Frederick National Laboratory for

n
l>o
Cancer Research, Frederick, MD

I n
I Standard Operating Procedure
Biopharmaceutical Development Program

Title: Standard Aseptic Practices for Cleanrooms and Biological Safety

Cabinets for Production Operations
SOP Number: 15137 Revision Number: 03
Supersedes: Revision 02 Effective Date: JAN 31 2020

Originator/Date:

Approval/Date:

Approval/Date:

Table of Contents

1.0 Purpose
2.0 Scope
3.0 Overview
4.0 Authority and Responsibility
5.0 Aseptic Practices
6.0 Personnel Monitoring
7.0 References and Related Documents

1.0 Purpose
This document provides guidance for aseptic technique within ISO 5 unidirectional flow
cleanrooms and biological safety cabinets used for the production of Good Manufacturing
Practices/Good Laboratory Practices (GMP/GLP) product.
2.0 Scope
This Standard Operating Procedures (SOP) applies to Biopharmaceutical Development Program
(BOP) personnel who work in cleanrooms or in biological safety cabinets for the production of
GMP/GLP product.

This procedure is made available through federal funds from the National Cancer Institute, NIH, under contract

UNCONTROLLED COPY FOR TRAINING AND REFERENCE PURPOSES ONLY

FNLCR, BDP Page 2 of 8
SOP Number: 15137 Revision Number: 03 Effective Date: JAN 31 2020
Title: Standard Aseptic Practices for Cleanrooms and Biological Safety Cabinets for Production Operations

3.0 Overview
3.1 Infection can be life-threatening; therefore, contamination control is an essential part of drug
manufacture. Drugs come in a variety of dosage forms (oral, injectable, eye/ear drops,
lotions, etc.). Because injectables bypass the body’s first line of defense (skin barrier), their
manufacture requires more stringent controls to ensure a contaminant does not get injected
into the body. The BDP manufactures injectable drugs.
3.2 Many drugs can be sterilized AFTER they have been filled into the final drug container
(terminal sterilization). However, for biologic drugs, terminal sterilization processes usually
destroy the activity of the drug. Therefore, biologic drugs must be produced and filled using
aseptic processes.
3.3 Contamination controls (a range of engineering controls, chemical controls, and personnel-
directed controls) are applied to minimize/prevent contamination. Strong controls for each
of these components provides layers of confidence that the manufacturing operation will
produce an aseptically safe drug product for patients.
3.4 The major source of contamination in a controlled environment is the personnel. This
procedure describes the considerations that personnel should give to the work they perform
under aseptic conditions.
4.0 Authority and Responsibility
4.1 The Director, Technical Operations, BDP has the authority to define this procedure.
4.2 Manufacturing personnel are responsible for performing this procedure.
4.3 Biopharmaceutical Quality Assurance (BQA) is responsible for quality oversight of this
procedure.
5.0 Aseptic Practices
5.1 Personal Health and Hygiene
5.1.1 Health: Criteria for the restriction of personnel from product contact environments
due to adverse health of employees are presented in SOP 21706 - Personnel
Health Restrictions in Product-Contact Environments.
5.1.2 Hygiene
Personnel shall practice good sanitation and health habits. For specifics refer to
SOP 19406 - Gowning Requirements for Personnel and Visitors:
Manufacturing and Support Areas and SOP 19410 - Gowning Requirements
for Personnel and Visitors for the Virus Production Facility
5.2 Gowning for Clean Room Environments
5.2.1 The gown should provide a barrier between the body and exposed sterilized
materials and should prevent contamination from particles generated by, and
microorganisms shed from, the body.

This procedure is made available through federal funds from the National Cancer Institute, NIH, under contract .

