Injection safety support

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71 countries have received Gavi’s injection safety support. By the end of 2009, 66 were reporting that they had sustained safe injection practices after Gavi support finished 

To date, 71 Gavi-eligible countries have received Gavi’s injection safety support (INS). By the end of 2009, 66 countries reported that they were supporting injection safety practices either through donor support or their own health ministry budgets.

As early as 2008, Gavi's 2009 evaluation report on injection safety support had reported that 56 of the 58 countries to receive the three-year time-limited support were able to replace and sustain the use of auto-disposable syringes (AD) and safety boxes after Gavi support ended (see diagram). According to the report:

  • 30 were fully funding their own injection safety programme;
  • 11 were relying on a mix of their own funding and donor support;
  • 15 were continuing to rely on donor funding

Spreading to other medical services

Over 90 percent of the countries consulted for the study stated that Gavi’s INS was instrumental in their decision to widen injection safety practices to the broader health sector.

According to the report, developing countries’ growing emphasis on injection safety is spreading beyond basic immunisation to other medical services and programmes, such as curative care, HIV/AIDS programmes and family planning.

INS support in Uganda

In the late 1990s, mothers in Uganda began fearing that their children would be exposed to HIV/AIDS through vaccination services. This has contributed to a drop in the national immunisation coverage rates – from 79% in 1994 to 58% in 2000.

In response to a survey that highlighted the mothers’ concerns, the Ugandan Health Ministry developed a plan to increase immunisation coverage that incorporated the introduction of auto disposable syringes, using Gavi support.

Increased confidence in the immunisation program in addition to strengthening the EPI programme resulted in a corresponding increase in immunisation coverage from 61% in 2002 to 84% in 2005.

Immunisation programmes have long been concerned with the risk of disease transmission through dangerous injection practices

Even after the advent of auto-disable (AD) syringes in 1992, many immunisation programme managers were not aware of the negative consequences of the reuse of single use injection equipment. Sadly, the case of a nurse in India, who allegedly administered 150-200 injections in four hours with only 10 syringes and 25 needles, was not infrequent in the nineties.1 

Prior to the AD, injection technology had offered few practical alternatives to the standard single use syringes. They included:

  • Reusable glass syringes that required autoclaving;
  • BCG syringes that required the needle to be passed through a flame;
  • Portable pressure cookers, developed by WHO and UNICEF in the early eighties, which sterilised plastic syringes and needles with pressurised steam;

WHO specifications

Then, in 1986, WHO developed specifications for a disposable vaccination syringe that could be used for only one injection. This led to the AD, a mechanism that automatically disables the plunger after the initial activation.

By the mid-nineties, UNICEF was supplying 25 million subsidised AD syringes every year to national immunisation programmes throughout the developing world. However, universal acceptance remained elusive because of the expensive price of the device.

There was also widespread fear that most developing countries lacked safe disposal practices and widespread AD use would result in infectious waste. This changed in 1999, with four significant developments:

  1. WHO, UNICEF and UNFPA recommend that all countries use only AD syringes for immunisation by 2004 and safe disposal boxes be bundled with syringes;
  2. Safe Injection Global Network (SIGN) established to support adoption of AD syringe technology;
  3. WHO Department of Immunizations, Vaccines and Biologicals forms Immunisation Safety Priority Project (ISPP); 
  4. Foundation of GAVI.

1 Reeler, Anne and Lone Simonsen. May 2000. Children’s Vaccine Program. Occasional Paper #2. Washington, DC; PATH

Gavi instituted injection safety support as one of its windows of support in 2000: a one-off, three-year grant was made available to all Gavi-eligible countries

Gavi began offering injection safety support (INS) in mid-2001 to countries that wanted to introduce or increase the use of auto-disable (AD) syringes and safety boxes into their national immunisation programmes for vaccines not supported by Gavi.

In addition, all Gavi supported vaccines are delivered with AD and safety boxes.


To encourage countries to find their own sustainable funding sources for injection safety, Gavi provided approved countries with sufficient AD syringes and safety boxes to immunise children and women for a period of three years only.

Initially, INS support was offered only to countries receiving immunisation services support (ISS), but eligibility was soon broadened to include all Gavi-eligible countries.

Map of countries approved for Gavi's injection safety support


Cash support

In addition to INS in the form of commodities, Gavi offered cash as an alternative form of support to countries where AD syringes and safety boxes were already being ordered.

Instead of actual AD syringes and safety boxes, national immunisation programmes in these countries received funding equivalent to the cost (at prices obtained by UNICEF) of purchasing the materials for three years. This helped countries reinforce their training and monitoring and evaluation activity related to injection safety.

Over 7 million

Since its launch in 2000, Gavi has helped developing countries to prevent more than 7 million future deaths from hepatitis B, Haemophilus influenzae type b, human papillomavirus, Japanese encephalitis, measles, meningitis A, pneumococcal disease, rotavirus diarrhoea and yellow fever.

Gavi / Bill & Melinda Gates Foundation 2015

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