WHO guideline on the use of safety-engineered syringes for intramuscular, intradermal and subcutaneous injections in health care settings.# External reviewers:
- Nancy Muller, Programme Officer at PATH, Seattle, WA, USA - Babacar Ndoye, Expert Consultant, Formateur, Hygiene hospitaliere/Controle des infections/Securite des patients, Dakar, Senegal - Joseph Perz, Team Leader, Quality Standards & Safety (Proposed), Prevention and Response Branch, Division of Healthcare Quality Promotion Centers for Disease Control and Prevention, Atlanta, GA, USA
- Glenn Post, Senior Medical Advisor USAID Office of HIV/AIDS, Washington DC, USA - Cristiane Rapparini, Riscobiologico.org, Rio de Janeiro, RJ, Brazil - Abimbola O. Sowande, Consultant/Expert, Injection Safety/HCWM in the context of IPC (Infection Prevention and Control), Regional Coordinator, Board of Trustees, International Federation Infection Control (IFIC), Surulere, Lagos, Nigeria

# Temporary advisers
We would like to credit the following researchers for developing, in collaboration with the technical officer in charge, the initial scoping document and for conducting all systematic reviews, evidence profiles and GRADE tables:
- Elie Akl, Department of Internal Medicine, American University of Beirut - Alain Harb, Lebanese University, Lebanon
- Rami Tarabay, Lebanese University, Lebanon
- Batoul Diab, Lebanese University, Lebanon - Rami A. Ballout, American University of Beirut We would like to thank Susan L. Norris, GRC Secretariat, for providing a technical presentation at the GDG meeting on the WHO guidelines' development process and for her guidance and support throughout the development of this guideline.

# Chairperson and methodologist
We would like to acknowledge the work of Gwen Orr Brachman for chairing the Guidelines Development Group. We thank Elie Akl for serving as methodologist and who oversaw the development of the PICO questions and the conduct of the systematic reviews, developed the evidence profiles and the GRADE tables.
The first drafts of the guidelines were written by Selma Khamassi, SDS Department. Drafts were reviewed and inputs provided by members of the GDG, peer reviewers and WHO Secretariat staff. The final draft was edited by Laura Pearson, SDS Department and Lisa Hedman, EMP Department.

