Meningitis Vaccine Policy in Saudi Arabia

Meningitis Vaccine Policy During Hajj

Overview of the Essay

This essay looks at the meningitis vaccine policy during Hajj in Saudi Arabia, first looking at the healthcare system in Saudi Arabia, in terms of how the health care system is structured and what the policies towards vaccination against meningitis are. The essay then moves on to discuss more general policies towards meningitis vaccination, from the World Health Organisation (WHO), for example, and how the Saudi model of vaccination fits in to this more general framework. The essay then moves on to looking at social theories that have been suggested to explain how organisations work, in terms of understanding how meningitis can be spread through the hajjis attending the Hajj pilgrimage.

The essay then moves on to look at what evidence has been gained from research in to meningitis outbreaks during Hajj, and meningitis control through vaccination. This is presented in the form of a literature review of the current, relevant, literature regarding meningitis outbreaks during Hajj, and meningitis control through vaccination. Literature that is specific to Saudi Arabia is focused on, although vaccination programmes that have been successfully attempted further afield will also be discussed.

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The essay then moves on to looking at how and when the current Saudi Arabian vaccination policy and how this policy differs from previous policies, in terms of why the new policy was introduced and what the positive and negative effects of this policy have been. This section incorporates research reviewed in the previous section, through the literature review of the relevant research, and also looks at how historical trends and international trends in healthcare have contributed to this policy. The impact of globalisation on health care is also discussed.

The essay then moves on to discuss any gaps that are present between the stated policy and the implementation of this policy, in terms of the organisational constraints that are present that directly affect policy implementation. The next section of the essay looks at the implications of the policy for nursing practice, in terms of the direct involvement of nurses, the need for counselling and educating parents, in terms of the historical development of nursing and the international trends in nursing.

Introduction

The Saudi Healthcare System

This section looks at how the health care system is structured in Saudi Arabia, and what the policies towards vaccination against meningitis are within the Kingdom of Saudi Arabia. The essay then moves on to discuss more general policies towards meningitis vaccination, from the World Health Organisation (WHO), for example, and how the Saudi model of vaccination fits in to this more general framework. The essay then moves on to looking at social theories that have been suggested to explain how organisations work, in terms of understanding how meningitis can be spread through the hajjis attending the Hajj pilgrimage.

The healthcare system in Saudi Arabia is essentially a national health care system, provided by the Government, which is overseen by the Ministry of Health (MOH), which provides primary healthcare services through a series of health care centres scattered throughout the Kingdom. These primary care centres refer applicable cases to advanced specialist curative services based in hospitals. In addition, secondary and tertiary care is provided by a variety of Ministries, and through a variety of private and public organisations: for example, Saudi Arabian universities provide specialist care, through their research hospitals and Saudi Arabian airlines provide health care to it’s employees. Emergency care is provided by the Saudi Red Crescent Society, and is also responsible for providing medical care during the Hajj and Umra pilgrimages. Health care is free, at the point of delivery, to all Saudi citizens and expatriates working in Saudi Arabia, and the Saudi Government spends an estimated ten per cent of its annual budget on health care: this seems to be a good investment as the Saudi’s have one of the highest life expectancy in the region, although obesity is becoming a concern in Saudi Arabia, due to the introduction of the ‘Western’ diet to the region.

Whilst a more than adequate health care system is provided by the Saudi Government, as has been seen, there is also a thriving private healthcare system which provides all levels of care, from primary to tertiary and including emergency medical services. The Saudi Government is also interested in reforming the health care system, with a desire to achieve coordination amongst the various sectors and to increase the number of Saudi medical and nursing graduates so that Saudi employees can work in this sector, rather than employing many hundreds of thousands of expatriate nursing and medical staff, as is currently the case. The Saudi Government is also attempting to introduce a cooperative health insurance scheme, which would cover all non-Saudi residents living and working in the country.

Infection Control for the Hajj

In order to attend the Hajj, vaccination against the A and C meningitis strains was made mandatory, following on from the worldwide outbreak of meningitis A which occurred following the 1987 Hajj (Fonkoua et al., 2002) and a 1992 outbreak of meningitis A which occurred amongst Umra pilgrims (Wilder-Smith et al., 2003). In addition to this requirement for travellers entering Saudi Arabia for the Hajj, all hajjis coming from countries belonging to the African meningitis belt, and those arriving from areas that had recently experienced a meningitis outbreak, were required to take a single dose of ciprofloxacin upon arrival to Saudi Arabia (WHO, 2001).

