Vol. 1, No.

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December 6, 2021

Pharma Island Free Press

“Lead, Follow or Get Out of the Way”
Council for Pharmaceutical Excellence
The title of this missive has been associated with many individuals: Thomas Paine, George
Patton. Lee Iacocca and others. It’s an appropriate message for the global healthcare industry that
is struggling with a variety of challenges. Product shortages, drug product pricing complaints,
increased public skepticism, difficulties with product quality, data integrity failures, heavy
reliance on personnel for critical tasks, heavy dependence on batch processing, and a general
inability to innovate are among the issues the industry is dealing with. For an industry so vital to
the health of global citizens, it’s appropriate to ask where we might look for answers to the many
circumstances which impede improvement.

Regulators
Relative latecomers in the healthcare area, regulators are charged with consumer protection to
ensure that products possess the quality, efficacy, identity, purity and strength necessary for
patients. Within that context they develop rules that producers must follow, approve new
products, and investigate firms for continued compliance. Their role is derivative, however, as
the requirements must necessarily follow invention. There was certainly no merit in developing
of regulations for cell and gene therapy or combination products before those emerged.
Regulators cannot and should not lead, and as their activities commence after actions of other, it
appears their most appropriate posture is on the sidelines in a monitoring roles.1,2 The more
prescriptive the regulation and guidance provided the greater obstacles it presents to
improvement.

Industry
The industry might seem to be the obvious choice to address the myriad of issues, however this
is possible only through consensus efforts rather than on an individual company basis. None of
the industry giants has much more than a 5% market share which limits the impact of any

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singular effort to change the overall landscape. Improvements can certainly be made by an
individual firm but typically only in an overall environment that is supportive. Comparatively
few firms have chosen a path unique from their peers. The norm across much of the global
healthcare industry is continue using older approaches and practices rather than push the
envelope.

Suppliers of Goods and Services

Production of healthcare products depends heavily on a bevy of suppliers offering goods and
services necessary for commercial scale operations. Within the community of vendors there are
many that have promoted change in an effort to grow their business. Their ability to do so is
limited by the willingness of their customers to incorporate their ideas into their operations.
Innovative suppliers can be an impetus for change, but given their reliance on industry to
implement it native conservativeness of the healthcare industry often restricts its spread.

Pharmacopeia
The global pharmacopeia rely on consensus input to establish standards for products. The
majority of their efforts are devoted to specifications and test methods. Within this area, there is
increasing flexibility for the establishment of alternative methods for analysis, which while
beneficial only minimally impact the larger issues facing the industry. There have been some
efforts with informational chapters to provide greater flexibility of approach in manufacturing,
however their non-mandatory status cannot assert sufficient influence to shift everyday
operational paradigms. The pharmacopeial organizations are best suited to a supportive role
providing the analytical tools needed.

Trade and Scientific Associations

There’s a diversity of associations active in the healthcare sector emphasizing different parts of
the industry – science, regulation, commerce, etc. Because their membership is comprised of and
their revenues heavily dependent on the regulated industry, associations take on many of the
same attitudes. It is here, however where opportunity for cooperative efforts can lead to broader
initiatives for improvement. The most important role that industry associations can play is to

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become strong advocates for change pushing for the advancement of technology, the easing of
restrictive regulation and adherence to science.

Regardless where it comes from, it is apparent that leadership is needed to move industry
forward. We need more of it if we are to continue to fulfill the world’s need for safe and
effective drugs at a reasonable cost.

1. Madsen, R., & Agalloco, J., “What, Not How”, published on-line at LinkedIn.com, April 2020.
2. Agalloco, J., “Some Further Comments on Aseptic Processing Guidance or The Fool on the Hill”, PDA Journal of
Pharmaceutical Science and Technology, Vol. 57, No. 5, p. 324-330, 2003.

The Fallacy of Sterile Gowns

Russell E. Madsen
Introduction
It is common practice in the pharmaceutical industry to use sterilized gowns in aseptic
processing areas. Great care is taken to keep the exterior surfaces of the gown sterile during the
gowning procedure and throughout its use. However, observation of the gowning process and
various studies confirm that microbes shed by personnel during the gowning process render
gown surfaces non-sterile as soon as the gowns are put on. A better approach might be to use
commercially laundered, non-sterilized gowns for aseptic processing operations. Surprisingly,
such gowns have been shown to contain few if any viable microorganisms prior to donning.
Switching to non-sterilized gowns would not jeopardize aseptic operations, would reduce costs
and save energy, making this a win-win-win option to the use of sterilized gowns.