# Overall coordination

# EXECUTIVE SUMMARY
Injections are one of the most common health care procedures. Every year at least 16 billion injections are administered worldwide. The vast majorityaround 90% -are given in curative care. Immunization injections account for around 5% of all injections, with the remaining covering other indications, including transfusion of blood and blood products, intravenous administration of drugs and fluids and the administration of injectable contraceptives (1,2).
Injection practices worldwide and especially in low-and middle-income countries (LMICs) include multiple, avoidable unsafe practices that ultimately lead to the large-scale transmission of bloodborne viruses among patients, health care providers and the community at large. While data are not available on the associated burden of all possible diseases, unsafe injection practices would logically impact on other bloodborne diseases transmitted through the re-use of injection equipment e.g. haemorrhagic fevers such as Ebola and Marburg viruses, malaria, and others. Re-use and unsafe practices also increase the risk of bacterial infections and abscesses at the injection site, which can cause long-term damage.
Unsafe practices include, but are not limited to, the following prevalent and high-risk practices:
- Re-use of injection equipment to administer injections to more than one patient, including reintroduction of injection equipment into multi-dose vials, re-use of syringe barrels or of the whole syringe, informal cleaning with re-use and other practices. These practices are often ingrained and believed to be safe, but in reality they lead to the transmission of bloodborne viruses such as HIV, HBV, and HCV, as well as bacterial infections and abscesses at the injection site. 3. Over-use of injections for health conditions where oral formulations are available and recommended as the first line treatment. Demand for and prescriptions of injectable medicines that are inappropriate include overuse of antibiotics, use of unnecessary injectable products such as certain vitamins, moving directly to second-line injectable treatments and others. Some of these issues are addressed through other WHO interventions to promote a rational and responsible use of medicines, and specific initiatives to combat overuse of antibiotics. Such initiatives use information and communication campaigns to target both HCWs and communities to decrease inappropriate demands for medicines, including injectable medicines. Similarly and in support of the guidance in this document, WHO will embark on an injection safety global campaign targeting both HCWs and communities as a means of decreasing demand for and over-prescription of injections.
Unsafe sharps waste management putting HCWs, waste management workers and the community at large at risk of needle-stick injuries and subsequent bloodborne infections. Unsafe management of sharps waste includes incomplete incineration, disposal in open pits or dumping sites, leaving used injection equipment in hospital laundry and other practices that fail to secure infected sharps waste. In some cases, used injection equipment is removed from open waste pits by people who scavenge through waste and then wash, repackage and resell the equipment as new. These issues will be covered by the recommendations made in this document to procure sufficient safety boxes for the containment of all safety-engineered devices, as well as through the global injection safety campaign to implement and adapt the recommendations to each country context.
RUP and SIP syringes, especially in curative services, are the focus of the recommendations contained in this document, along with the provision of sharps waste management equipment. As above, reducing inappropriate demand will be addressed separately through other WHO initiatives. As part of a comprehensive package of interventions to ensure safe and rational use of injections -including communication and behaviour change strategies, supportive policies and provision of sufficient quantities of the appropriate injection equipment -WHO has analysed the potential contribution of safety-engineered syringes in reducing the problem of re-use and preventing needle-stick injuries.
Safety syringes are well established and available in global markets. Official performance requirements and definitions have been added and developed over time, beginning with AD syringes for immunization in 1990 and progressing to models with re-use prevention in 2006 and sharps injury protection features in 2012. The International Organization for Standardization (ISO) has well defined requirements for producers of these products related to performance and fitness for purpose of safety syringes.
This document references safety syringes according to their ISO definition to provide an exact definition of the safety mechanism of each type of syringe and allow a common understanding between all guideline readers. The ISO definitions also provide guidance for procurers in determining the specifications and minimum standards for performance of safety-engineered devices for the selection of appropriate devices. The three main ISO definitions are below, along with additional clarifying descriptions.
- ISO 7886 -Part 3: "sterile hypodermic syringes for single use -Part 3: autodisable syringes for fixed-dose immunization (AD)." This definition includes syringes that deliver fixed doses, most have non-removable needles and all have a feature that blocks the syringe from being used a second time. This definition is limited to equipment for immunization services, and are typically 0.1 -0.5 and 1.0 ml in size.
- ISO 7886 -Part 4: "sterile hypodermic syringes for single use with a re-use prevention feature (RUP)." This definition includes syringes that can measure flexible dosing amounts, have removable needles and a feature that blocks the syringe from being used a second time. The RUP feature is activated following a single aspiration and injection in RUP syringes Type A while in syringes Type B the mechanism allows multiple plunger aspirations if reconstitution of the medication or the vaccine is required, or if multiple drugs need to be mixed in the same syringe before being administered to the patient. This definition is provided for syringes used in curative services where a broad range of injection procedures are performed and are typically 2.0 -10.0 ml in size.
- ISO 23908: "sterile hypodermic syringes with a sharps injury protection feature (SIP)". Some SIPs also have a built-in RUP feature. SIPs cover AD and RUP syringes that have an additional feature to prevent sharps injury, such as a means to contain the infected sharp after use.
The evidence-based policy guidance contained in this document will be the first WHO policy document that specifically addresses the use of safety-engineered injection devices for therapeutic injections. It complements and expands previously issued WHO guidance, including the following:
- WHO-UNICEF-UNFPA Joint Policy Statement issued in 1999 (.
int/injection_safety/toolbox/resources/en/). The 1999 policy recommends the exclusive use of AD syringes for all immunization injections;
- "Guiding principles to ensure injection device security" (4) issued by SIGN in 2003, which states: "syringes with a RUP feature offer the highest level of safety for injection recipients. They should be considered for use for therapeutic injections where local data indicate that unsafe practices are particularly common.";
- WHO best practices for injections and related procedures toolkit, published by WHO in 2010 (5), which notes the importance of sufficient supply of qualityassured syringes and matching quantities of safety boxes.
It is expected that the evidence-based policy guidance in this document will additionally contribute to preventing the re-use of syringes on patients and to a decrease in the rate of needle-stick injuries in HCWs related to injection procedures, thus contributing to the prevention of injection-transmitted infections. Based on the findings of the systematic review, out of every 1000 HCWs in settings where SIP devices are introduced, nine fewer (from six fewer to 11 fewer) are likely to suffer a needle-stick injury in a one year period. There are no expected harms. Greater benefits can be expected in settings with higher HIV, HBV and HCV disease prevalence, higher sharps injury frequency and higher rate of re-use of injection equipment.
WHO has developed the policy recommendations in this document using the procedures from the WHO handbook for guideline development. The steps in this process include: (i) identification of priority questions and outcomes; (ii) retrieval of the evidence; (iii) assessment and synthesis of the evidence; (iv) formulation of recommendations, including research priorities; and (v) planning for dissemination, implementation, impact evaluation and updating of the guideline when new evidence is available.
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was followed to prepare evidence profiles related to preselected topics, based on up-to-date systematic reviews.
The Guideline Development Group (GDG) and the Guideline External Expert Group comprised content experts, methodologists, representatives of professional associations, key NGOs and organizations working on injection safety and representatives of patients' associations.
The GDG met at a WHO technical consultation held in Geneva in March 2014. Members of the External Experts Group were identified through previous collaborative work in injection safety, from the Safe Injection Global Network (SIGN) members and through a public call for comment published in SIGN Post, an electronic weekly newsletter which has 1500 subscribers interested in injection safety. The SIGN Post members were involved in an external peer review once the recommendations had been developed by the GDG.
The GDG agreed, by consensus among its members, on the strength of recommendations, taking into consideration: (i) the benefits and possible harms of this intervention; (ii) the quality of the available evidence; (iii) the values and preferences related to the intervention in different settings; and (iv) the cost of different devices available in the international market.
To ensure there were no conflicts of interest, all members of the GDG completed a Declaration of Interests form prior to the meeting and the development of the policy recommendations.
The GDG made the following recommendations:
- "We recommend the use of injection devices with a sharps injury protection feature (SIP), as opposed to devices without a sharps injury protection feature, by HCWs delivering intramuscular, subcutaneous or intradermal injectable medications to patients (conditional recommendation, moderate quality evidence)".
We recommend the use of injection devices with a re-use prevention feature (RUP), as opposed to devices without re-use prevention features, by HCWs delivering intramuscular, subcutaneous or intradermal injectable medications to patients (conditional recommendation, very low quality evidence)".
The conditional nature of the recommendations is consistent with the quality of the level of evidence on the impact of introducing safety-engineered devices.
The current prevalence of the problem, however, suggests that doing nothing is not an acceptable course of action (13).