UNCONTROLLED COPY FOR TRAINING AND REFERENCE PURPOSES ONLY

FNLCR, BDP Page 3 of 8
SOP Number: 15137 Revision Number: 03 Effective Date: JAN 31 2020
Title: Standard Aseptic Practices for Cleanrooms and Biological Safety Cabinets for Production Operations

5.2.2 Specific gowning requirements are listed in the following SOPs:

• SOP 19406 - Gowning Requirements for Personnel and Visitors:
Manufacturing and Support Areas,
• SOP 19410 - Gowning Requirements for Personnel and Visitors for the
Virus Production Facility
5.2.2.1 Prior to and throughout aseptic operations, an operator may not engage
in any activity that poses an unreasonable contamination risk to the gown
and/or product.
5.2.2.2 Inspect gowns on a periodic basis for integrity. If any part of the aseptic
garment has been compromised, exit the cleanroom area and re-gown as
required.
5.2.2.3 Gowns must be monitored at the end of processing before tear-down of
the filling equipment. Do not disinfect gloves or gowning immediately
prior to microbial monitoring. After monitoring, wipe gloves with sterile
70% Isopropyl alcohol (Decon-Ahol, BDP Part # 30129 or Alcoh-Wipe,
BDP # 22328) to remove residual media. If continuing to perform aseptic
operations discard outer gloves and replace.
5.3 Sterile Packaged Gloves
5.3.1 Sanitizing of gloves is not required immediately following sterile glove replacement.
Sanitizing of gloves with sterile 70% Isopropyl alcohol (Decon-Ahol, BDP Part #
30129 or Alcoh-Wipe, BDP # 22328) before performing activities in critical areas,
prior to performing any aseptic manipulations, or immediately prior to moving from
the ISO 7 (Class 10,000) area to any ISO 5 (Class 100) area. If there has been a
known potential for glove contamination, gloves should be replaced.
5.3.2 Disinfect the entire surface of the gloves so the sides, between the fingers, and the
front and back of the gloves down to the wrist receive alcohol contact.
5.3.3 Position your hands such that overspray and room airflow is away from the filling
machine, open components, and/or equipment such as the particulate counter.
NOTE: It may be preferable to use the sterile Alcoh-Wipe to avoid overspray in
these situations.
5.3.4 Gloved hands are to be held in such a way during production so as to
minimize/eliminate contact of the gloves with the operators gowning, carts, walls,
etc., in order to minimize possible contamination. If contact does occur, disinfect
gloves as in Step 5.3.2.
5.3.5 Inspect gloves frequently and replace if torn, punctured, or soiled.
5.3.6 Avoid unnecessarily touching non-sterile objects during aseptic operations. If
necessary, spray, wipe or change gloves after touching a potentially non-sterile
object before proceeding to another aseptic operation.

This procedure is made available through federal funds from the National Cancer Institute, NIH, under contract .

UNCONTROLLED COPY FOR TRAINING AND REFERENCE PURPOSES ONLY

FNLCR, BDP Page 4 of 8
SOP Number: 15137 Revision Number: 03 Effective Date: JAN 31 2020
Title: Standard Aseptic Practices for Cleanrooms and Biological Safety Cabinets for Production Operations