This policy was in place in Saudi Arabia until the recent outbreak of the W-135 serogroup. The current concern of health professionals and health organisations is, however, the W-135 serogroup, due to the recorded outbreak of meningitis amongst Singaporean pilgrims returning from the Hajj in 2001, many of whom had been vaccinated with the quadrivalent vaccine (Wilder-Smith et al., 2003). As stated in Wilder-Smith et al. (2003), there was a massive outbreak of serogroup W-135 meningitis in the 2000 and 2001 pilgrimages, through pharyngeal carriage of the serotype in pilgrims returning from the Hajj. Wilder-Smith et al. (2003) looked at meningitis carriage during the minor pilgrimage (Umra) and found that, whilst the W-135 serotype was carried, it was at a much lower rate of incidence, at 1.3% versus the 17% found in Hajj pilgrims, leading to their conclusion that in order to reduce the potential introduction of N.meningiditis W-135 in to the countries of origin of the pilgrims, then attentions would be better focused on those pilgrims attending the Hajj rather than the Umra.

Following on from the Hajj-associated outbreak of W-135 serogroup, the Saudi Arabian Ministry of Health changed their policy with regards to meningitis and made it mandatory for hajjis to receive the quadrivalent vaccine (against A, C, Y and W-135) as a visa requirement from 2002 for people entering Saudi Arabia for the purposes of the Hajj (Wilder-Smith et al., 2003). In addition, the Saudi Arabian Ministry of Health administers antibiotics to all local Saudi hajjis in order to eradicate the carriage of the W-135 serogroup and to reduce transmission to local contacts and to the larger community (Wilder-Smith et al., 2003).

In terms of more general policies with regards to vaccination programmes against meningitis, the World Health Organisation (WHO) recommended control practices for meningitis involve vaccination with the A/C vaccine in response to epidemics, which requires that epidemics are detected early and that stocks of vaccines be set up in at-risk regions, so that vaccination can be rapid (Fonkoua et al., 2002). Whilst other outbreaks of the W-135 strain of meningitis are becoming increasingly common, such as the outbreaks in Yaounde in Cameroon (Fonkoua et al., 2002) and in Burkina Faso (which killed 1500 people of the 13000 known to have been infected), the WHO is recommends preventative vaccination to protect those individuals at risk (for example, travellers, people in the military and pilgrims) (WHO, 2003) and vaccination for those who have been in close contact with known meningitis cases. In terms of vaccination for epidemic control, the WHO recommends that in the African meningitis belt, the known hotspot for meningitis, stretching from Senegal to Ethopia, epidemics be controlled with enhanced surveillance and the use of oily chloramphenicol, with mass vaccinations for those areas in the epidemic phase and those contiguous areas that are in alert phase: such mass vaccination, promptly administered is estimated to prevent seventy per cent of cases (WHO, 2003).

As shown in a 2001 WHO report (WHO, 2001) on the emergence of the W-135 strain of meningitis, infection with this strain can lead to outbreaks of considerable size and because the epidemiology of this strain is not well understood, there is a serious need for travellers to the Hajj to be protected. The 2001 outbreak of W-135 strain of meningitis at the Hajj spread worldwide with a total of 304 cases reported and this outbreak raised serious questions as to whether the W-135 strain of meningitis will become a major public health problem at national and international levels (WHO, 2001).

As shown in the NHS leaflet specially designed for UK citizens and residents planning on attending the Hajj, the W-135 strain of meningitis is deadly and vaccination against the A and C strains of meningitis does not protect an individual against this more deadly strain: only the quadrivalent vaccine will protect individuals against the W-135 strain of meningitis (NHS, 2007). In terms of the WHO policy on the W-135 strain of meningitis, the WHO has stated that the currently available vaccine is too expensive to be applicable for mass vaccination programmes that are known to be effective in the prevention of the epidemic outbreak of other meningitis strains, and so the WHO is pressing for an affordable vaccine against the W-135 strain, i.e., a vaccine at a price that would be affordable in an African situation, given that the majority of outbreaks of meningitis occurring worldwide occur in the African meningitis belt (WHO, 2003).

