Transfusion Medicine, 2003, 13, 417–423
REVIEW ARTICLE
Quality issues in stem cell and immunotherapy laboratories
L. Smith and M. W. Lowdell Department of Haematology, Royal Free & University College Medical School, London, UK
Accepted for publication 9 October 2003
SUMMARY. The advent of the Code of Practice for
Tissue Banks has led to the requirement for quality
systems to be established in all laboratories involved
in the production or processing of all cellular tissues
to be used therapeutically. The quality system is all-
encompassing from process validations and quality
assurance to the standard of facilities and staff train-
ing. This seems self-evident to those working within
the transfusion field but is a relatively novel concept
to many hospital laboratories preparing transplant
For over 40 years, patients have been receiving haema-
topoietic stem cell transplants as part of their treatment
for leukaemia and other haematological disorders.
Most clinical transplant units have, by necessity, estab-
lished their own stem cell processing laboratories or, in
the case of smaller units, used facilities provided by
larger transplant centres or local blood bank facilities.
This pattern is seen throughout the world and is typi-
fied by the current situation within the UK. Large stem
cell transplant centres have tended to establish their
own laboratories within the hospital, incorporating
cell processing and storage facilities. These laboratories
have tended to be a mixture of research and clinical
service, and this has been reflected in the backgrounds
and training of the staff involved. Few, if any, of these
laboratories have been managerially independent of the
end user, the transplant physicians. In most centres, the
processing has been conducted within class II micro-
biological safety cabinets in conventional laboratories
with little or no awareness of cGMP issues. The
processing and storage of haematopoietic stem cells
on a single-patient basis in the UK has fallen outside
national regulatory legislation, and laboratories under-
taking such work have not been inspected or licensed.
Correspondence: Dr Mark W. Lowdell, Department of
Haematology, Royal Free & University College Medical School
(RF-Campus), London NW3 2PF. Tel.: þ44 20 78302183;
fax: þ44 20 77940645; e-mail: m.lowdell@rfc.ucl.ac.uk
# 2003 Blackwell Publishing Ltd
products such as bone marrow or peripheral blood
derived haematopoietic stem cells. This review places
the current guidelines in an historical context and
explains many of the central tenets and requirements
of the Code of Practice while outlining a process to
facilitate preparation for accreditation.
Key words: haematotherapy, immunotherapy, quality
assurance, quality control.
The first UK national guidelines for Haemopoietic
Stem Cell Transplant (HSCT) laboratories were pub-
lished by the UK Department of Health (DoH) in
1997. This publication ‘Guidance Notes on the Pro-
cessing, Storage and Issue of Bone Marrow and
Blood Stem Cells’ heralded the dawn of regulation
of HSCT laboratories but was not a statutory instru-
ment and had no associated inspection and accredit-
ation regime. At the same time, the International
Society for Haematotherapy and Graft Engineering
(ISHAGE) (Europe) and the European Group for
Bone Marrow Transplantation (EBMT) had estab-
lished a joint accreditation committee – Joint Accredit-
ation Committee of ISHAGE and EBMT (JACIE) –
for HSCT centres which would encompass harvest-
ing, processing, storage and clinical transplantation.
This was planned to mirror the Foundation for the
Accreditation of Hematotherapy and Cell Therapy
(FAHCT) in the US, and the standards adopted
were comparable. The JACIE standards were for-
mally adopted by EBMT in 1998. Although training
sessions for JACIE inspections have been conducted,
the process of implementation has been slow in most
European countries. One of the requirements of
accreditation of clinical transplant programmes is
that they receive HSCT products only from JACIE/
FAHCT-accredited laboratories. Thus accreditation
of production facilities must occur first.
Self-regulation of professions and processes
which effect the general public is not popular with
417
418 L. Smith and M. W. Lowdell
governments and, irrespective of the success or other-
wise of the JACIE standards, individual nation states
have begun to implement their own standards and
inspection systems. This appears to be in preparation
for a future European Union Directive.
In the UK, the current DoH standards are
restricted to the production of the graft or other
therapeutic cellular infusion and, in contrast to
JACIE and FAHCT, do not attempt to set quality
standards for the clinical transplant procedure. The
UK standards are set out in the ‘Code of Practice
(CoP) for Tissue Banks Providing Tissues of Human
Origin for Therapeutic Purposes’ (February 2001).
This code covers all human tissues used for thera-
peutic purposes, including clinical trials other than
those cells already covered by national regulations.
