal conditions
which are not necessarily grounds for definitive corrective action but which
require follow-up investigation.
Authorised person
Person recognised by the authority as having the necessary basic scientific and
technical background and experience.
Batch (or lot)

A defined quantity of starting material, packaging material or product processed
in one process or series of processes so that it could be expected to be
homogeneous.
Note: To complete certain stages of manufacture, it may be necessary to divide

a batch into a number of subbatches, which are later brought together to
form a final homogeneous batch. In the case of continuous manufacture,
the batch must correspond to a defined fraction of the production,
characterised by its intended homogeneity.
For the control of the finished product, a batch of a medicinal products comprises
all the units of a pharmaceutical form which are made from the same initial mass
of material and have undergone a single series of manufacturing operations or a
single sterilisation operation or, in the case of a continuous production process,
all the units manufactured in a given period of time.
Batch number (or lot number)

A distinctive combination of numbers and/or letters which specifically identifies a
batch.
Biogenerator
A contained system, such as a fermenter, into which biological agents are
introduced along with other materials so as to effect their multiplication or their

Glossary
production of other substances by reaction with the other materials.

Biogenerators are generally fitted with devices for regulation, control, connection,
material addition and material withdrawal.
Biological agents
Microorganisms, including genetically engineered microorganisms, cell cultures
and endoparasites, whether pathogenic or not.
Bulk product
Any product which has completed all processing stages up to, but not including,
final packaging.
Calibration
The set of operations which establish, under specified conditions, the relationship
between values indicated by a measuring instrument or measuring system, or
values represented by a material measure, and the corresponding known values
of a reference standard.
Cell bank
Cell bank system: A cell bank system is a system whereby successive batches
of a product are manufactured by culture in cells derived from the same master
cell bank (fully characterised for identity and absence of contamination). A
number of containers from the master cell bank are used to prepare a working
cell bank. The cell bank system is validated for a passage level or number of
population doublings beyond that achieved during routine production.
Master cell bank: A culture of (fully characterised) cells distributed into containers
in a single operation, processed together in such a manner as to ensure
uniformity and stored in such a manner as to ensure stability. A master cell bank
is usually stored at -70°C or lower.
Working cell bank: A culture of cells derived from the master cell bank and
intended for use in the preparation of production cell cultures. The working cell
bank is usually stored at -70°C or lower.
Cell culture
The result from the in-vitro growth of cells isolated from multicellular organisms.
Clean area
An area with defined environmental control of particulate and microbial
contamination, constructed and used in such a way as to reduce the introduction,
generation and retention of contaminants within the area.
Note: The different degrees of environmental control are defined in the

Supplementary Guidelines for the Manufacture of sterile medicinal
products.
Clean/contained area
An area constructed and operated in such a manner that will achieve the aims of
both a clean area and a contained area at the same time.

Glossary
Containment
The action of confining a biological agent or other entity within a defined space.
Primary containment: A system of containment which prevents the escape of a

biological agent into the immediate working environment. It involves the use of
closed containers or safety biological cabinets along with secure operating
procedures.
Secondary containment: A system of containment which prevents the escape of

a biological agent into the external environment or into other working areas. It
involves the use of rooms with specially designed air handling, the existence of
airlocks and/or sterilises for the exit of materials and secure operating
procedures. In many cases it may add to the effectiveness of primary
containment.
Contained area
An area constructed and operated in such a manner (and equipped with
appropriate air handling and filtration) so as to prevent contamination of the
external environment by biological agents from within the area.
Controlled area
An area constructed and operated in such a manner that some attempt is made
to control the introduction of potential contamination (an air supply approximating
to grade D may be appropriate), and the consequences of accidental release of
living organisms. The level of control exercised should reflect the nature of the
organism employed in the process. At a minimum, the area should be maintained
at a pressure negative to the immediate external environment and allow for the
efficient removal of small quantities of airborne contaminants.
Computerised system
A system including the input of data, electronic processing and the output of
information to be used either for reporting or automatic control.
Cross contamination
Contamination of a starting material or of a product with another material or
product.
Crude plant (vegetable drug)

Fresh or dried medicinal plant or parts thereof.
Cryogenic vessel
A container designed to contain liquefied gas at extremely low temperature.
Cylinder
A container designed to contain gas at a high pressure.
Exotic organism
A biological agent where either the corresponding disease does not exist in a
given country or geographical area, or where the disease is the subject of
prophylactic measures or an eradication programme undertaken in the given
country or geographical area.

