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Monday, January 28, 2013

Now that FUTO establish Institute of Environmental Health

By Sani Garba Mohammed

Environmental Health remains at the periphery of sustainable development, because it is inadequately defined, rarely quantified, and institutionally fragmented. Failing to address environmental health amplifies the burden of diseases, which impinges on Sub-Saharan Africa's overall economic performance and well being of the population especially the poor.

---James A Listorti et al

The dearth of Environmental health practitioners better known as Environmental Health Officers [EHOs] in Nigeria is a great set back to the healthcare delivery which is making not only primary health care services off target, but equally other health services.
This is because "to a greater extent" said Aniefiok Moses, Journal of Environmental Health June 2006, "the development of environmental health in Nigeria has been retarded due to the dominant influence of the medical profession, which assumed superiority and erroneously annexed everything health into medical practice.....”
This strange marriage existed for so long that it was near impossible to established or convince anyone that Environmental health was a profession. Whereas, World Health Organization has recognized Environmental Health as a profession, it was totally impossible to say so among policy makers in the health sector in Nigeria, more so, even in Britain, where the development of Environmental Health started in 1877, it was not recognized and regarded as profession until 1956. Here in Nigeria it in 2002 that environmental health was recognized as a profession by act no 11 of 2002.

Notwithstanding that 70% of Nigeria's health problems are environmental health related, effort directed at improving environmental health services are challenges by structural and political problems [like weak governmental policy and legislation, high level of ignorance, poor political will and commitment, poor funding, etc.]; environmental and technological problems [like poor training and human resources development]; and attitudinal and psychological problems.

Educationally, most of the practitioners stops at Higher National Diploma, being the highest educational level they can attain after scrapping its degree programme being offered by the then university of Ife, now obafemi Awolowo University in 1980s due to professional biasness, and all effort to retard the profession was placed by those who see it as threat to them. These, nonetheless, could not stop the profession to continue to exist and salvage Nigeria from unquantifiable loss to issues address by environmental health practice.
With the coming of Environmental Health Officers Registration Council of Nigeria [EHORECON] on board, it gives emphasis on education, went to many universities across the nation for the possible starting of degree programme in environmental health, but dearth of manpower affected the move until 2011 and 2012 when Federal University of Technology, Owerri [FUTO] and Kwara State University started respectively, and many more are coming.

FUTO pioneer the degree programme in collaboration with EHORECON for HND holders, and the progress made so far, couple with the ever increasing demands of environmental health practitioners across the country, and in order to tap to maximize the situation makes the current Vice Chancellor, The most Environmental health friendly VC, Prof CC Asiabaka to establish a pioneer Institute of Environmental Health Technology, the first of its kind not only in Nigeria, but across West Africa, to challenge the dearth of manpower.

The objectives of the institute include the following: to run certificate, Post-graduate Diploma, M.Sc/M.EH and Doctor of Philosophy degree courses in Environmental health sciences [Ph.D.] or Doctorate degree in Environmental Health [D.EH]. as well as to mount special undergraduate program for professional Environmental Health Officers [EHOs] with Higher national Diploma [HND] in environmental health technology from West African Health Examination Board [WAHEB]; To provide technical and advisory services to its members, Nigeria and the ECOWAs region in all areas of Environmental health, including but not limited to water supply, liquid waste and excreta disposal, solid waste management, water resources management, coastal zone management [including beach pollution control], air pollution, occupational health, health, safety and environment, pest and vector control, pesticide use and application, toxicity assessment, disaster prevention and preparedness, environmental epidemiology, environmental toxicology, hospital sanitation, ecological sanitation, institutional sanitation, food sanitation and safety, abattoir and market sanitation, community-led total sanitation, natural resource conservation, environmental institution development and socio-economic, built environment sanitation, Environmental health emergencies and planning, etc.; to promote and collaborate in the planning of symposia, workshops, and on-the-job training for environmental health professionals in Nigeria and beyond; To conduct certificate courses, seminars, symposia and other workshops at either the institute or other selected regional institutions; to arrange and accept grants for financing scholarships and fellowships to facilitate the training of environmental and public health personnel or people in allied professions/public health;  to act as a national or regional reference centre for the collection and dissemination of technical and scientific information, and a focal point for various environmental monitoring networks for the collation, collection and dissemination of environmental health data, especially health-related, in Nigeria and in the sub-region; to promote and coordinate applied research relevant to the environmental health problems in the Eastern zone and Nigeria as a whole as well as to provide laboratory services and other related environmental services for Nigeria, in accordance with the needs of Nigerians, etc.