# SCOPE AND PURPOSE
This guideline provides global, evidence-based recommendations on the use of safety-engineered injection devices to prevent the re-use of syringes and/or prevent needle-stick injuries in health care workers (HCWs). The ultimate aim is to make injection practices safer for patients and HCWs, and to prevent the injection-related transmission of deadly viruses, particularly HIV, hepatitis C and hepatitis B.
The procedures covered are intramuscular (IM), intradermal (ID) and subcutaneous (SC) injections, including the syringes needed for the reconstitution of medication or vaccines when required.
Other procedures, such as intravenous injections and infusions, blood collection for laboratory testing, and capillary blood sampling, will be covered by another guideline to be issued separately by WHO.
The policy recommendation aims to support Member States (MS) and development partners in making informed decisions on the appropriateness of introducing safety-engineered syringes for all injections in health care settings.
WHO guideline on the use of safety-engineered syringes in health care settings

# TARGET AUDIENCE
The target audience for this guideline includes the staff from ministries, agencies and other entities that have a critical role to play in the adoption and implementation of the policy, namely in endorsing the policy, manufacturing the devices, ensuring their procurement and distribution at country level, promoting their correct use by health care providers and their evaluation in terms of safety and effectiveness. Examples include:
- ministers of health and finance
- national advisory bodies responsible for policy-making on injection safety as part of a comprehensive infection control programme
- public and private health institutions
- professional societies
- patients' associations
- UN agencies
- international development partners
- injection device manufacturers and their umbrella organizations.
Injections are among the most common health care procedures. Every year at least 16 billion injections are administered worldwide. The vast majorityaround 90% -are given in therapeutic care. Immunization accounts for around 5% of all injections and the remaining percentage is associated with transfusion of blood and blood products, intravenous administration of drugs and fluids and administration of injectable contraceptives (1,2).
Injections are invasive procedures and are administered in high frequency, therefore, meeting minimum safety standards is imperative as a means of protecting against the avoidable transmission of disease or injuries. However, assessments performed in many countries over the past decade show that safety precautions are often not respected, exposing patients and health care workers to a severe risk of bloodborne infections and injuries, putting human lives at risk.
WHO defines a "safe injection" as one which does not harm the recipient, does not expose the provider to any avoidable risk and does not result in waste that is dangerous for the community (6). We can identify four main problems which make injections potentially dangerous for the patient, the health care worker and the community at large, (when sharps waste is not safely collected and disposed of):
- Re-use of injection equipment for administering injections or to access shared medications leads to the transmission of bloodborne viruses such as HIV, HBV and HCV from one patient to another. A literature review, conducted in 2000, on the use of injections in health care settings worldwide, estimated that the proportion of injections administered with unsterilized re-used equipment, ranged from 1.2% to 75% (8). 3. Over-use of injections for health conditions, where oral formulations are available and recommended as the first-line treatment. In many countries, injections are perceived as the optimal form of care and assumed to be more effective and faster acting to treat health conditions. Surveys conducted in various settings have indicated that the proportion of prescriptions including at least one injectable preparation is high (up to 56%) and the annual ratio of injections per person per year ranged from 1.7 to 11.3, suggesting that injections are overused for administering medications when an oral formulation would be equally or more appropriate for the indication (7,8). Among injectable medicines, antibiotics are the most frequently overused drugs, including use for viral infections where they are not indicated. Therefore, reducing unnecessary injections may simultaneously contribute to reductions in over-use of antibiotics and the associated concern around antimicrobial resistance, which is another WHO priority.
WHO guideline on the use of safety-engineered syringes in health care settings
Background Injection over-use is a critical issue that will be addressed by a global campaign WHO is planning to implement in support of the new policy. This campaign will target reducing the over-use of injections through global communication, prescribers' education, and awareness-raising campaigns targeting HCWs, communities and patients, to decrease demand for and over-prescription of injections.
- Unsafe sharps waste, when inappropriately collected and discarded putting the health care provider, waste handler and the community at risk of sharps injuries and subsequent bloodborne infections. Unsafe management of sharps waste will be covered by the new policy through the recommendation to procure sufficient quantities of safety boxes for containment of all safety-engineered devices and will also be addressed in the global campaign and implementation plan of the new policy and adapted to country contexts.
Risks of unsafe injections include the transmission of bloodborne pathogens such as hepatitis B and C and HIV to patients through the re-use of syringes, while risks for HCWs are primarily related to accidental NSIs. Re-using syringes to access multi-dose medication vials/containers that are used for multiple patients can also lead to the spread of viruses, bacteria and other pathogens. These diseases reduce the life expectancy and productivity of patients and HCWs and burden communities and health care systems with avoidable high treatment and opportunity costs.