Discussion
Personnel are the primary source of microbial contamination in pharmaceutical cleanrooms.1
Fully gowned operators (suit, hood, boots, and gloves) emit about 17,000 particles per minute.2 It
is obvious that many of these particles are microorganisms that are detectable as colony forming
units (CFU) in the cleanroom environment and on the surfaces of the operators’ gowns.

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No matter how carefully gowns are put on, studies have shown that their exterior surfaces collect
microorganisms.3 Also, bacteria may penetrate through the clothing system material and
contaminate the outer surfaces of the cleanroom garments.4 Whyte and Eaton have shown that
cleanroom garments transfer microorganisms to hard surfaces with a mean transfer coefficient of
0.6 (microorganisms present versus those transferred to the surface).5 Satter et al. have developed
a quantitative model for the transfer of bacteria from fabrics to hands and other fabrics.6

Commercially laundered cleanroom garments washed in water at 75 °C for six minutes before
drying in HEPA-filtered air prior to packaging in individual heat-sealed polybags have been
shown to contain very few, if any, viable microorganisms prior to donning.7 Immediately
following a careful and controlled gowning process, these gowns were tested with contact plates
at multiple locations. Positives were observed in all areas tested. Thus, the microbiological
quality of the gown had been degraded by the gowning process, leading to the question as to why
sterilized cleanroom garments are required in the first place.

Conclusion
Non-sterilized, commercially laundered cleanroom clothing offers significant advantages over
sterilized cleanroom clothing in terms of cost and environmental impact without adversely

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affecting the quality of aseptically produced pharmaceutical and biopharmaceutical products; it

is known from controlled studies that the exterior surfaces of worn cleanroom clothing contain
microorganisms even if such clothing was sterile to begin with. Furthermore, studies have
demonstrated that commercially laundered cleanroom clothing can have vanishingly small
numbers of microorganisms prior to use.

1
Reinmüller B and Ljungqvist B. Modern cleanroom clothing systems: people as a contamination source. PDA
Journal of Pharmaceutical Science and Technology 2003;57(2):114–25.
2
Strauss L, Larkin J and Zhang KM. The use of occupancy as a surrogate for particle concentrations in
recirculating, zoned cleanrooms. Energy and Buildings 2011;43(11):3258-62.
3
Smith L, O’ Driscoll N and Lamb A. A comparison of the bacterial contamination of the surface of cleanroom
operators’ garments following donning with and without gloves. European Journal of Parenteral and
Pharmaceutical Sciences 2021;26(3):263-80.
4
Grangé J, Nguyen S, Bordenave J, et al. Contamination of integral protective suits in the sterile environment
used for producing total parenteral nutrition bags. Le Pharmacien Hospitalier 2011;46(1):e12-18.
5
Whyte W and Eaton T. Microbial transfer by surface contact in cleanrooms. European Journal of Parenteral
and Pharmaceutical Sciences 2015;20(4):127-31.
6
Sattar SA, Springthorpe S, Mani S, et al. Transfer of bacteria from fabrics to hands and other fabrics:
development and application of a quantitative method using Staphylococcus aureus as a model. Journal of
Applied Microbiology 2001;90(6):962-70.
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Smith L. A comparison of the bacterial contamination of the surface of cleanroom operators’ garments. EJPPS
2021;26(3):263-80.

Controlled non-Classified Environment: Does it belong in Sterile Manufacturing?

Phil DeSantis

In the course of my consulting practice, I have had the opportunity to review designs for more
than a few facilities for the manufacture of sterile drugs via the aseptic processing route. (Prior to
consulting, when I worked in the industry directly, I probably reviewed hundreds.) In reviewing
more recent designs, often at the preliminary stage, but sometimes as late as after construction,
there is a trend among architects and design engineers that causes me some concern.

Why has the use of CnC become so prevalent in sterile manufacturing facilities? No regulation
or regulatory guideline for sterile facilities mentions CnC, except that the proposed revision to
Annex 1 defines it, but does not include it in the document body. My comment to EMA was that
it did not even belong in the glossary.

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The history of CnC is that in the early days of biotech, engineers and architects were designing
areas for closed bioreactors that did not need to be Classified, but were perceived to need some
level of control. They initially defaulted to the term "Class 100,000 non-validated." As a
compliance guy in a big Engineering firm, my objection was that the term might be perceived
with skepticism by the regulators, so we came up with the term "Controlled non-Classified." We
then had a controlled space designed to Class 100,000 specifications (remember, this preceded
Annex 1 and its Grade A, B, C, D nomenclature) but without operating limits. Later this
classification was applied to other non-sterile manufacturing operations like solid dosage and
topicals. It serves to keep the area clean without the requirement to validate and monitor airborne
particulates. (I do routinely commission CnC for airborne particulate count, though, as a prudent
exercise.)