Glossary
Finished product
A medicinal products which has undergone all stages of production, including
packaging in its final container.
Herbal medicinal products

Medicinal products containing, as active ingredients, exclusively plant material
and/or vegetable drug preparations.
Infected
Contaminated with extraneous biological agents and therefore capable of
spreading infection.
In-process control
Checks performed during production in order to monitor and if necessary to adjust
the process to ensure that the product conforms to its specification. The control
of the environment or equipment may also be regarded as a part of in-process
control.
Intermediate product
Partly processed material which must undergo further manufacturing steps
before it becomes a bulk product.
Liquifiable gases
Those which, at the normal filling temperature and pressure, remain as a liquid
in the cylinder.
Manifold
Equipment or apparatus designed to enable one or more gas containers to be
filled simultaneously from the same source.
Manufacture
All operations of purchase of materials and products, Production, Quality Control,
release, storage, distribution of medicinal products and the related controls.
Manufacturer
Holder of a manufacturing authorisation.
Media fill
Method of evaluating an aseptic process using a microbial growth medium.
(Media fills are synonymous to simulated product fills, broth trials, broth fills etc.).
Medicinal plant
Plant the whole or part of which is used for pharmaceutical purpose.
Medicinal products
Any medicine or similar product intended for human use, which is subject to
control under health legislation in the manufacturing or importing State.

Glossary
Packaging
All operations, including filling and labelling, which a bulk product has to undergo
in order to become a finished product.
Note: Sterile filling would not normally be regarded as part of packaging, the
bulk product being the filled, but not finally packaged, primary containers.
Packaging material
Any material employed in the packaging of a medicinal products, excluding any
outer packaging used for transportation or shipment. Packaging materials are
referred to as primary or secondary according to whether or not they are intended
to be in direct contact with the product.
Procedures
Description of the operations to be carried out, the precautions to be taken and
measures to be applied directly or indirectly related to the manufacture of a
medicinal products.
Production
All operations involved in the preparation of a medicinal products, from receipt of
materials, through processing and packaging, to its completion as a finished
product.
Qualification
Action of proving that any equipment works correctly and actually leads to the
expected results. The word validation is sometimes widened to incorporate the
concept of qualification.
Quality control
See Chapter 1.
Quarantine
The status of starting or packaging materials, intermediate, bulk or finished
products isolated physically or by other effective means whilst awaiting a decision
on their release or refusal.
Radiopharmaceutical
"Radiopharmaceutical" means any medicinal products which, when ready for
use, contains one or more radionuclides (radioactive isotopes) included for a
pharmaceutical purpose.
Reconciliation
A comparison, making due allowance for normal variation, between the amount
of product or materials theoretically and actually produced or used.
Record
See Chapter 4.
Recovery
The introduction of all or part of previous batches of the required quality into
another batch at a defined stage of manufacture.

Glossary
Reprocessing
The reworking of all or part of a batch of product of an unacceptable quality from
a defined stage of production so that its quality may be rendered acceptable by
one or more additional operations.
Return
Sending back to the manufacturer or distributor of a medicinal products which
may or may not present a quality defect.
Seed lot
Seed lot system: A seed lot system is a system according to which successive
batches of a product are derived from the same master seed lot at a given
passage level. For routine production, a working seed lot is prepared from the
master seed lot. The final product is derived from the working seed lot and has
not undergone more passages from the master seed lot than the vaccine shown
in clinical studies to be satisfactory with respect to safety and efficacy. The origin
and the passage history of the master seed lot and the working seed lot are
recorded.
Master seed lot: A culture of a micro-organism distributed from a single bulk into
containers in a single operation in such a manner as to ensure uniformity, to
prevent contamination and to ensure stability. A master seed lot in liquid form is
usually stored at or below -70°C. A freeze-dried master seed lot is stored at a
temperature known to ensure stability.
Working seed lot: A culture of a micro-organism derived from the master seed lot
and intended for use in production. Working seed lots are distributed into
containers and stored as described above for master seed lots.
Specification
See Chapter 4.
Starting material
Any substance used in the production of a medicinal products, but excluding
packaging materials.
Sterility
Sterility is the absence of living organisms. The conditions of the sterility tests are
given in the European (or other relevant) Pharmacopoeia.*
Validation
Action of proving, in accordance with the principles of Good Manufacturing
Practice, that any procedure, process, equipment, material, activity or system
actually leads to the expected results (see also qualification).
* The procedures and precautions employed should be such as to give a theoretical level of not more
6
than one living micro-organism in 10 units in the final product.