Data are available on the prevalence and cost of treatment of HIV, HBV and HCV and on their potential to be transmitted by unsafe injection practices. In assessing the burden of disease caused by unsafe injections, these three infections are used to demonstrate significant areas of cost and burden (9,10). It should be noted, however, that the burden of unsafe injection carries much further than these three pathogens. Other complications include nosocomial bacterial infections, the transmission of malaria and viral haemorrhagic fever and other viruses. Muscle necrosis, various skin lesions due to cutaneous tuberculosis and skin granulomas have also been documented. While it is logical that other bloodborne transmissions and infections are a risk, data for additional modelling are not sufficiently available and the large number of other potential risks could make additional modelling impractical.
Substantial efforts to address unsafe injection practices have been made by WHO, the Safe Injection Global Network (SIGN) and other key international health players since 2000. WHO, with the support of SIGN, has developed and assisted countries in implementing a strategy with three pillars consisting of: (i) behaviour change among patients and HCWs aiming to reduce unnecessary injections and ensure safe injection practices; (ii) increasing the availability of high quality injection devices; and (iii) implementing a sound sharps waste management system. To support implementation of these strategies, WHO has issued a number of policies and guidance documents including:
- WHO-UNICEF-UNFPA Joint Policy Statement issued in 1999 (.
int/injection_safety/toolbox/resources/en/). The 1999 policy recommends the exclusive use of AD syringes for all immunization injections.
- "Guiding principles to ensure injection device security" (4) issued by SIGN in 2003, which states: "syringes with a re-use prevention feature offer the highest level of safety for injection recipients. They should be considered for use for therapeutic injections where local data indicate that unsafe practices are particularly common."
- WHO best practices for injections and related procedures toolkit, published by WHO in 2010 (5), which notes the importance of sufficient supply of qualityassured syringes and matching quantities of safety boxes. A list of key dates in injection safety is included in Table 1.  (11) attempted to document the impact of all these global efforts by measuring the variation between 2000 and 2010 of the two key injection safety indicators, which are the number of injections per person per year and the re-use rate of injection equipment. The key findings of this study show that from 2000 to 2010, in LMICs, the average number of injections per person per year has decreased by 15% from 3.4 to 2.9 but two WHO sub-regions saw an increase (Americas Region B and Western Pacific Region B). The proportion of re-use of injection equipment decreased by 86% from 39.6% to 5.5%. This decrease was seen in all but two sub-regions (Americas Region B and European Region B).
Such progress in injection practice is due to global multifaceted interventions developed and implemented worldwide, including the policy which supports the introduction of auto-disable syringes for immunization injections and the introduction of injection safety into therapeutic programmes in PEPFAR-funded countries. Safety-engineered syringes with different mechanisms, including those which prevent re-use and/or needle-stick injuries, have been available on the international market since 1990 for AD syringes and 2004 for RUP and SIP models. Some models are similar in cost to standard single-use syringes, while others, depending on the technical complexity of the safety mechanism, are up to five times more expensive, which can be prohibitive for some LMICs.
The definitions of safety features established by the ISO are important in understanding the various types of syringes available for different injection procedures. While research and development may yield additional product definitions in the future, it is important that syringes procured and distributed are certified against ISO standards or other internationally recognized standards to ensure their performance and quality. Tables 2 and 3 provide additional information to compare and describe the different safety features.  - population: HCWs delivering intramuscular, subcutaneous, or intradermal injectable medications
- intervention: introduction of syringes with a SIP mechanism
- comparison: no introduction of safety devices
- setting: health care settings
- perspective: health systems.
- Primary outcomes:
incidence of HIV, HBV and HCV infections among HCWs incidence of abscesses (septic, aseptic) among HCWs incidence of other bloodborne infections (e.g. viral haemorrhagic fevers)
WHO guideline on the use of safety-engineered syringes in health care settings - Secondary outcomes:
incidence of NSIs among HCWs quality of life among HCWs social impact (e.g. stigma, job loss) among HCWs.
Question 2: should syringes with a RUP feature be introduced among HCWs delivering intramuscular, subcutaneous, or intradermal injectable medications?
PICO elements of question 2:
- population: HCWs delivering intramuscular, subcutaneous, or intradermal injectable medications
- intervention: introduction of syringes with a RUP feature
- comparison: no introduction of safety devices
- setting: health care settings
- perspective: health systems.
- Primary outcomes:
incidence of HIV, HBV and HCV infections among patients receiving injections incidence of other bloodborne infections (e.g. viral haemorrhagic fevers) among patients.
- Secondary outcomes:
quality of life among patients social impact (e.g. stigma, job loss) among patients incidence of NSIs and incidence of HIV, HBV and HCV infections among HCWs.