5.4 Tools and Instruments

5.4.1 Contact sterile materials only with sterile instruments i.e., forceps, vial pusher, vial
handling tools, pipettes, held in a manner that prevents contamination. Replace
instruments as necessary throughout an operation.
5.4.2 Sterile instruments used must be sanitized prior to each use, preferably by dry heat
sterilization or autoclaving or be single use disposable in nature. Use disposable
sterile plastic ware and utensils when possible.
5.4.3 When a sterile instrument is not actively being used during an operation, it must be
either placed within a sterile area such as an autoclave pouch or otherwise be
stored to ensure its integrity. Replace the tool/instrument if the integrity is
suspected to be compromised.
NOTE: Sterile conical tubes that have been placed in stainless steel brackets on
the inside corners of the Flexicon plexiglass RAB are used for storage of
tools used to manipulate vials during filling operations. These are treated
as a single use item and replaced for each fill or if compromised during
processing.
5.4.4 Non-routine tools (for example, repair tools) must be autoclaved or sanitized with
an approved sporicide (Steri-Perox 6%, BDP part # 10665 is preferred as
secondary wiping with alcohol is not required) and if a sporicide other than Steri-
Perox 6% is used are wiped with sterile 70% Isopropyl alcohol (Decon-Ahol or
Alcoh-Wipe) prior to use.
5.5 Tables, Carts and Trash Containers
5.5.1 Avoid disrupting the air flow in the clean room areas by positioning tables, carts,
and trash containers so they are a minimum of several inches away from walls.
Use surfaces that are perforated, made of wire, or other materials that do not
obstruct air flow whenever practical and possible.
NOTE: sterile trash can liners (BDP part #21561) Within the ISO 5 area, sterile
trash can liners may only be used alone as no hard trash receptacles are permitted.
5.5.2 Do not store equipment or materials in front of room return air ducts. Materials
should be stored at least one foot above the height of any air return duct. This is
done to both ensure that airflow is not restricted and to avoid materials being in
contact with air potentially carrying particulates.
5.6 Movements in Unidirectional Flow Clean Rooms and Within BSCs
5.6.1 Movement in unidirectional air flow will disrupt air patterns. Move slowly and
deliberately. Rapid movements can create unacceptable turbulence in a critical
area presenting a challenge beyond intended clean room design and control
parameters. Follow the principle of slow, careful movement throughout the ISO 5
(Class 100) environment.
5.6.2 ISO 5 environments create an aseptic environment – not a sterile environment.
Consideration for how work is performed provides additional protection against
contamination.
This procedure is made available through federal funds from the National Cancer Institute, NIH, under contract .

UNCONTROLLED COPY FOR TRAINING AND REFERENCE PURPOSES ONLY

FNLCR, BDP Page 5 of 8
SOP Number: 15137 Revision Number: 03 Effective Date: JAN 31 2020
Title: Standard Aseptic Practices for Cleanrooms and Biological Safety Cabinets for Production Operations

5.6.3 Unidirectional air flow design is used to protect sterile equipment surfaces,
container-closures, and product. Disruption of the path of unidirectional flow air in
the critical area can pose a risk to product sterility. Minimize actions within this
critical area and limit to those interventions verified during validations.
5.6.4 Observe principle of “First Air” when working in ISO 5 areas. This principle
emphasizes the need for HEPA filtered air moving in a unidirectional flow to contact
critical components of the operation (open vials, vial closure components, open
product, etc.) or aseptic processes prior to contacting any operator. Failure to
follow “First Air” principles would result in HEPA filtered air flowing over part of the
operator or other objects and then coming into potential contact with critical
components or aseptic processes.
5.6.5 Any operator involved with the handling of open vials or making aseptic
manipulations during operations is restricted to those operations and should not be
involved with other operations that could increase the likelihood of glove or sterile
gown contamination that could jeopardize the sterility of finished product. Other
operations that would be prohibited would include but not be limited to the handling
of batch records, performing concurrent EM, moving back and forth between
different classification areas, handling of trash, removing outer layers of wrapping
from sterile supplies etc.
5.6.6 Do not pass objects, including hands or non-sterile instruments, over open sterile
materials. Perform aseptic manipulation from the side and not above the product.
5.6.7 Limit the time sterile containers are open to the environment whenever possible.
5.6.8 Avoid movement of used (dirty) items overtop of clean items. Separate clean and
used (dirty) items within the workspace.
5.6.9 Refrain from unnecessary speaking when in direct proximity to the critical area.
5.6.10 Do not lean against walls or equipment such as tables, carts, and trash containers.
The integrity of these items and your sterile gown can be compromised by contact
with any of these items.
5.6.11 Do not kneel or lay directly on the floor. If necessary, place a sterile pad on the
floor to protect the integrity of the gown or change your gown before proceeding to
other activities.
5.6.12 Do not compress trash down into the waste container. This may force “dirty” air
into the room environment. When the container is full, use another container.
5.6.13 Avoid picking up items that have fallen on the floor until the operation has been
completed. When necessary, fallen items can be pushed out of the way with your
foot.
5.6.14 Avoid unnecessarily touching non-sterile objects with your hands during aseptic
operations. When not performing manipulations, keep hands in front of the body
such that they are not in contact with anything. If necessary, spray or change
gloves after touching a potentially non-sterile object and before proceeding to
another aseptic operation.
This procedure is made available through federal funds from the National Cancer Institute, NIH, under contract .

