Despite the overwhelming impact of vaccines on child health and the tremendous progress in vaccine coverage globally, challenges of vaccine inequities persist. Missed opportunities for vaccination (MOV) is defined as any contact with health services by an individual who is eligible for vaccination which does not result in the recommended vaccines being given. This is common in several countries, and it presents a window of opportunity to provide vaccine services to those vulnerable children accessing healthcare facilities.

The overall purpose of this project is to reduce missed opportunities for vaccinations by targeting hospitalized children who are vulnerable to poor health outcomes, but who are also within easy access of the healthcare system. The research team proposes implementing the Missed Opportunities for Vaccination Equity (MOVE), an intervention to improve timeliness and coverage of vaccination, and increase demand for vaccination services, through a combination of sensitization of children's caregivers and health workers, manual vaccination data capture in the ward, and re-purposed vaccination resources. The strategy engages key stakeholders in the design of the intervention through a co-creation workshop; their involvement in the design and execution of the intervention will improve sustainability in the long-term. This intervention builds on existing healthcare systems, and, when scaled up, can target inequities in vaccination coverage in the general population, without placing additional strain on the healthcare system in terms of workforce or financial resources.

This pilot project is structured as a pre-post analysis of an implementation strategy to address missed opportunities for vaccination (MOV) among hospitalized children in India and Nigeria. India and Nigeria have similar rates of missed opportunities for vaccinations, and similar discrepancies with monitoring vaccination records when a child is in the hospital. The research team intends to collect the same pre-data in both India and Nigeria, implement the same intervention in both countries, and collect the same post-data in both study sites.

The pre-intervention, intervention, and post-intervention, are all described below.

Pre-Intervention period: The first three months of the project constitute the pre-intervention period, and they will consist of a situational analysis which will assess the burden of MOV as well as the barriers and facilitators for reducing MOV. Eligible participants will be enrolled after providing informed consent. Procedures would include verifying vaccination cards and medical records at admission and at discharge, conducting in-depth interviews with parents or caregivers during the hospital course, and administering structured questionnaires to hospital healthcare personnel crucial to hospitalized child care and provision of vaccinations.

Intervention: This will begin with a co-creation workshop where the results of the pre-intervention period will be discussed, and the MOV intervention will be implemented. In summary, the intervention will include four components which are: (1) Disseminate (vaccination awareness among healthcare providers and child caregivers); (2) Document (vaccination status); (3) Deploy (vaccines); and (4) Discharge (provide advice/referrals for catch-up and routine vaccinations).

Using a human-centered design approach, the research team will design an intervention, endorsed by local healthcare providers and stakeholders, which will be implemented primarily by the existing hospital healthcare staff. Research staff will play a role in data collection for monitoring purposes, but will not play a role in implementing the intervention.

Post-Intervention period: Ongoing data collection after the MOV intervention is initiated and continued, will constitute the 'post-intervention' period. During this period, data collectors will collect the same data that is being collected in the pre-intervention. The research team intends to compare the results of our pre and post intervention data, to determine if this intervention has reduced the amount of children who are missed for vaccinations.

Inclusion Criteria:

• Children between the ages 0-23 months who are admitted into the emergency or inpatient unit of the hospital
• Caregiver has access to the child's vaccination card or has direct knowledge of the child's vaccination history
• Caregiver willing to provide informed consent for the study

Exclusion Criteria:

• Health condition that precludes the use of vaccines such as a primary or secondary immune deficiency, such as HIV, malignancy requiring chemotherapy, or ongoing steroid therapy
• Allergies or contraindications to any vaccine (or component thereof) in the national schedule