Pe 009 17 GMP Guide Xannexes

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PHARMACEUTICAL INSPECTION CONVENTION

PHARMACEUTICAL INSPECTION CO-OPERATION SCHEME

GUIDE TO GOOD MANUFACTURING

Editor: PIC/S Secretariat

PE 009-17 (Annexes) 25 August 2023

Annex 1 (Manufacture of sterile medicinal products) 1

PE 009-17 (Annexes) -i- 25 August 2023

Annex 3 (Manufacture of radiopharmaceuticals) 127

Annex 5 (Manufacture of immunological veterinary medical products) 136

PE 009-17 (Annexes) -ii- 25 August 2023

Starting materials 142

Annex 6 (Manufacture of medicinal gases) 146

Annex 7 (Manufacture of herbal medicinal products) 157

Annex 8 (Sampling of starting and packaging materials) 162

Annex 9 (Manufacture of liquids, creams and ointments) 164

Annex 11 (Computerised systems) 168

PE 009-17 (Annexes) -iii- 25 August 2023

Annex 12 (Use of ionising radiation in the manufacture of medicinal products) 173

Annex 13 (Manufacture of investigational medicinal products) 180

PE 009-17 (Annexes) -iv- 25 August 2023

Premises and equipment 204

Annex 15 (Qualification and validation) 211

Annex 16 (Authorised person and batch release) 226

Annex 17 (Real Time Release Testing and Parametric Release) 239

Annex 18 [GMP Guide for active pharmaceutical ingredients]** 244

Annex 19 (Reference and retention samples) 245

PE 009-17 (Annexes) -v- 25 August 2023

Storage conditions 247

Annex 20 (Quality risk management)*** 250

Appendix I: Risk Management Methods and Tools 261

Appendix II: Potential Applications For Quality Risk Management 265

*** This Annex is voluntary.

PE 009-17 (Annexes) -vi- 25 August 2023

MANUFACTURE OF STERILE MEDICINAL PRODUCTS

Section Number General overview

1. Scope Includes additional areas (other than sterile products) where

2. Principle General principles as applied to the manufacture of sterile

4. Premises General guidance regarding the specific needs for premises

5. Equipment General guidance on the design and operation of equipment.

6. Utilities Guidance regarding the special requirements of utilities such

7. Personnel Guidance on the requirements for specific training, knowledge

8. Production and specific Guidance on the approaches to be taken regarding aseptic

11. Glossary Explanation of specific terminology.

PE 009-17 (Annexes) -1- 25 August 2023

i. Facility, equipment and process should be appropriately designed, qualified

PE 009-17 (Annexes) -2- 25 August 2023

sterile product during the manufacturing, packaging and distribution

2.2 Processes, equipment, facilities and manufacturing activities should be managed

2.3 A Contamination Control Strategy (CCS) should be implemented across the

i. design of both the plant and processes including the associated

PE 009-17 (Annexes) -3- 25 August 2023

ii. premises and equipment;

v. raw material controls – including in-process controls;

vi. product containers and closures;

vii. vendor approval – such as key component suppliers, sterilisation of

viii. management of outsourced activities and availability/transfer of critical

ix. process risk management;

xi. validation of sterilisation processes;

xii. preventative maintenance – maintaining equipment, utilities and premises