UNCONTROLLED COPY FOR TRAINING AND REFERENCE PURPOSES ONLY

FNLCR, BDP Page 6 of 8
SOP Number: 15137 Revision Number: 03 Effective Date: JAN 31 2020
Title: Standard Aseptic Practices for Cleanrooms and Biological Safety Cabinets for Production Operations

5.6.15 To move through a curtain, part the curtain with your gloved hand. Sanitize gloves
following entry to the area.
5.6.16 If you sneeze or cough, turn completely away from your work surface.
5.7 Handling Supplies
5.7.1 Unwrapping Sterilized Components and Tools
5.7.1.1 Sterilized components and tools are wrapped to protect them during
holding and storage. All sanitization is performed using sterile 70%
Isopropyl alcohol (BDP part # 30129 or BDP part # 22328). Always spray
in a location such that airflow will not carry aerosols into critical areas.
NOTE: When unwrapping items that have been sealed with autoclave
tape it is best to open using sterile scissors to avoid getting tape
residue on gloves.
• For double-wrapped items, sanitize and remove the outer wrap without
touching the inner wrapping. Then move the item (now single-
wrapped) into the critical area.
• For single-wrapped items, sanitize the item and remove the wrap
within the critical area without touching the product-contact surfaces of
the item.
NOTE: The unwrapping of sterile items is often performed using two
people. One person removes the outer wrapping of double-
wrapped items and moves the item into the critical area. The
second person, in the critical area, removes the inner
wrapping.
5.7.1.2 Do not re-enter a sterile bottle with a “used” pipette. Use a fresh, sterile
pipette for each entry into a sterile bottle.
5.7.1.3 Do not return any excess material back into its original container.
5.7.2 Store sterilized items in such a way that they maintain first contact with clean
laminar flow air and are not potentially contaminated by air that has first washed
over other surfaces or items.
5.8 Specialized Processes
5.8.1 Aseptic Connections
5.8.1.1 All aseptic connections are made in an ISO 5 (Class 100) environment.
5.8.2 Product Sampling
5.8.2.1 Product-sampling processes must occur in a manner to protect the purity
and aseptic integrity of the bulk being sampled and the sample itself.
• Sample containers must protect the integrity of the sample.
• Do not re-enter a sterile bottle with a “used” pipette. Use a fresh,
sterile pipette for each entry into a sterile bottle.
This procedure is made available through federal funds from the National Cancer Institute, NIH, under contract .

UNCONTROLLED COPY FOR TRAINING AND REFERENCE PURPOSES ONLY

FNLCR, BDP Page 7 of 8
SOP Number: 15137 Revision Number: 03 EffectiveDate: JAN 31 2020
Title: Standard Aseptic Practices for Cleanrooms and Biological Safety Cabinets for ProductionOperations