Thus, there is no widespread vaccination programme with the quadrivalent vaccine, which protects against the W-135 strain of meningitis, unlike the routine vaccination programmes with the vaccines that are effective against the A and C strains. As the WHO, the Saudi government and various Governments who deal with their citizens who attend the Hajj (for example, the UK) are recommending, it is, at the moment, sufficient that the quadrivalent vaccine is given only to those who are at risk, i.e., those who are planning on entering a region that is known to have the W-135 strain. Widespread vaccination against the W-135 strain of meningitis is not being practiced anywhere in the world, mainly, it seems, due to the high cost of the vaccine but also due to the fact that there is no scientific evidence as to the global direction of the W-135 strain of meningitis i.e., the fact that there is no evidence, as yet, to suggest that the W-135 strain of meningitis will become a global scourge (WHO, 2001) and, as such, that it is not certain, as yet, as to whether a mass vaccination against this strain is necessary.

Due to this information, the Saudi Arabian government implemented a mass vaccination with the tetravalent vaccine, active against the A, C and W strains of meningitis (WHO, 2001) and put in place the controls for hajjis as previously outlined: i) making it mandatory for hajjis to receive the quadrivalent vaccine (against A, C, Y and W-135) as a visa requirement from 2002 for people entering Saudi Arabia for the purposes of the Hajj (Wilder-Smith et al., 2003); ii) administering antibiotics to all local Saudi hajjis in order to eradicate the carriage of the W-135 serogroup and to reduce transmission to local contacts and to the larger community (Wilder-Smith et al., 2003); and iii) requiring all hajjis coming from countries belonging to the African meningitis belt, and those arriving from areas that had recently experienced a meningitis outbreak, to take a single dose of ciprofloxacin upon arrival to Saudi Arabia (WHO, 2001).

Social theories to explain how organisations work

This section looks at some of the social theories that have been suggested to explain how organisations work, in terms of understanding how meningitis can be spread through the hajjis attending the Hajj pilgrimage.

In terms of the social theories that have been suggested to explain how organisations work, in terms of understanding how meningitis can be spread through the hajjis attending the Hajj pilgrimage Bourdieu, writing in Hillier and Rooksby (2005) talks about the concept of ‘habitus’ in terms of describing both geographical and social spaces or dispositions, which Bourdieu (2005) describes as permanent manners of being, seeing, acting and thinking, a permanent structure of perception, conception and action. Bourdieu’s (2005) thinking on habitus and dispositions can be applied to participation in the Hajj, as Bourdieu (2005) widens his definition of habitus to include unity of human behaviour, or what he terms lifestyle: that is, a set of acquired characteristics which are the product of prevailing social conditions. Bourdieu (2005) argues that this habitus, this disposition, can lead to entrenched behaviours and responses, especially in religious beliefs, for example, which leads, for example, to people wishing to attend the Hajj pilgrimage as part of their religious beliefs.

Other social theories that have been put forward to explain organisational behaviour include social network theory (Barnes, 1954) which explains how social networks are formed, through the formation of nodes (i.e,, individuals) which are bound together through interdependency such as values or visions or disease transmission. The use of this theory can help epidemiologists explain how, for example, meningitis is spread amongst and beyond hajjis, leading to the development of plans and policies to contain the spread of meningitis. This will be looked at in more detail later in the essay.

The Evidence from the Research

This section looks at what evidence has been gained from research in to meningitis outbreaks during Hajj, and meningitis control through vaccination. This is presented in the form of a literature review of the current, relevant, literature regarding meningitis outbreaks during Hajj, and meningitis control through vaccination. Literature that is specific to Saudi Arabia is focused on, although outbreaks and vaccination programmes that have been successfully attempted further afield will also be discussed.

There was a massive outbreak of serogroup W-135 meningitis in the 2000 and 2001 Hajj pilgrimages, through pharyngeal carriage of the serotype in pilgrims returning from the Hajj (Wilder-Smith et al., 2003). Wilder-Smith et al. (2003) looked at meningitis carriage during the minor pilgrimage (Umra) and found that, whilst the W-135 serotype was carried, it was at a much lower rate of incidence, at 1.3% versus the 17% found in Hajj pilgrims, leading to their conclusion that in order to reduce the potential introduction of N.meningiditis W-135 in to the countries of origin of the pilgrims, then attentions would be better focused on those pilgrims attending the Hajj rather than the Umra. Outbreaks of the W-135 strain of meningitis are becoming increasingly common further afield, such as the outbreaks in Yaounde in Cameroon (reported in Fonkoua et al., 2002) and in Burkina Faso (which killed 1500 people of the 13000 known to have been infected) (reported in WHO, 2001).