# Systematic review
In preparation for the guideline consensus meeting, the systematic review team conducted systematic reviews on:
- The effects of use by HCWs of syringes with a SIP mechanism;
- The effects of use by HCWs of syringes with a RUP feature;
- The knowledge, attitudes, beliefs, values, preferences and feasibility related to SIP syringes and RUP syringes.
Systematic reviews and meta-analysis of the literature were commissioned to address the research questions and outcomes. Criteria for inclusion and exclusion of literature for the reviews were based on relevance of available evidence in answering the research questions.
The systematic reviewers used the GRADE approach to rate the quality of evidence.

# GRADE approach
WHO follows the Grading of Recommendations ( 12), Assessment, Development and Evaluation (GRADE) approach for grading the quality of evidence and the strength of recommendations. GRADE emphasizes a structured, explicit and transparent approach.
GRADE separates the rating of the quality of the evidence from the grading of the recommendation itself.

# (a) Quality of evidence
In the context of a recommendation, the quality of evidence reflects the confidence that the estimates of effect are adequate to support a particular recommendation.
The GRADE system classifies the quality of evidence into one of four levels: high, moderate, low and very low.

# Quality Definition
This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different is low.
This research provides a good indication of the likely effect. The likelihood that the effect will be substantially different is moderate.
This research provides some indication of the likely effect. However, the likelihood that it will be substantially different is high.

# Very low
This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different is very high.
Based on a rating of the available evidence, the quality of evidence for each critical outcome was categorized as high, moderate, low or very low. Summaries of the quality of evidence to address each outcome were entered in a GRADE table. Rating of the quality of evidence was first done by outcome before an overall assessment was made. Rating of the quality of evidence started as high when based on randomized controlled trials (RCTs), and as low when based on observational studies. Subsequently, the rating may be decreased for several reasons, including risk of bias, inconsistency of results, indirectness of evidence, imprecision and publication bias. In the case of both PICO questions, the body of observational studies had no reason for downgrading. It could be increased if the magnitude of the treatment effect was very large, if there was evidence of a dose response relationship or if all plausible biases would underestimate the effect.

# (b) Strength of recommendation
The strength of a recommendation reflects the extent to which confidence exists that the desirable effects of an intervention outweigh the undesirable effects.
The GRADE system classifies recommendations into two strengths -'strong' and 'conditional'. A recommendation can also be either in favour of, or against the intervention in question. As a result, there are four types of recommendations based on the following combinations of strength and direction:
- strongly in favour of the intervention;
- conditionally in favour of the intervention;
- conditionally against the intervention;
- strongly against the intervention.
The strength of recommendation has different implications for the patient, clinician and policy-maker, as follows:

# Strong recommendation Conditional recommendation
Most people in your situation would want the recommended course of action and only a small proportion would not
The majority of people in your situation would want the recommended course of action, but many would not
Most patients should receive the recommended course of action Be prepared to help patients to make a decision that is consistent with their own values
The recommendation can be adapted as a policy in most situations
There is a need for substantial debate and the involvement of stakeholders Two technical groups worked on the development of this guideline.

# The Guideline Steering Committee
An The steering committee formed at the onset of the process was asked to review previous WHO guidelines and recommendations related to injection safety. The steering committee identified the gaps that needed to be addressed through this policy guidance which intends to promote safety of all injections. The group identified the two key questions that needed to be answered and put them in the PICO format.
Systematic reviews to answer the two guideline questions were outsourced to an expert who has worked extensively with WHO and is familiar with WHO guideline development procedures. The Guideline Steering Committee led by the Service Delivery and Safety Department guided the development of this guideline and provided overall supervision of the guideline development process.