My point is that CnC was never meant for sterile manufacturing. It is fine for bulk biotech in my
opinion because bulk biotech has no claim of sterility. Sterile manufacturing via traditional
aseptic processing should employ Grade D as it was intended. It should be the first step into the
manufacturing zone after entry from the common access areas. A Grade D access/exit corridor
obviates the need for two-stage airlocks into Grade C, while providing a controlled, sanitized and
monitored barrier between the manufacturing core and the outer environment.

It is my opinion that the use of CnC for this purpose is mere laziness. The design and operating
characteristics are the same, so what you are saving is sanitization, monitoring and allowing for
less restricted access. But if you are doing all these things, then it should be classified as Grade D
anyway. (I am sure many will disagree, but to quote a recent pop culture icon, "This is the way.")

What Might Have Been

Russell E. Madsen
In October 1991, FDA published a Proposed Rule, “The Use of Aseptic Processing and Terminal
Sterilization in the Preparation of Sterile Pharmaceuticals for Human and Veterinary Use,” to

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amend current good manufacturing practice (CGMP) regulations to require the use of terminal
sterilization of sterile drug products unless that process would adversely affect the drug product.1
The Proposed Rule would have amended 21 CFR § 211.113 Control of Microbiological
Contamination by adding paragraph (c) to read:

(c)(1) Drug products purporting to be sterile shall be sterilized by terminal

sterilization unless such process will adversely affect those drug products. In
cases where terminal sterilization is determined by the manufacturer to be
inappropriate, the written procedures described in paragraph (b) of this section
shall include a justification for this determination.
(2) Biological products for human use are exempt from the requirements of
paragraph (c)(1) of this section.

At that time, it was common for manufacturers to employ steam sterilization “overkill” cycles,
e.g., 121 °C and 15 minutes, for terminal sterilization processes. Many drugs could not tolerate
such conditions and manufacturers pushed back, essentially saying the proposal was burdensome
in requiring justification for something that was already well known. However, the proposed
rule did not specify the terminal sterilization conditions or method, leaving the way open to
alternatives such as using the product bioburden as the basis for evaluating the lethality of the
applied sterilization process in lieu of resistant biological indicator microorganisms, yielding
contamination rates equivalent to the one in one million [10-6] units filled afforded by the
overkill approach.

One of FDA’s justifications for amending the CGMP regulations was the lower contamination
rates which could be achieved by terminal sterilization as compared with aseptic processing.
The proposed rule stated, “. . . current aseptic processing methods, even when performed under
optimal conditions, can only be validated to ensure that the contamination rate is no greater than
1 contaminated unit per 1,000 [10-3] filled.”

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The Parenteral Drug Association (PDA) commented on the proposed rule, concluding “the
proposed ruling is a beneficial action on the part of the [FDA] that will surely enhance the level
of sterility assurance associated with sterile drug products.”2 To address FDA’s concern that
aseptic processing did not provide sterility assurance levels equivalent to terminal sterilization,
PDA’s comments stated, “With knowledge and control of the indigenous bioburden, and its
resistance to the sterilization process, sterility can be consistently achieved by processes which
will not adversely impact product quality. Where an aseptic process is followed by a terminal
sterilization procedure, a modest moist heat treatment would be sufficient to assure that the fluid
is sterile.”

In its comments, PDA had captured the key issue inhibiting the use of terminal sterilization for
many sterile products: “It is the PDA’s belief that the focus on overkill cycles has contributed to
a narrower application of terminal sterilization in the industry than would otherwise be the case.”

In any event, FDA’s proposed rule was never adopted.

Another impediment to the widespread use of terminal sterilization was the release for
consultation in 1998 and publication in 2000 of the CPMP “Decision Trees for the Selection of
Sterilisation Methods.”3 This document specified as a starting point for aqueous products
terminal sterilization at 121 °C and 15 minutes, with identified alternatives if this was not
achievable. The document reflected the standard moist-heat sterilizations specified in the
European Pharmacopoeia.

This leads to the current sterile pharmaceutical manufacturing situation. Terminal sterilization is
not widely used because of unrealistic expectations regarding overkill cycles and the resulting
detrimental effects on product quality. In terms of sterility assurance, terminal sterilization is the
best option, but it is not being used to the degree it should.

