Article Text

Original research
Determining the burden of missed opportunities for vaccination among children admitted in healthcare facilities in India: a cross-sectional study
  1. Nicholas Albaugh1,
  2. Joseph Mathew2,
  3. Richa Choudhary3,
  4. Sadasivan Sitaraman3,
  5. Anjali Tomar3,
  6. Ishumeet Kaur Bajwa2,
  7. Baldeep Dhaliwal4,
  8. Anita Shet4
  1. 1Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
  3. 3Pediatrics, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, India
  4. 4International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  1. Correspondence to Dr Anita Shet; ashet1{at}


Objectives Children accessing healthcare systems represent a vulnerable population with risk factors for poor health outcomes, including vaccine-preventable diseases. We aimed to quantify missed vaccination opportunities among hospitalised children in India, and identify vaccination barriers perceived by caregivers and healthcare providers.

Design Cross-sectional study.

Setting Two public-sector tertiary-care hospitals in northern India, during November 2018 and March 2019.

Participants We tracked 263 hospitalised children aged 1–59 months through hospital discharge, to assess vaccination status, and document catch-up vaccinations given during the hospital stay. We interviewed caregivers and healthcare providers to assess their perceptions on vaccination.

Outcomes Proportion of hospitalised children considered under-vaccinated for their age; proportion of missed opportunities for vaccination among under-vaccinated children who were eligible for vaccination; and vaccine coverage by antigen.

Results We found that 65.4% (172/263) of hospitalised children were under-vaccinated for their age when they presented to the hospital. Among under-vaccinated children, 61.0% were less than 4 months old, and 55.6% reported prior contact with a health facility for a sick visit. The proportion of under-vaccinated children in hospitals were higher compared with the general population as indicated by regional vaccination coverage data. Among under-vaccinated children who were tracked till discharge, 98.1% (158/161) remained incompletely vaccinated at discharge and were considered ‘missed opportunities for vaccination’. Perceived vaccination contraindications that are not part of established contraindications included in national and international guidelines was the most common reason for healthcare providers not to vaccinate children during hospital stay. Among caregivers of under-vaccinated children, 90.1% reported being comfortable having their children vaccinated while they were sick, if recommended by the healthcare provider.

Conclusion This pilot study confirmed that hospitalised sick children had substantial missed vaccination opportunities. Addressing these opportunities through concerted actions involving caregivers, healthcare providers and healthcare systems can improve overall vaccination coverage.

  • paediatrics
  • paediatric infectious disease & immunisation
  • public health

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  • Contributors NA, JM and AS conceived the study with contributions from SS. NA prepared the dataset and conducted the analysis of the data. NA, BD and AS prepared the first draft of the manuscript. NA, RC, AT and IKB were responsible for overseeing the acquisition and management of the data for the study. All authors reviewed the drafts of this manuscript, provided critical input and approved the final version for submission.

  • Funding This MOVAHC study was funded through the Bill and Melinda Gates Foundation Gates Grand Challenges (No. OPP1217304).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health and local Institutional Ethics Committees at the Postgraduate Institute of Medical Education and Research, Chandigarh and Sawai Man Singh Medical College and attached hospitals, Jaipur. Written informed consent was obtained from participants prior to enrollment and implementation of study procedures. All anonymised data were collected on paper and entered into REDCap.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. De-identified data generated by this research will be made available after publication of this article upon request to the corresponding author.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.