A 4½-year-old on long-term systemic glucocorticoids is scheduled for vaccines usually given in the clinic. Which vaccines are appropriate?

• A. DTaP and IPV only
• B. MMR and Varicella only
• C. DTaP, MMR, Varicella, and IPV
• D. Hib and Polio only

Answer: (A)

When a child is on long-term systemic glucocorticoids, the immune system is suppressed, especially T-cell–mediated responses. Live vaccines pose a risk of causing disease in an immunosuppressed person and may not provoke an adequate protective response, so they are avoided. Inactivated vaccines, on the other hand, can be given safely and are appropriate for routine immunization in this setting.

At 4½ years, the vaccines typically given in the clinic include DTaP, MMR, Varicella, and IPV. Because MMR and Varicella are live vaccines, they should be deferred while the child is on ongoing systemic steroids. DTaP and IPV are inactivated and are appropriate to administer now, fitting the common catch-up pattern for a child in this situation. Hib would also be inactivated, but at this age it is not routinely due in many schedules, and the key point is that the inactivated vaccines (DTaP and IPV) are the safe, appropriate choices during ongoing immunosuppression. Plan to administer the live vaccines only after immune function has recovered and steroid therapy is paused or discontinued.