Had the CGMP regulations been amended as proposed in 1991, leading to the use product
bioburden-based terminal sterilization in lieu of overkill sterilization, it is likely that terminal

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sterilization would today be the method of choice, followed by advanced aseptic processing
technologies and the abandonment of manned cleanrooms. This scenario would have increased
patient safety, simplified the design of manufacturing processes, and eliminated much of the
cleanroom space and operational inefficiencies and activities (e.g., extensive and expensive-to-
operate HVAC systems and environmental monitoring programs) which simply increase costs
without product quality and patient safety benefits.

Let’s not be so quick to reject a good regulatory proposal when we see it. Perhaps we should
revisit this one with the perspective of over twenty years hindsight.

1
Federal Register, Vol. 56, No. 198, October 11, 1991, 51354-58.
2
Akers, J.E., et al, PDA Response FDA Proposal to Amend cGMP’s Entitled–Use of Aseptic Processing and
Terminal Sterilization in the Preparation of Sterile Pharmaceuticals for Human and Veterinary Use. J Pharm Sci
Technol 1992, 46 (3), 65-8.
3
EMEA Committee for Proprietary Medicinal Products (CPMP), Decision Trees for the Selection of Sterilisation
Methods (CPMP/QWP/054/98 Corr), 5 April 2000.

The Fallacy of Proposed Annex 1 Revision Regarding Isolator Leak Testing

James Akers, Ph.D.

In my opinion the concerns expressed in GMP Annex 1, Draft Version 12, Example 4.23
regarding barrier technology and barrier glove integrity testing are excessive and do not consider
actual risk.

I must assume that the hypothesis supporting proposed requirement 4.23 is that there is a critical
level of risk associated with integrity of the isolator enclosure and with gloves used to conduct
interventions during operations. To consider the actual risk associated with the use of gloves and
isolator chamber integrity we must consider our history with isolators in terms of actual
microbiological contamination risk. It is in my view inappropriate to initiate a regulatory
compliance requirement based on a conclusion arrived at in the absence of actual data.

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Fortunately, such data exists, and studies have been done to evaluate the actual impact of gloves
on microbial contamination risk.

There was information in the early days of isolator implementation circa 1990 that gloves
installed in isolators were the primary mechanism for microbial ingress into isolator systems.
The general cause of this problem was discovered to be the use of neoprene (polychloroprene)
gloves. These gloves had two significant drawbacks: they were poorly resistant to puncture and
prone to pinch damage and they deteriorated upon repeated exposure to vapor phase hydrogen
peroxide (VPHP) used in isolator decontamination. The solution to this problem, which has
proven to be extremely effective, was the use of chlorosulfanated polyethylene (CSPE) which
was originally a product of DuPont Performance Elastomers and marketed under the tradename
Hypalon.

Hypalon was both resistant to repeat exposures to VPHP and resistant to both penetration and
pinch punctures. The switch to CSPE gloves in and of itself diminished glove leaks by well over
95%. The leaks occasionally observed in the mid-90s, when CSPE gloves were used nearly
exclusively, were wear leaks at the glove gauntlet, where an O-ring seal attached the glove
gauntlet to the sleeve. This minor risk has been obviated by a better attention to ergonomics in
isolator design to avoid excessive stretching of the glove at critical access points and by ensuring
that the glove was sized to fit the person assigned to an operation.

A further risk mitigation factor, introduced when neoprene gloves were common, was the use of
a sterile clean room glove under the CSPE glove. This so-called “underglove” became a standard
practice in the early 1990s, and while in my experience no studies were done to gauge its
effectiveness it is important to note that glove integrity other than discarding obviously damaged
gloves is not done at all in conventional clean room aseptic processing. It is safe to assume that
the secondary clean room glove is as safe in an isolator operation as it is in aseptic processing in
clean rooms.

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In some operations single piece CSPE glove/gauntlet/sleeve assemblies have been used to
eliminate completely the possibility of O-ring wear point leaks. This strategy is most often
implemented at glove locations where critical interventions are most likely to occur. As an
additional risk abatement strategy, isolator operators were trained in aseptic processing and
proper use of isolator gloves and emphasis was placed in not touching product contact surfaces
or components with gloves, just as that good practice is emphasized in clean rooms.
The final and perhaps most significant factor in reducing glove risk is the design of isolator-
friendly production equipment. In the early days when leakage in gloves was a key concern,
isolators were built over current aseptic processing equipment designs. These production line
designs were not optimized for minimal reliance on intervention. However, over the last twenty
years isolator-friendly designs have become the norm and the use of machine automation and
robotics has reduced reliance on gloves for critical operations.