From the perspective of the HSCT laboratory, it
covers ‘haematopoietic progenitor cells, donor leuco-
cytes and autologous cell systems’. It incorporates
donor selection, product manipulation and cryopre-
servation, labelling and transport. It defines a quality
system and, most radically, it prescribes the facilites
in terms of the buildings and environmental controls.
The 1997 Guidelines had recommended that all pro-
cessing be conducted within a class II microbiological
safety cabinet (grade A air) (Table 1) within a dedi-
cated laboratory with restricted access and which
should be kept locked when not in use.
The CoP requires all procedures to be conducted
within a grade A air environment within a grade B
background. Environmental monitoring must be in
place to ensure that this is achieved and maintained.
In contrast to the pre-exisiting UK guidelines, produc-
tion facilities are expected to accredit to the CoP after
a process of formal inspection. This is being conducted
by the Medicines Control Agency (MCA). The cost
implications associated with accreditation are often
very significant (our facility at the Royal Free Hos-
pital has cost in excess of £500 000), and the changes
Table 1. Air classification system
Maximum permitted number of particles per m2 at or above size specified
At rest
Grade 0
5 mm 5 mm
A 3500 0 3500
B 3500 0 350 000
C 350 000 2000
D 3500 000 20 000
# 2003 Blackwell Publishing Ltd, Transfusion Medicine, 13, 417–423
in practice associated with compliance have on-going
cost implications in terms of increased staff numbers,
environmental monitoring, emergency cover for plant
and equipment and much else besides. These capital
and running costs have prevented many units from
applying for accreditation thus far.
The central tenet of the CoP is the establishment of
a ‘quality system’ to incorporate all aspects of process-
ing, storage and release of products.
PLANNING THE QUALITY SYSTEM
A quality system defines the documents and a series
of systematic processes that are followed to ensure
that quality is evident in every part of the organiza-
tion.
Standard operating procedures (SOPs) are used to
document and control all activities that affect quality.
It is important to describe all elements that make
up the quality system and how they will be con-
trolled. SOPs must control all aspects of the process-
ing of product and the control of the production
environment.
An index is required for all quality manuals that
list all the sections within it and individual SOPs that
control each section of the quality system.
Review of the quality system
The first SOP to write is the document control pro-
cedure which controls the documentation content,
revision, approval, distribution and removal from
the documentation system which is crucial. The tem-
plate for all the SOPs within the system will be
detailed in this document and ensures that there is
uniformity within the system.
Each SOP should have a unique reference number
and version number in order for it to be a controlled
In operation
0
5 mm 5 mm
0
2000
3500 000 20 000
Not defined Not defined
 Quality issues in stem cell and immunotherapy laboratories
document. A document cannot be altered without
going through the controlled amendment procedure,
which generates a new version of the document, and
the amendments made are logged on the document
history page of the SOP.
The SOPs should have several levels of approval
sign off, the first by the person that generated the
document a technical signatory and a quality assur-
ance (QA) signatory.
A quality manual index is used to log all the SOPs
within the quality system that list the location of the
SOPs to assist the document retrieval process and
individual SOPs that control each section of the qual-
ity system.
It is important to describe all elements that make up
the quality system and how they will be controlled.
The document should clearly define the organization’s
purpose and commitment to quality and takes the
form of a quality policy. The policy should also
facilitate the development of quality objectives and
make a commitment to continuous improvement by
a system of reviewing the quality objectives. This
document evolves as the quality system is written
and is used as a framework for the process.
The quality system should be reviewed at a defined
time interval against the CoP for Tissue banks and
the SOPs within the system to enable continuous
improvement. The quality audit should be detailed
in an SOP that defines the frequency of audits and
links to an audit schedule.
The type of audit will also be specified. There will
be checklist audits, which verify the content of SOPs
by checking each section whilst watching the process.
There shall also be GMP audits, which look for good
practice and knowledge of GMP.
The SOP shall also detail those responsible for
the audit process. The person responsible for quality
and the Laboratory Manager usually conduct the
audits.
It is important to define management responsib-
ility for both the access to areas for audit and the
actions required to correct any nonconformances
found.
The format of the audit reports should be con-
trolled within the SOP, the audit observations will
be graded to help the interpretation and corrective
action where required. If a procedure were not being
followed then this would be recorded as a major
nonconformance that requires immediate action.
The auditor should suggest some corrective actions
for the nonconformance in the audit report. The SOP
should also state a time frame in which corrective
actions take place and detail a re-audit procedure
where necessary.
