Vaccination Management in Immunosuppressed Child
The most appropriate approach is Option D: Replace OPV with IPV, give MMR and Tdap—however, this requires critical modification: MMR must be deferred until corticosteroid dose is reduced below safety thresholds, while IPV and Tdap should be administered immediately. 1
Immediate Vaccination Strategy
Inactivated Vaccines: Safe to Administer Now
- Tdap should be given as scheduled despite ongoing immunosuppression, as it is an inactivated vaccine that poses no safety risk in immunocompromised patients 1
- IPV must replace OPV in this immunosuppressed child, as OPV is a live vaccine that is absolutely contraindicated 1
- Inactivated vaccines can and should be administered to children on immunosuppressive therapy, though immune response may be suboptimal 1
Live Vaccines: Must Be Deferred
- MMR must be delayed until the child's prednisone dose falls below either 1 mg/kg daily or 2 mg/kg on alternate days 1
- The rationale for deferring live vaccines is to prevent vaccine-strain viral disease in immunocompromised hosts 1
- Live vaccines are absolutely contraindicated in children receiving corticosteroid-sparing immunosuppressive agents, regardless of corticosteroid dose 1
Critical Pitfall to Avoid
Do not give MMR at this visit. The question stem indicates "long-term oral corticosteroid therapy," which typically means doses exceeding the safety threshold for live vaccines. Children with nephrotic syndrome commonly receive prednisone at 2 mg/kg/day during induction or 2 mg/kg on alternate days for maintenance 2, 3, both of which meet or exceed the contraindication threshold 1.
Why Other Options Are Incorrect
- Option A (Tdap only): Too conservative—unnecessarily withholds IPV, which is safe and needed 1
- Option B (DT only): Incorrect—there is no indication to remove pertussis component; Tdap is safe in immunosuppressed patients 1
- Option C (Avoid live vaccines, delay MMR and OPV): Partially correct but flawed—OPV should not just be delayed but permanently replaced with IPV in this patient 1
Additional Protective Measures
- Children with nephrotic syndrome should receive pneumococcal vaccination (PCV13) due to increased risk of invasive pneumococcal disease 1
- Annual influenza vaccination should be given to both the child and household contacts 1
- Healthy household contacts should receive all recommended live vaccines to create a protective cocoon around the immunosuppressed child 1