In summary, Annex 1 requirement 4.23’s concerns regarding gloves is something I would have
expected to read in 1990 when experience with isolator operations in aseptic processing was
limited, neoprene gloves were the norm, and the use of undergloves was not universal. An article
by Gessler et al entitled “How Risky Are Pinholes in Gloves? A Rational Appeal for the Integrity
of Gloves for Isolators” was published in 2011 (PDA J Pharm Sci. Technol. Jun 2011;65(3) 227-
241). This article reported that pinholes are not necessarily predictive of contamination risk, that
microbiological monitoring is not generally effective at evaluating glove risk and finally that a
combination of “semi-automatic physical testing, visual inspection and control of bioload” has
the effect of “minimizing risk” and assuring “maximum safety.” A key finding was that visual
inspection is an excellent means of detecting leakage.

My experience aligns well with Gessler et al. I have not found isolator gloves in modern isolator
installations, which I’ll characterize as early 2000s onward, to be a significant contamination
risk. Certainly, firms should have detailed procedures for glove selection, testing and
management. They should also use undergloves and consider single piece gloves where work
requirements dictate. They should also routinely inspect the gloves visually with care and in
good lighting and have procedures for periodically inspecting glove/sleeve connection points and

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the mounting points to isolator walls. In my experience visual checks, because they can be done
frequently, are far more critical than physical leak testing, which has limitations in practical use.
I believe the physical testing of gloves before and after shifts is unnecessary and potentially
detrimental. Isolators are often used in a campaign approach, and I suggest my clients carefully
inspect gloves and do physical tests between campaigns. In my experience isolator (or closed
RABS) gloves are much more reliable than standard clean room gloves which in my experience
rarely have a useful lifetime that exceeds two hours. Clean room gloves are fragile and easily
damaged while CSPE isolator gloves are not.

The second point raised in 4.23 has to do with the leak integrity of the isolator enclosure. In my
experience this is not a risk modality for microbial contamination at all! Isolators for aseptic
processing are generally run at a positive pressure of 15-30 Pa relative to the surrounding room.
The surrounding room is typically ISO 7 or 8 although in my experience this has no impact on
risk relating to the microbial or particulate air quality within an isolator. I have worked with
many isolators used for aseptic production of milk or low acid juices which are
typically done in unclassified spaces and in my experience the risk of contamination in these
systems is as low as pharma isolators located in classified clean rooms.

Also, most continuous throughput operations rely on an opening often called a “mousehole” for
transit of product in its sealed primary package to the labeling and secondary packaging
operations. Thus, these isolators are reliant on an air seal for maintenance of integrity in
operation. This is a zero-risk operation in properly designed isolators and although the
mousehole has been the subject of much speculation there is scant evidence of it presenting any
contamination risk at all. I have run studies of up to 30 days duration with clients in which we
did both media fill testing and extensive monitoring using both growth and fluorimetric methods
and have observed no contamination entering the isolator. We have done these studies in
unclassified machine assembly halls and observed no contamination in any experiment. I have
not observed ANY contamination entering an isolator through a mousehole or any other leak.
even when we have purposely taken the pressure differential to zero for 30- 60s in unclassified
environments.

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The integrity of the isolator is critical only from the standpoint of ensuring safety during VPHP
decontamination if people are present in the area around the isolator during decontamination,
which is most often not the case. Therefore, I find that the requirements in 4.23 are quite
excessive and wholly unnecessary. In closed isolators used for batch operations, pathogen
research, general R&D, sterility testing or cell processing the pressure differential is maintained
typically in the 12.5-20 Pa range and there is no mousehole. All isolators read internal pressure
in real time and control to an established set point. I have not seen an installation that did not
alarm in the event of a pressure differential reading outside the set control limits. In some cases,
they are interlocked to air handler or pressure alarms and the processing line is shut down
immediately and automatically.

The recommendations in 4.23 may be well-intentioned but they betray a lack of awareness
regarding modern isolator operations and harken back to a time 30 or so years ago when
experience with isolator systems was limited, glove/sleeve materials were less reliable, and
equipment was far from isolator-friendly or ergonomically installed. Thus, the excessive
attention to integrity in 4.23 will not positively impact process safety which is already
outstanding.

The Council for Pharmaceutical Excellence

James Agalloco
James Akers
Phil DeSantis
Karen Ginsbury
Russell E. Madsen
Karen McCullough
Robert Mello

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