# 2003 Blackwell Publishing Ltd, Transfusion Medicine, 13, 417–423
419
Observations should also be logged on audit
reports when the information can be used to improve
the quality system by updating SOPs and/or the
training of personnel to prevent nonconformances
in the future.
NONCONFORMANCE SOP
This SOP is required to investigate nonconformances
to establish why the incident occurred and how to
prevent it in the future; it should not just investigate
nonconforming product, it should be used to investi-
gate all forms of nonconformance.
There should be a link to the audit procedure, as
nonconformances raised in audits will require inves-
tigation.
The SOP controls the content of the documenta-
tion for the nonconformance investigation report.
Each nonconformance report should have a unique
number that is generated from an index.
The nonconformance report should contain the
date initiated, incident details, who reported the inci-
dent, person responsible for action, the action
required and the outcome of the investigation. Any
preventative action that has taken place to prevent
the incident recurring should also be noted. This
enables the system to continuously improve.
The responsibility for the co-ordination of the
investigation and the assigning of actions should be
clearly defined.
The management of the section in which the non-
conformance occurred shall be responsible for the
actions assigned.
Actions carried out in the response to an audit
nonconformance should be added to the audit report
as directed by the SOP.
Any additional training resulting from the investi-
gation should be added to the training record of the
person concerned with a reference to the nonconform-
ance report number.
Personnel training
Training personnel against the SOPs in the quality
system is an important way of maintaining quality.
Documentation of such training is very important,
and everyone should have a training record which
illustrates that they have the correct education, skills,
experience and training to carry out the role they are
employed to do. The training record form should
detail the SOP number and version number, the
document title and importantly should be signed by
both trainee and trainer. An SOP should detail the
420 L. Smith and M. W. Lowdell
training process and the documentation involved.
For new personnel, a training manual is often used
which details all the training required.
An important part of the training process for com-
pliance with the CoP for Tissue Banks is training staff
in good clean room practice, control of contamin-
ation, clean room technology and the CoP for Tissue
Banks. This is essential for personnel to understand
the changes in working practice detailed in the CoP for
Tissue Banks and the rationale for the change.
Operator broth validations should also be carried
out to verify good aseptic technique and involve the
transfer of a general purpose broth. Kits are available
from the suppliers of microbiological growth media.
CLEAN ROOM CONSTRUCTION
The construction of the clean room is a major
requirement for compliance with the DoH CoP for
Tissue Banks. A specification should be generated for
both newly constructed and modified buildings that
the engineers have to be in compliance with.
The clean room must be constructed with walls,
floors and ceilings of nonporous smooth surfaces that
can be cleaned easily.
A changing room and washing facilities should be
adjacent to the processing area.
The quality of air must be defined for each type of
processing area. The CoP for Tissue Banks defines
the classifications as follows:
Critical work areas where the product is exposed to
the environment should have a class A air quality.
The background air quality for a grade A critical
zone is class B.
When the construction is complete it is advisable to
hire an independent clean room validation company
to ensure that the clean room is in compliance with
clean room standards for air change rate, pressure
differentials, particle levels and that the Hepa filters
are integral. This clean room validation should be
repeated annually.
Table 2. Microbiological monitoring of critical work areas
Air sample (cfum3) Settle plates (cfu per 4 h)
A <1 <1
B 10 5 5
C 100 50
D 200 100
CLEAN ROOM CONTROL
When the clean room validation is complete there are
further SOPs required to control the environment of
the clean room as follows:
Environmental monitoring of the clean room
In addition to the standards for free particulates in
the air of the clean room (Table 1), there are stand-
ards for microbial contamination of work areas
against which the clean room must be monitored
(Table 2).
The type of media to be used should be clearly
defined, and the plates should be clean room grade,
i.e. triple-bag irradiated. For each batch of plates,
fertility test data should be obtained from the sup-
plier to ensure that the plates support growth.
The monitoring locations are listed and controlled
forms provided for the logging of data.
The environmental monitoring procedure should
be derived from an environmental monitoring valid-
ation in which many positions are monitored to ensure
that the clean room environment is satisfactory.
An SOP is generated with specified monitoring
locations and frequency of testing.
The method of testing should be detailed and
include settle plates, contact plates and active air
sampling. The incubation temperature and length of
incubation should also be stated.
The acceptance criteria should be clearly defined
and derived from the MCA Orange Guide Annex
1(4). An action level should be set and instructions
given for when an area exceeds specification. Extra
cleaning should be carried out with the appropriate
disinfectant; this shall be influenced by the hospital
disinfection policy and the type of organism(s) pre-
sent. Environmental monitoring is carried out pre-
and postcleaning to determine its effectiveness. The
investigation of the nonconformance should be
linked to the nonconformance SOP.