# The Guideline Development Group (GDG)
A GDG was established to review the GRADE tables related to the PICO questions and help WHO make an evidence-based policy recommendation. The group members were selected on the basis of their expertise in infection control, injection safety, occupational health and NSI prevention and reporting systems, procurement of injection equipment and supplies on behalf of Member States, and country work on injection safety.
The GDG met once in person after receiving full copies of the draft recommendations, the full systematic review report, the summary of evidence and the GRADE tables. The in-person meeting of the GDG was held at WHO headquarters on 18-19 March 2014 with the following objectives:
- to review the evidence and the grading of evidence on the harm and benefits of safety-engineered syringes in response to the two PICO questions;
- to develop recommendations on the use of RUPs and SIPs for injections; and
- to discuss the outline of the policy flyer to be extracted from the full guideline document.
The draft recommendations, the full systematic reviews report, the summary of evidence and the GRADE tables were provided to the meeting participants in advance.
Decision-making, scope of the guideline and evidence appraisal by the GDG.
The systematic review team filled out the research evidence section where evidence was identified. During the meeting, any additional relevant information brought forward by the panel members was included under additional considerations. During the meeting, the panellists discussed and agreed on the rating for each criteria included in the Evidence to Decision (ETD) Framework.
The panel used the ETD Framework to grade and develop the recommendations. The ETD Framework is structured around the following criteria, listed in rows:
- extent of the problem;
- values and preferences;
- quality of evidence;
- balance of benefits and harms;
- resource use;
The panel completed one ETD Framework for each recommendation. The table included columns for:
- research evidence: this was based on the evidence identified systematically by the systematic review process, was included in the table ahead of the guideline meeting, and presented to the panellists at the time of the meeting;
- additional considerations: these were considerations brought up by the panellists and included in the table at the time of the meeting;
- judgements: these reflected the panellists' judgement for each of the criteria, were based on the research evidence and the additional considerations, and were completed at the time of the meeting.
After completing the ETD Framework for the above criteria, the GDG discussed the type of recommendation and developed the wording as a group. The process was by discussion consensus and not voting. GDG also agreed that the following aspects would be considered with each of the recommendations:
- additional considerations;
- implementation considerations;
- monitoring and evaluation considerations;
- research priorities.
All judgements, the final recommendation statement and the accompanying statements were reached by consensus. All members of the GDG agreed on the recommendations and all other statements.
Based on the meeting discussions, GRADE tables and recommendations developed during the GDG meeting, a draft full guideline document was developed by the Technical Focal Point on Injection Safety in the SDS Department. It was shared with the WHO Steering Committee, other WHO Departments at headquarters, WHO regional injection safety focal points and the GDG for review. It was subsequently sent for external peer-review.

# External experts for final peer-review
This group was consulted on the scope of the guideline, the questions addressed and the choice of important outcomes for decision-making, as well as to review the completed draft guideline. The external experts group included key WHO partners, country development partners, key funders of health programmes in countries, country injection safety/infection control focal points, professional associations, patients' associations, infection control societies, NGOs and major injection devices manufacturers (contacted as observers through their umbrella organization, the Global Medical Technology Alliance (GMTA). The consultation with the external experts was carried out via email with selected members known for their experience in injection safety and also through the SIGN Post List Serve (an electronic weekly newsletter), which has more than 1500 subscribers. A high interest in this new policy guidance was expressed by the external experts who provided valuable comments. The comments were taken into account in the final version of the guideline.
Comments were catalogued and addressed in the final drafts presented to support the GDG meeting above. External reviewers who responded are noted in the acknowledgements.

# MANAGEMENT OF CONFLICTS OF INTEREST
According to WHO rules, all experts must declare their relevant interests prior to participating in WHO meetings. All GDG members were therefore required to complete a Declaration of Interests form before the group composition and invitations were finalized.
Procedures for the management of conflicts of interest were followed in accordance with the WHO Guidelines for the Declaration of Interests (WHO experts).
In summary, all members of the GDG declared that they had no commercial, financial or personal interests which directly or indirectly related to the topic of the meeting/guideline.
Should syringes with a sharps injury protection feature be introduced among health care workers delivering intramuscular, subcutaneous, or intradermal injectable medications?
We recommend the use of syringes with a sharps injury protection feature (SIP devices), as opposed to syringes without a sharps injury protection feature, by health care workers (HCWs) delivering intramuscular, subcutaneous or intradermal injectable medications to patients (conditional recommendation, moderate quality evidence).

