Chronic Steroid Use and Live Vaccine Contraindication
Chronic steroid therapy is a contraindication for live vaccines only when the dose exceeds 20 mg/day of prednisone (or equivalent) or 2 mg/kg/day for patients weighing >10 kg, administered for more than 2 weeks. 1
Dose-Specific Guidelines
High-Dose Steroids (Contraindication)
Live vaccines must be withheld in patients receiving:
- Prednisone ≥20 mg/day (or equivalent) for ≥14 days 1
- ≥2 mg/kg/day for patients weighing >10 kg for ≥14 days 1
After discontinuation of high-dose therapy, wait at least 1 month before administering live vaccines 1. Some experts recommend waiting 3 months for maximum safety 1.
Low-to-Moderate Dose Steroids (NOT a Contraindication)
Live vaccines can be safely administered in patients receiving:
- Short-term therapy (<2 weeks duration) regardless of dose 1
- Low-to-moderate doses (<20 mg/day prednisone) 1
- Alternate-day treatment with short-acting preparations 1
- Maintenance physiologic/replacement doses 1, 2
- Topical, inhaled, or intra-articular administration 1
Live Vaccines Affected by This Contraindication
The following live vaccines are contraindicated during high-dose immunosuppressive steroid therapy:
- MMR (measles, mumps, rubella) 1
- Varicella (chickenpox) 1, 3
- Live attenuated influenza (intranasal) 1
- Yellow fever 1
- Oral typhoid (Ty21a) 1
- BCG 1
- Live zoster vaccine (Zostavax) 1
- Rotavirus 1
Important exception: Recombinant zoster vaccine (Shingrix) is NOT a live vaccine and can be given to patients on any dose of steroids 1.
Non-Live Vaccines (Always Safe)
All inactivated vaccines can be administered regardless of steroid dose, including:
- Inactivated influenza vaccine 4
- Pneumococcal vaccines 4
- COVID-19 vaccines 2
- Hepatitis vaccines 1
- Tdap/Td 1
However, antibody response may be suboptimal on high-dose steroids (≥20 mg/day), so consider deferring pneumococcal vaccination until the dose is tapered below 20 mg/day if clinically feasible 4. Influenza vaccine should never be deferred regardless of steroid dose 4.
Critical Safety Considerations
Risk of Vaccine-Strain Disease
The FDA drug label for prednisone explicitly states that "administration of live or live, attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids" 3. This is based on the risk of vaccine-strain viral replication and dissemination in immunosuppressed patients 5, 6.
Fatal cases have been documented:
- One patient on methotrexate/dexamethasone who received yellow fever vaccine developed fatal vaccine-associated viscerotropic disease 5
- Infants exposed to biologics in utero who received BCG developed fatal disseminated infection 5
- Adults on low-dose prednisone (10 mg/day) developed severe complications after live zoster vaccination 6
Common Pitfalls to Avoid
Don't assume all "chronic" steroid use is immunosuppressive: Physiologic replacement doses (e.g., for Addison's disease or congenital adrenal hyperplasia) do NOT contraindicate live vaccines 2, 3
Don't forget the 2-week duration threshold: A patient on prednisone 30 mg/day for only 10 days can receive live vaccines immediately after stopping 4
Don't confuse live attenuated influenza (contraindicated) with inactivated influenza (always safe): The injectable flu vaccine is NOT live and should be given to all patients on steroids 1, 4
Don't delay vaccination unnecessarily: If a patient was vaccinated while on high-dose steroids, they should be considered unimmunized and revaccinated ≥3 months after therapy discontinuation 1
Practical Algorithm
Step 1: Determine current prednisone dose (or equivalent) and duration
- If <20 mg/day OR <14 days duration → Live vaccines are safe 1
- If ≥20 mg/day for ≥14 days → Live vaccines contraindicated 1
Step 2: If live vaccine is contraindicated, determine urgency
- If urgent (e.g., yellow fever for imminent travel): Consider risk-benefit with infectious disease consultation 5, 7
- If not urgent: Wait until dose tapered below 20 mg/day, then wait additional 1 month 1
Step 3: For non-live vaccines
- Administer without delay for influenza 4
- Consider deferring pneumococcal vaccine until <20 mg/day for optimal response 4
- Continue steroids without interruption around vaccination 4, 2
Step 4: Special populations