To this end, as will be seen, whilst there is a vaccine against the W-135 strain of meningitis, this vaccine is extremely expensive and, as such, is not suitable for mass vaccination programmes. The vaccine is currently only in usage for travellers who are expecting to travel in to high risk regions, i.e., hajjis travelling to the Hajj which happens in a known outbreak area. It is hoped, however, that the WHO lobbying of the pharmaceutical companies will produce a more affordable version of the vaccine that would then be utilised in mass vaccination programmes, particularly across the African meningitis region, in order to minimise the spread of the deadly W-135 strain of meningitis.

The Saudi Arabian Vaccination Policy

This section looks at the current Saudi Arabian vaccination policy and how this policy differs from previous policies, in terms of why the new policy was introduced and what the positive and negative effects of this policy have been. This section incorporates research reviewed in the previous section, through the literature review of the relevant research, and also looks at how historical trends and international trends in healthcare have contributed to this policy. The impact of globalisation on health care is also discussed.

Prior to the W-135 meningitis outbreak amongst those who had attended the 2001 Hajj, and following on from the worldwide outbreak of meningitis A which occurred following the 1987 Hajj (Fonkoua et al., 2002) and a 1992 outbreak of meningitis A which occurred amongst Umra pilgrims (Wilder-Smith et al., 2003), the Saudi Arabia vaccine policy was for mandatory vaccination against the A and C meningitis strains for all hajjis, with the necessity to present a certificate of vaccination upon application for a visa to travel to Saudi Arabia for the Hajj. In 2003, similarly to many other countries, such as the UK, who also undertake such a mass vaccination scheme, the Saudi Arabian government implemented a mass vaccination with the tetravalent vaccine, which is active against the A, C and W strains of meningitis (WHO, 2001).

Following the 2001 W-135 outbreak, the Saudi Arabian Government put in place several controls for hajjis: i) it became mandatory for hajjis to receive the quadrivalent vaccine (against A, C, Y and W-135) as a visa requirement from 2002 for people entering Saudi Arabia for the purposes of the Hajj (Wilder-Smith et al., 2003); ii) the Saudi Arabian Government administered antibiotics to all local Saudi hajjis in order to eradicate the carriage of the W-135 serogroup and to reduce transmission to local contacts and to the larger community (Wilder-Smith et al., 2003); and iii) it became a requirement for entry to the country that all hajjis coming from countries belonging to the African meningitis belt, and those arriving from areas that had recently experienced a meningitis outbreak, were to take a single dose of ciprofloxacin upon arrival to Saudi Arabia (WHO, 2001).

In terms of how international trends in healthcare and globalisation have contributed to these changes in the policy of the Saudi Arabian Government towards controlling meningitis, whilst the Hajj has always attracted pilgrims from all over the world, only recently has the deadly W-135 strain of meningitis reared its head, presenting a potentially disastrous scenario if this disease became epidemic as a consequence of the ideal conditions for disease replication that the Hajj presents. Thus, the Saudi Arabian Government has had to work fast to draw up a policy that minimises, as far as possible, the chances of a W-135 epidemic. The Saudi Arabian response to this threat has been impressive, in terms of drawing up practical, preventative measures so quickly and putting these in to practice so quickly.

Globalisation has speeded up international travel and, through globalisation, the world has become, in a very real sense, smaller. One can literally travel wherever one desires, faster than ever before. The fact that there was an outbreak of W-135 in Singapore, amongst Singaporean hajjis, shows that what could once, historically, have been an isolated outbreak of such a deadly disease now has the potential to affect many thousands of individuals, as those infected could, potentially, travel on many different modes of transport, across many thousands of miles, coming in to contact with many different individuals, who could then become carriers of the disease, spreading the disease far afield and leading to different outbreaks of the same disease in places where the disease has never been reported previously.

Problems Facing the Policies in Place to Prevent Meningitis Outbreaks During the Hajj

This section discusses the gaps that are present between the stated policy and the implementation of this policy, in terms of the organisational constraints that are present that directly affect policy implementation.