# Rationale for the recommendation
A systematic review concluded that moderate quality evidence supported a recommendation for the use of SIPS to reduce the incidence of NSIs among HCW and patients. Limitations of the review were lack of peer-reviewed published studies that specifically link the use of particular injection devices with a reduction of specific diseases. While the evidence was considered to be of moderate quality, the benefit would very likely outweigh the risks. Preliminary results of a costeffectiveness study undertaken by WHO support the recommendation. We anticipate the guideline will be published soon and the cost-effectiveness analysis will be considered in the guideline update.
- Moderate quality evidence for effectiveness, but the balance of benefit to harm is judged as probably favourable, with benefits outweighing harm: in settings where SIP devices are introduced, and when considering 1000 HCWs, nine fewer (from six fewer to 11 fewer) are expected to suffer an NSI over a one year period. There are no expected harms. Greater benefits can be expected in higher HIV, HBV and HCV disease prevalence/higher sharps injury frequency settings.
- Values and preferences that HCWs place on the outcomes highly depend on the culture and background of HCWs. It also highly depends on awareness-raising campaigns on the risk of injury and the risk of transmission of diseases. A systematic review on attitudes, values, preferences and feasibility identified evidence from six studies suggesting that safety syringes are generally perceived as easy to use, safe, and tolerated by patients. There were few reports of technical problems while using the devices. Nurses' preferences and satisfaction were not consistent across studies. The included studies suffered from methodological limitations.
- Uncertainty was expressed by the panel concerning the cost-effectiveness of introducing SIP devices, because this aspect was not covered by the systematic reviews. A cost-effectiveness study coordinated by the SDS Department was completed subsequent to the GDG meeting. Preliminary results demonstrate cost-effectiveness of such an introduction. This study will be published shortly and will be considered in the guideline update.
- It is expected that market forces would have an impact on pricing, as economies of scale and competition will lower the unit price. Accordingly the cost-effectiveness of SIP devices is expected to improve.
- There is a notable lack of published research from LMICs (one unpublished PATH study on the use of retractable syringes in South Africa was noted but not included in the review as it had not been published).

# Considerations for end-users
- The use of SIP devices is an essential component of a comprehensive approach that must include an education and training strategy, surveillance, reporting and management of NSIs, including post-exposure prophylaxis (PEP), involvement of frontline workers in the selection of the safety devices, immunization of HCWs against HBV, advocacy for standard precautions, monitoring and evaluation of recommendation implementation and impact, as well as safety of the actual device.
- Estimated costs of implementing the recommendation should include the cost of implementation of all components of the comprehensive approach, as well as the cost of the SIP devices themselves.

# Question 2
Should syringes with a re-use prevention feature be introduced among HCWs delivering intramuscular, subcutaneous, or intradermal injectable medications?
We recommend the use of syringes with a re-use prevention feature (RUP devices), as opposed to devices without, by HCWs delivering intramuscular, subcutaneous or intradermal injectable medications to patients (conditional recommendation, very low quality evidence).

# Rationale for the recommendation
Evidence from a systematic review supported a recommendation to incorporate RUP syringes for HCWs administering injections. The evidence identified was considered to be of very low quality. A limitation of the study was the absence of peer-reviewed studies linking RUP syringes with specific re-use reduction. Practical experience with the use of a substantially similar product, i.e. AD syringes in immunization programmes, however strongly suggests that the benefits outweigh any risks and is very likely to reduce re-use. A WHO cost-effectiveness study pending publication supports the recommendation.
- Very low quality evidence for effectiveness, but the balance of benefit-to-harm is judged as probably favourable, with benefits outweighing harm. In settings where RUP devices have been introduced for immunization injections, or for therapeutic injections post-intervention assessments documented a decrease in the rate of re-use of syringes. This reduction had an impact on the number of diseases transmitted through unsafe injection practices (13). There are no expected harms. Greater benefits can be expected in higher disease prevalence/high re-use rate settings.
- Values and preferences that HCWs place on the outcomes highly depend on the culture and background of HCWs. It also highly depends on awarenessraising campaigns on the risk of injury and the risk of transmission of diseases. A systematic review on attitudes, values, preferences and feasibility identified evidence from six studies suggesting that safety syringes are generally perceived as easy to use, safe, and tolerated by patients. There were few reports of technical problems while using the devices. Nurses' preferences and satisfaction were not consistent across studies. The included studies suffered from methodological limitations.
- Uncertainty was expressed by the panel concerning the cost-effectiveness of introducing SIP devices, because this aspect was not covered by the systematic review. A cost-effectiveness study coordinated by the SDS Department was completed subsequent to the GDG meeting. The preliminary results showed clear cost-effectiveness of such an introduction.
- It is expected that market forces would have an impact on pricing as economies of scale and competition will lower the unit price. Accordingly, cost-effectiveness of RUP syringes is expected to improve.
- There is a notable lack of published research, in particular in LMICs.

# Considerations for end-users
- The use of RUP devices is an essential component of a comprehensive approach that must include education and training; surveillance and the reporting of adverse events following injections in patients and NSIs in HCWs; surveillance, reporting and the management of NSIs including post-exposure prophylaxis (PEP); involvement of frontline workers in the selection of the safety devices, immunization of HCWs against hepatitis B, advocacy for standard precautions and monitoring and evaluation of all components of the strategy, including the safety of the devices and their use.
- Estimated cost-effectiveness of implementing the recommendation should include the cost of implementation of all components of the comprehensive approach, as well as the cost of the RUP devices themselves.

# IMPLICATIONS FOR FUTURE RESEARCH
Discussion during the Guideline Development Group meeting highlighted the limited evidence available in some areas and highlighted the need for further research on harms and benefits, effectiveness and cost-effectiveness of the adoption of RUP and SIP devices to administer intramuscular, subcutaneous and intradermal injections.