Contact plates (cfu per plate) Glove print (cfu per glove)
<1 <1
5
25 –
50 –
# 2003 Blackwell Publishing Ltd, Transfusion Medicine, 13, 417–423
 Quality issues in stem cell and immunotherapy laboratories
SOP FOR CLEANING THE CLEAN ROOM
An SOP is required that details the cleaning proced-
ure for the clean room and the materials required and
the frequency of the cleaning process.
The materials used for cleaning should be lint-free
materials and clean room grade materials. All clean-
ing equipment used must be designated for clean
room use only to prevent the spread of contamin-
ation in the clean room.
The cleaning technique used must minimize the
spread of contamination. Training and documentation
of the process is crucial especially for auxiliary staff.
A schedule for cleaning is defined which details the
number of items to be cleaned and the frequency of
cleaning.
Controlled forms should be provided to log the
cleaning process.
PRESSURE DIFFERENTIALS
The routine monitoring of pressure differentials
within the clean room is a crucial way of monitoring
the performance of the clean room.
The readings can be carried out using pressure
gauges within the room, and a controlled sheet for
logging data is present in which the current data is
logged. This is compared with data from the previous
week to enable trending of data.
An alternative and more controlled method is the
use of electronic sensors, which are connected to a
monitoring system that will trend the data and gen-
erate reports. This method generates much more con-
trolled data on the room and can be programmed to
alarm when data go out of specification.
Some monitoring systems are able to contact engin-
eers immediately to enable repairs to be carried
quickly, if required.
This SOP should be linked to the nonconformance
SOP to formally log the investigation of any out-of-
specification data.
CLEAN ROOM CLOTHING
In order to control contamination within the clean
room, the operators have to wear clean room cloth-
ing that is made of nonshedding material and act as a
body filter to minimize contamination in the clean
room by shedding of skin particles.
Clean room laundries specialize in the supply of
the garments and also launder them using a biocide
wash and process them in a clean room environment.
It is a good idea to order garments well in advance, as
there can be long lead times.
# 2003 Blackwell Publishing Ltd, Transfusion Medicine, 13, 417–423
421
A clean room mobcap should be worn to prevent
shedding from the hair.
Sterile gloves should also be worn for all critical
procedures.
An SOP is required that details the order in which
to don the clean room clothing and the type of cloth-
ing to select. The frequency of change, usually daily,
is stated, and the procedure for the removal of clean
room clothing is also included.
Training in the donning procedure is important.
The trainee should be observed and all training fully
documented.
TRANSFER OF ITEMS INTO THE CLEAN
ROOM
Items should be sprayed with industrial methylated
spirits (IMS) and wiped, as they are transferred in the
clean room, preferably through a transfer hatch, to
minimize contamination entering the clean room.
The sanitization procedure with IMS should be
validated to ensure that the contact time with the
IMS is sufficient to reduce the bioburden on the sur-
face of the transferred item.
The SOP should then state how long the IMS must
be in contact with the items prior to transfer into the
area.
The sanitization process is usually repeated prior
to transfer into the critical zone for processing.
PREVENTION OF CROSS CONTAMINATION
SOP
This SOP is required to prevent cross-contamination
between products from different donors.
This procedure should document the control pro-
cedures in place for processing samples, e.g. that only
one product shall be processed in a cabinet at any one
time.
The screening procedures that are carried out on
the sample prior to processing to ensure that it is safe
to process.
All products are sprayed with IMS during the
transfer process, and all final products should be
double bagged prior to transfer out of the area.
The control of stored material to prevent cross-
contamination should also be described.
PROCESS CONTROL
SOPs, to ensure that the product is traceable during
all stages of processing, should control all stages of
each production process.
422 L. Smith and M. W. Lowdell
All materials entering the process need to be con-
trolled and the type, grade and supplier of products
listed in an SOP. A certificate of analysis should be
obtained for incoming material where possible.
The expiry dates on material should be noted and stock
rotated to ensure that the oldest items are used first.
If material has to be supplied from a different
supplier, there should be documented proof that the
material is of the same grade and manufactured to
the same standards as an existing supplier.
An SOP is required to control the receipt of pro-
duct and the verification of patient details. There
should be a processing sheet for each type of process,
which is assigned a unique number. The processing
form shall be completed contemporaneously and
signed by the person responsible for that task. The
batch numbers of all items used during processing
should be logged on the processing sheet.