The actual situation of meningitis control amongst hajjis requires attention, as it is known that many hajjis enter Saudi Arabia illegally and thus are not reached by formal checks or health services whilst entering Saudi Arabia (WHO, 2001). This leads to the situation where diseases could be spread through an individual slipping through the many and varied controls that have been put in place by the Saudi Arabian Government, as it is known that many of these illegal immigrants come from countries that do not have vaccination programmes in place and who, therefore, are highly unlikely to have been vaccined prior to travelling to Saudi Arabia for the Hajj. For this reason, aside from the formal border controls on entry of hajjis, vaccination posts have been established in the last few years around the Holy Mosque (WHO, 2001).

In addition, risks are presented by the arrival, at Saudi Arabian border entry ports, of individuals bearing false vaccination certificates. This presents a particular problem as these individuals put at risk the Saudi Arabian control policies that are in place, through the fact that these individuals may be carriers of disease, and may pass disease to the hajjis, but also because the need to vaccinate these individuals, often numbering in to the thousands, costs the Saudi Arabian Government time and money, paying for and administering the vaccine, a vaccine that is in short global supply and which is expensive (WHO, 2001).

In terms of minimising the chances of such problems occurring, the Saudi Arabian Government has been in close talks with the Governments of countries of the African meningitis belt to offer direct, on the spot, help with vaccination programmes, donating vaccines to those countries who cannot afford them and opening temporary health centres in those countries that do not have the necessary infrastructure for the administration of said vaccines (WHO, 2001). The Saudi Arabian Government is also involved in research looking at, for example, carriage prevelance of meningitis strains in Mecca and the impact of mass chemoprophylaxis with ciprofloxacin (Who, 2001).

Thus, whilst there are gaps that are present between the stated policy and the implementation of this policy, in terms of the organisational constraints that are present that directly affect policy implementation, the Saudi Arabian Government seems, really, as shown through this in-depth study, to be doing literally all it can to attempt to control, as far as possible, the outbreak of various strains of meningitis amongst hajjis during Hajj.

Implications of the Saudi Arabian Policy for Nursing Practice

The next section of the essay looks at the implications of the policy for nursing practice, in terms of the direct involvement of nurses, the need for counselling and educating parents, in terms of the historical development of nursing and the international trends in nursing.

There are many and varied problems presented to UK nurses by the Saudi Arabian policy on vaccination against meningitis, in terms of the fact that UK nursing staff need training to understand the cultural significance of the Hajj to their muslim patients, in order to understand any potential requests for vaccination and to diagnose any potential diseases on their return from the Hajj. Nurses dealing directly with hajjis also require further training in the current vaccination requirements for hajjis, as determined by the Saudi Arabian Government’s vaccination policy, as shown through their visa requirements, in order to administer the correct, required, vaccines. The nursing staff in contact with hajjis should also be fully versed in the symptoms of all types of meningitis (including the deadly W-135) and other diseases that could be contracted whilst undertaking the Hajj, in order for timely diagnoses to be made, and timely treatment to be delivered to the patient.

The fact that there was an outbreak of W-135 in Singapore, amongst Singaporean hajjis, shows that what could once, historically, have been an isolated outbreak of such a deadly disease now has the potential to affect many thousands of individuals, as those infected could, potentially, travel on many different modes of transport, across many thousands of miles, coming in to contact with many different individuals, who could then become carriers of the disease, spreading the disease far afield and leading to different outbreaks of the same disease in places where the disease has never been reported previously.

Thus, globalisation has led to the situation where nursing staff need to be attuned to the possibility of ‘local’ patients presenting with ‘tropical’ or ‘foreign’ diseases. Whilst there is a system of reporting set up for such diseases, the early diagnosis of such diseases is often mistaken for common ailments, such as flu, for example, and diagnosis and treatment delayed, often leading to the spreading of the disease whilst the patient is ‘at large’ and not contained. This was the case in the 2001 outbreak of W-135 meningitis in the UK, with only 8 of the 51 total cases being actual pilgrims and 22 cases being contacts of the pilgrims, with 21 cases not having any apparent contact with the pilgrims: transmission was maintained for several months prior to diagnosis which is suspected to have led to many of the additional cases (WHO, 2001).

Thus, nursing staff in countries that host Hajj attendees, such as the UK, need to be aware not only of current policies which affect the vaccination requirements of hajjis, but also of diseases that could be contracted whilst at the Hajj, in terms of knowing what symptoms to look for in patients returning from the Hajj. Saudi Arabian policies that are aimed at controlling the spread of meningitis during the Hajj thus not only have an effect on Saudi Arabian nursing staff, in terms of requiring them to administer any necessary vaccines and/or other medication, but also have a direct impact on nursing staff in those countries that host hajjis, for example, the UK, requiring special training for nursing staff.