• Do not return any excess material back into its original container.
5.9 Working in Biological Safety Cabinets (BSCs)
5.9.1 BSC Setup
5.9.1.1 Use the BSC including disinfection and cleaning per SOP 19102 -
Routine Use and Disinfection of Biological Safety Cabinets,
Incubators, Shakers, and Centrifuges).
5.9.1 .2 Sanitize supplies and equipment with sterile 70% IPA prior to placing
items into the BSC.
5.9.1.3 Organize materials within the hood so that air flow is not blocked. Do not
obstruct the grills at the front and back of the BSC.
5.9.1.4 Maintain the sash at the proper height for optimized air flow within the
BSC.
5.9.1.5 Following the guidelines for sterile packaged gloves in Section 5.3 add
sterile sleeves and a new pair of sterile gloves within the BSC before
beginning work. Sterile sleeves should be donned first and then the outer
pair of sterile gloves added, taking care not to touch any outer portion of
the second set of gloves with the original pair of gloves. Upper sleeve
cuffs should be rolled up after donning the second pair of sterile gloves
and done so by sliding the fingers of the opposite hand under the rolled
cuff and sliding upwards to unroll the cuff.
5.9.2 BSC Operations
5.9.2.1 As much as possible, work in the middle of the BSC where conditions are
optimized.
5.9.2.2 Limit movements in the proximity of the hood and the entry and exit of
people into the area to those movements and staff required for the
operation while the BSC is in use. Movement of objects and personnel
behind the hood operator can disrupt the proper air flow patterns within
the hood and allow room air to enter the hood environment. Use slow
deliberate movements when working in the vicinity of BSCs in use.
5.9.2.3 Set pan lids etc., in the BSC in such a way that they do not block the grill
area in the front or rear of the BSC or in any way significantly impede the
air flow.
5.9.2.4 Passing materials in and out of the BSC during operation.
5.9.2.4.1 For double-wrapped items; an operator outside the BSC will
sanitize the outer wrap and hands, open the outer wrap
partially and present the package to the edge of the BSC so
that the operator in the BSC may remove the inner wrapped
package.

This procedure is madeavailable through federal funds from the NationalCancerInstitute, NIH, under contract

UNCONTROLLED COPY FOR TRAINING AND REFERENCE PURPOSES ONLY

FNLCR, BDP Page 8 of 8
SOP Number: 15137 Revision Number: 03 EffectiveDate: JAN 31 2020
Title: Standard Aseptic Practices for Cleanrooms and Biological Safety Cabinets for ProductionOperations

5.9.2.4.2 For single-wrapped items; an operator outside the BSC will

sanitize the outer wrap and hands and present the package to
the edge of the BSC so that the operator in the BSC may
retrieve the package.
5.9.2.4.3 To hand materials out; decontaminate object (applies to virus
processes only) and then present the object to the edge of the
BSC where they can be retrieved.
5.9.2.4.4 During these operations, the hands of the outside operator
should not enter the BSC and the hands of the operator within
the BSC should not exit the BSC.
6.0 Environmental/Personnel Monitoring
6.1 Environmental and Personnel Monitoring is performed a ified in
SP22
13-
Environmental Monitoring in BDP GMP Areas at the_ .
6.2 Do not change or spray gloves with sterile 70% IPA I (Decon-aholor equivalent)
immediately before personnel monitoring. While changing and periodic spraying of gloves
to reduce glove bioburden is an expected practice, spraying or changing gloves
immediately before personnel monitoring does not generate data that is reflective of the
actual condition of gloves during aseptic processing of product.
6.3 Gowns should be monitored at the end of processing before any disassembly of equipment.
Do not leave an ISO 5 area before being monitored, do not remove hands from the BSC
until immediately prior to monitoring as this could negatively impact results.
6.4 If continued work in the cleanroom or BSC is required after the processing of product and
after personnel monitoring is completed, change the outer layer of gloves or wipe with
sterile 70% lsopropyl alcohol (Decon-Ahol or equivalent) to remove residual media before
proceeding.
7.0 References and Related Documents
7.1 SOP 21706 Personnel Health Restrictions in Product-ContactEnvironments
7.2 SOP 19406 Gowning Requirements for Personnel and Visitors:- Manufacturing
and Support Areas
7.3 SOP 19410 Gowning Requirements for Personnel and Visitors for th Virus
Production Facility
7.4 SOP 19102 Routine Use and Disinfection of Biological Safety Cabinets, Incubators,
Shakers, and Centrifuges
7.5 SOP 22315 Environmental Monitoring in BOP GMP Areas at the• .

This procedure is madeavailable through federal funds from the NationalCancerInstitute, NIH, under contract

UNCONTROLLED COPY FOR TRAINING AND REFERENCE PURPOSES ONLY