The labelling of the product is another crucial stage
controlled by SOP. The document should define the
detail required on the labels, the content of the label
double checked and a sample label attached to the
processing sheet.
There should be SOPs for all in the process checks
on the product and a section on the processing sheet
to log the detail contemporaneously.
An SOP and product release form should control
the process review and release of product from the
processing unit.
The packaging of the product and transport con-
ditions should be documented in an SOP.
For products that are to be cryopreserved, an SOP
is required for the process and the cryopreservation
process validated. This validation should be repeated,
if the bags used for storage or the volume stored
changes.
An SOP should be in place for the control and
storage of product to ensure that there is no deteri-
oration of the product and that there is no risk to
cross-contamination. All stored product should be
fully traceable back to processing sheets and the loca-
tion of product easily traced using the unique process-
ing reference numbers.
An SOP for recall should exist, although it is
impossible to recall a product unless it has been
stored. The procedure should detail the notification
process that occurs if a product fails its sterility test
and that product is still likely to be used.
EQUIPMENT CONTROL
All equipment within the quality system should be
controlled by a planned maintenance SOP and
# 2003 Blackwell Publishing Ltd, Transfusion Medicine, 13, 417–423
calibrated where appropriate. An equipment inventory
should be generated within an SOP that details the
maintenance and calibration requirements of equip-
ment within the quality system. It is very important
to file all equipment calibration documentation as this
often reviewed by MCA inspectors.
An SOP shall also detail the procedure for setting
up third party agreements in which the quality of the
service or product is detailed and the certification
level required by the provider, e.g. ISO registration.
Critical suppliers of product can be requested to fill
in a quality questionnaire to assess the details of their
quality system.
The ability to audit critical suppliers when required
should be included in the procedure.
TEMPERATURE MONITORING OF
FRIDGES AND FREEZERS
The control of fridge and freezer temperature is cru-
cial for the storage of finished product, thus an SOP
is required to detail the process.
The frequency of temperature logging is detailed
and shall be at least once per day. This preferably can
be a manual or automatic system.
An acceptable temperature range above and below
the desired temperature should be set.
Action required, if the temperature falls outside
this range, should be described in detail.
All freezers should have N2 backup and an alarm
system, which informs designated members of staff
that there is a problem.
Controlled forms for the logging of temperature
data should be supplied in the SOP where required,
if there is no electronic printout.
VALIDATION
The documentation of validations is a crucial part of
the quality system, and an SOP should describe the
protocol content.
Before a validation commences, the process must
be planned and the acceptance criteria for the valid-
ation protocol derived where possible from a relevant
regulatory source.
The validation should be carried out at least three
times to illustrate reproducibility of the process.
The protocol shall have an introduction, which
describes the purpose of the validation.
The methodology to be used must be clearly
described in the validation protocol. If external contrac-
tors are involved, include their details in the protocol
with clear instructions for the work to be carried.
 Quality issues in stem cell and immunotherapy laboratories
Before the work commences, the protocol will need
to be approved by the Compliance Officer and a
technical signatory where necessary.
There shall be a results section in which to log
all data for protocol data, which is completed
contemporaneously throughout the validation. All
raw data should be included.
All data should be analysed and compared against
the acceptance criteria.
Any equipment used in the validation should have
a current calibration certificate that shall be included
in the protocol.
Any substances or media used will require certificates
of analysis, which should be included in the protocol.
The conclusion section of the protocol shall detail
compliance with the acceptance criteria. If there is non-
compliance with the acceptance criteria then sugges-
tions for further work shall be discussed in this section.
Each validation protocol is a controlled document
with a unique number and issue number. If further
work is required in a protocol, a new version will be
raised but there should be full trace ability back to
the first version.
# 2003 Blackwell Publishing Ltd, Transfusion Medicine, 13, 417–423
423
There should also be an index that lists the valid-
ation number, title of protocol, person responsible,
date commenced and date completed.
Some processes require revalidation, thus it is good
practice to schedule validations and revalidations
annually, to ensure the correct frequency of testing,
e.g. the clean room revalidation.
CONCLUSION
In the UK, the DoH CoP is a nonstatutory docu-
ment, and the inspection process is voluntary. The
DoH has, however, informed all NHS Trust Chief
Executives that, as of 1 April 2004, they are respon-
sible for ensuring that patients treated in hospitals
under their authority only receive cells from
accredited Tissue Banks. Many NHS Trusts will not
meet this deadline.
The implementation of the CoP is arduous but is
an excellent preparation for subsequent JACIE
accreditation and for the inevitable EU Directive in
this area.