# DISSEMINATION, ADAPTATION AND IMPLEMENTATION
The ultimate goal of this guideline is to improve the quality and safety of care and health outcomes related to injection practices. Therefore, dissemination and implementation of this guideline are crucial steps that should be undertaken by the international community and local health care services. The WHO Department of Service Delivery and Safety has developed a global campaign to promote injection safety which includes, in addition to this policy guidance, a list of priority actions including advocacy, information and communication which will be used by WHO and other partners to foster dissemination and implementation of this policy guidance.
The current guideline will be translated into all official UN languages and disseminated electronically through the main WHO web site, as well as regional and WHO country office websites. Other modes of dissemination will include CD-ROMs and slide presentations.
The guideline will also be disseminated through a broad network of ministries of health, international partners, other UN organizations managing injectable vaccines and medications (e.g. UNICEF, UNFPA, GAVI, Global Fund, UNITAID, UNAIDS), WHO collaborating centres, universities, professional associations, nongovernmental organizations and trade union federations.
A brochure that summarizes the essential guideline information and recommendations will also be produced for ease of reference and to enhance dissemination of the guidance. It will also be used as an advocacy tool for high level decision-makers. It will include the rationale behind the policy development, guiding principles, the evidence-based recommendation about the use of RUP and SIP syringes for all injections and the implementation requirements. Existing documents will either be incorporated or updated into the dissemination strategy as appropriate.
It is anticipated that the guideline will be launched by the Director-General of WHO during a high-level meeting where key WHO partners, UN organizations, WHO regional offices, NGOs and the umbrella organizations of injection device manufacturers, will be invited to promote broad uptake of the new policy guidance.

# Adaptation and implementation
Despite the scarcity of studies, especially in LMICs, documenting the impact of introducing safety-engineered syringes on re-use of syringes and NSIs (leading to a conditional recommendation), based on the evidence that doing nothing will continue to cause significant harm (13), WHO recommends that all countries should transition by 2020 to the exclusive use, where appropriate (syringes which RUP features are not suitable for certain medical procedures, including the maintenance of intravenous lines, local anaesthesia and nasal feeding, for example), of WHO prequalified (or equivalent) safety-engineered injection devices, including RUP syringes and SIP devices for therapeutic injections, and develop related national policies to bring about a smooth transition. Prior to country implementation of the policy, this new guideline should have well-defined objectives based on national epidemiological data on the re-use rate of injection devices and the frequency of NSIs in HCWs. Assessments have been performed by WHO in many countries over the past decade which show that safety precautions are often not respected, exposing patients and HCWs to severe risk of bloodborne infections and injuries and putting human lives at risk. This information can be retrieved by looking at available injection safety assessments, grey literature, research reports and local studies looking at these two issues. Upon request, WHO can reach out to countries having a high burden of bloodborne diseases, high expected rates of transmission from re-use and high use of injections, to assist them in gathering local epidemiological data. Implementation of the guideline should also take available resources into account,
- set health-system-wide policies and standards for procurement, use and safe disposal of disposable syringes in situations where they remain necessary as described above, including in syringe programmes for people who inject drugs;
- procurement should be based on the development of tender specifications reflecting local needs and the safety profile of the device (Not all RUP and SIP models provide similar protection in all clinical applications);
- priority should be given to the procurement of devices that have both RUP and SIP features built into the same device;
- procurement should favour passive designs that offer safety passively and automatically, i.e. which do not require user compliance and additional action on the part of the user;
- as per ISO 7886-4, Clause 5.2, the RUP feature is categorized as follows:
-Type 1: operates automatically during or upon completion of intended single use;
-Type 2: requires elective activation upon completion of intended single use.
In high-risk countries, where re-use of syringes is highly prevalent, Type 1 RUP syringes would address the spread of infection/cross contamination from re-use and would therefore be the recommended type of device for these countries.
Post-marketing surveillance would be needed to report on defects, effectiveness and any issues encountered during use of the new safety devices.

# Monitoring and evaluation of guideline implementation
A plan for monitoring and evaluation with appropriate indicators is encouraged at all levels. Implementation of the recommendations can be evaluated within countries (i.e. monitoring and evaluation of the scale of implementation of the recommendation: nationwide versus partial, public versus private, urban versus rural) and across countries (i.e. adoption, adaptation and implementation globally). Its implementation should also be monitored at health service level. Injection safety assessment, clinical audits, supervision, NSIs surveillance and reporting systems are some of the means to monitor the implementation and impact of the policy recommendation.
Clearly defined indicators are needed and these could be associated with locally agreed targets. The GDG strongly recommends that uptake of the recommendation to introduce safety-engineered syringes for all injections be used as a process indicator for the monitoring of injection practices and the prevention of bloodborne virus transmission through unsafe injection practices in health care settings.