Conclusion

This essay has looked at the meningitis vaccine policy during Hajj in Saudi Arabia, first looking at the healthcare system in Saudi Arabia, in terms of how the health care system is structured and what the policies towards vaccination against meningitis are. It was seen that the Saudi Arabian policies to vaccination against meningitis have changed somewhat in light of the 2001 outbreak of the W-135 strain of meningitis, which led to a tightening of requirements for entry to the country for the purposes of the Hajj and to a widespread vaccination programme across Saudi Arabia, and a local vaccination and medication programme in the immediate vicinity of the Hajj sites. The essay then moved on to discuss more general policies towards meningitis vaccination, from the World Health Organisation (WHO), for example, and how the Saudi model of vaccination fits in to this more general framework. As seen, the WHO is concerned that a major outbreak of the W-135 strain of meningitis could not be controlled, due to the high cost of the vaccine; the Saudi mondel fits in to this general framework in terms of aiming to prevent an outbreak not through mass vaccination with the quadrivalent vaccine but through the careful control of individuals entering the Hajj zone.

The essay then moved on to looking at social theories that have been suggested to explain how organisations work, in terms of understanding how meningitis can be spread through the hajjis attending the Hajj pilgrimage, showing that many social theories are applicable to explain how diseases are transmitted across the Hajj period. The evidence that has been gained from research in to meningitis outbreaks during Hajj was then discussed, as was the historical treatment of meningitis control through vaccination. This was presented in the form of a literature review of the current, relevant, literature regarding meningitis outbreaks during Hajj, and meningitis control through vaccination. Literature that is specific to Saudi Arabia was focused on, although vaccination programmes that have been successfully attempted further afield were also discussed.

The essay then moved on to look at how and when the current Saudi Arabian vaccination policy has changed, and how this policy differs from previous policies, in terms of why the new policy was introduced and what the positive and negative effects of this policy have been. It was shown that, prior to the W-135 meningitis outbreak amongst those who had attended the 2001 Hajj, and following on from the worldwide outbreak of meningitis A which occurred following the 1987 Hajj (Fonkoua et al., 2002) and a 1992 outbreak of meningitis A which occurred amongst Umra pilgrims (Wilder-Smith et al., 2003), the Saudi Arabia vaccine policy was for mandatory vaccination against the A and C meningitis strains for all hajjis, with the necessity to present a certificate of vaccination upon application for a visa to travel to Saudi Arabia for the Hajj. In 2003, similarly to many other countries, such as the UK, who also undertake such a mass vaccination scheme, the Saudi Arabian government implemented a mass vaccination with the tetravalent vaccine, which is active against the A, C and W strains of meningitis (WHO, 2001).

Following the 2001 W-135 outbreak, the Saudi Arabian Government put in place several controls for hajjis: i) it became mandatory for hajjis to receive the quadrivalent vaccine (against A, C, Y and W-135) as a visa requirement from 2002 for people entering Saudi Arabia for the purposes of the Hajj (Wilder-Smith et al., 2003); ii) the Saudi Arabian Government administered antibiotics to all local Saudi hajjis in order to eradicate the carriage of the W-135 serogroup and to reduce transmission to local contacts and to the larger community (Wilder-Smith et al., 2003); and iii) it became a requirement for entry to the country that all hajjis coming from countries belonging to the African meningitis belt, and those arriving from areas that had recently experienced a meningitis outbreak, were to take a single dose of ciprofloxacin upon arrival to Saudi Arabia (WHO, 2001).

In terms of how historical trends and international trends in healthcare have contributed to this policy, and the impact of globalisation on health care, it was shown that globalisation has meant that diseases can spread far more rapidly and widely than ever before, and that this has grave consequences in terms of deadly diseases such as the W-135 strain of meningitis. Various problems for the Saudi Arabian vaccination policy were then discussed, and the relevant solutions were given, and then the essay moved on to discussing the role of nurses involved in the care potential hajjis and of returning, infected, hajjis, in terms of the implications of the Saudi Arabian vaccination policy for nursing practice, in terms of the direct involvement of nurses, the need for counselling and educating parents, and in terms of the historical development of nursing and the international trends in n