The pioneer Coordinator, environmental health programme, and the current head of department, Public health, and an indispensable resource person in Environmental/Public health practice in West Africa, Prof Amadi A. N expressed his appreciation to the VC, principal officers and the Senate of the university for graciously approving the institute, which when fully operational shall excel and make a great impact in shaping environmental and public health practice across West Africa.
                                 
With this landmark development, the institute can address the challenges of Environmental health practitioners in many areas of specializations; equip them with technical knowhow in research, evidence based practice and other development that will change the trends of health care policies in Nigeria to a better, efficient and reliable one.
For my fellow environmental health practitioners, it is a chance and a challenge to further their knowledge on the current and modern evidence based practice, to appreciate the prospects of their profession. There is no excuse of not seeking knowledge, it is you either joins the train of progress sown by FUTO or remain static and be left behind. A stitch in time saves nine, FUTO has started, and this is just the beginning.


Sani Garba Mohammed, public health department, federal university of technology, Owerri





Friday, January 25, 2013

NOSOCOMIAL DISEASE PREVENTION AND CONTROL IN HEALTH CARE DELIVERY SYSTEM: THE ROLE OF ENVIRONMENTAL HEALTH OFFICER

 A PAPER FOR THE 45TH NATIONAL CONFERENCE/SCIENTIFIC WORKSHOP OF THE ENVIRONMENTAL HEALTH OFFICERS ASSOCIATION OF NIGERIA (EHOAN) HELD FROM 19TH-23RD NOVEMBER,2012, AT FUNFIELD PARKS & EVENTS CENTRE, OSHOGBO, OSUN STATE, NIGERIA.

1.0 Introduction:
Right from time the dispensation of health care services has always been accompanied with one adverse effect or the other occasionally. With the institutionalization of health care, a prominent hazard whose consequence has the tendency of spreading within the health care community emerged and this consequence is nosocomial infection. It is also called hospital acquired infection (HAI) or healthcare associated infection but here for consistency we will adopt the terminology, “nosocomial infection”.

Nosocomial infection can be defined as adverse biological response to pathogenic micro organism’s presence or the presence of its toxin in a patient undergoing treatment that was not manifested or incubated before admission (Garner, Jarvis, Emori, Horan & Hughes, 1996, P.AI; Inweregbu, Dave & Pillard, 2005; WHO, 2002). Operationally, infection that commenced 48hours after admission, within 3 days after discharge or 30 days after operation is regarded as nosocomial infection (Inweregbu, Dave & Pillard, 2005).

Nosocomial infection continues to present challenges to healthcare and patients safety despite the advances in healthcare technology. This is because as state-of-art technologies emerge for the delivery of effective and efficient health care for the population, these technologies involve invasive devices, the hospitals in most developing world is being crowded, patients population is becoming older, increase in immune compromised patients and improper use of antibiotics.
Organisms responsible for nosocomial infections are bacteria, fungi, viruses and parasites (CDC, n.d.).

2.0 Public health and economic burden
In the United States of America, about 1.7million people suffer from nosocomial diseases annually (CDC, 2010). Among these patients; 52,328 are newborns, 417,946 are adults and children in intensive care units, while 1,266,851 are children and adults from other units (CDC, 2010). It is estimated that about 5% of hospitalized patients acquire nosocomial infection in America, while in the European countries, it is about 10% of hospitalized population and recent studies put in between 10-15% (Yinnon et al., 2012; CDC 2010). Dilek, et al (2012) observed that nosocomial infection rate in developing countries is about three to five times higher than the rate in America. A patient with nosocomial infection spends 21/2times longer in hospital accumulating additional cost of £3,000 more hospital bill in Europe (Inweregbu, et al., 2005). They also estimated that 5,000 deaths are due to nosocomial infection annually causing up to one billion pounds to the National Health Service. Study indicated that intensive care units have nosocomial infections prevalence of about 20.6% (Inweregbu, et al., 2005), and blood stream infection forms between 31.5% to 82.4% of intensive care unit nosocomial infection morbidity and mortality (Chang et al., 2011).

3.0 Common sites of infection and responsible organisms
Site
Organisms
Signs and Symptoms
Mode of Infection
Urinary tract infection (UTI)
  • Escherichia coli
  • Enterococci
  • Pseudomonas aeruginosa
  • Candida species
  • Proteus mirabilis
  • Providencia stuartii
Fever, frequent urination, dysuria and supra public tenderness
Catheter
Lower respiratory infection or pneumonia
  • Klabsiella species
  • Staplylococcus aureus
  • Pseudomonas aeruginosa
  • Enterobacter species
  • Legionella species
  • Aspergillus species
Cough, high blood temperature and purulent sputum

Inhalation of aerosol or droplet discharges
Surgical site infection
  • Staphylococcus aureus
  • Enteroccoccus
  • Yeast
  • Gram-negative organisms
Can be as for UTI, pneumonia and blood stream infections
Surgical wounds
Bloodstream infection
  • Staphylococcus
  • Euterococus
  • Canadida species
  • Klebsiella pneumoniae
  • Entcrobacter species
  • Canadida species
Fever, chills, malaise, anxiety, nausea, vomiting and others
Inversive techniques
Gastro intestinal infection
  • Clostridium difficile
  • Rotavirus
  • Salmonella species
Diarrhea

Ingestion
Eye infection
  • Chlamydia trachomatis
  • Staphylococcus species
  • Neisseria gonorrhoeae
  • Adenovirus typeB
-          Pains in the eye
-          Foreign body sensation
-          Bloody or other coloration of the eye
-          Fever
-          Redness of the eye
-          Excessive watering
Contact infection
Central Nervous System Infections
  • Streptococcus pneumonia
  • Hemophilus influenza
Headache, Nausea vomiting & Light secession  fever
Wounds, foreign bodies, head trauma, neuroinvaside procedures
Airborne & droplet

Other emerging and re-emerging organisms can also cause nosocomial disease. Examples are those resistant to common antimicrobial agents like Methicilin Resistant Staphylococcus Aureus (MRSA), Vancomycin Resistant Enterococcus (VRE), Penicillin Resistant Streptococcal Pneumonia and Sever Acute Respiratory Syndrome (SARS) (Chotani, Roghmann & Peri, 2007, P.535 – 6).

4.0 Mode of transmission
The mode of transmission of nosocomial infection is related to sources of infection. Nosocomial infection can be transmitted from two main sources: exogenous and endogenous sources: Exogenous sources are factors within the healthcare environments including building, plants, devices, instrument, patients and health workers. Endogenous sources are normal flora organisms of a patient. Normal flora organisms could be part of the patient flora before admission and is responsible for primary endogenous infection, while those that become part of the flora during patients stay in the hospital cause secondary infection (Chotani et al., 2007, P.517). Nosocomial infection transmission can occur through airborne, droplets, direct or indirect contact, ingestion or administration of contaminated water, food, medication, intravenous fluids and blood products.



5.0 Risk factors for Nosocomial infection
Host factor, environmental, microbiological and extrinsic factors can constitute risk factors for nosocomial infection (WHO, 2002). Extreme young or old age, nature of illness, poor nutrition, underlying conditions like obesity, abnormal functioning or inadequate ventilators, dusty conditions, wet surfaces and walls can posse danger of nosocomial infection. Water systems can be colonized by legionella organisms, pseudomonas species, Acinobacters and others, while inanimate objects like formite can encourage the spread of VRE or MRSA. Other risk factors are duration of stay in the hospital and use of total parenteral nutrition (Saloojee & Steenhoff, 2001)
Three main microbiological risk factors of nosocomial diseases are the organism’s virulence, ability to survive in the healthcare environment and ability to resist antimicrobial agents, extrinsic factors are medical procedures and chemotherapeutic agents (WHO, 2002).

6.0 Prevention and Control of Nosocomial infection
In every given healthcare setting the existence of an integrated arrangement that would involve infection control department in conjunction with other units like the microbiological laboratory, staff health services, pharmacy and Data/computer units is vital to surveillance and prevention of nosocomial infection. An infection control committee should be formed, where the infection control officer would either chair or be the secretary to the committee. The committee organizes surveillance activities, collect data on exposures, antibiotic use, pathogenic isolates and molecular finger printing, antimicrobial resistant organisms and so on. The committee should draw a check list on hygiene practices among the health workers, organize training and monitor the implementation in the wards. Infectious disease control rounds that adopted check list and monthly report on nosocomial disease situation in a hospital unit is associated with a significant decline in nosocomial infection in that unit (Linnon et al., 2012). This is also consistent with the observation that education of health worker on good hygiene and aseptic techniques proved successful but unfortunately is not sustainable (Saloojee & Steenhoff, 2001). In a related study device associated nosocomial infection was reduced on the application surveillance procedures in a hospital (Dilek et al., 2011).
This is mainly where the Environmental Health Personnel should make an impact as the infection control officer/personnel. The committee should designate environmental health officers to survey the hospital plants, environment and instruments for efficient functioning and hygiene purposes and report to it. Where necessary the infection control officer should make adequate arrangement to secure the abatement of nuisance detected and ensure regular flushing and cleansing of water systems.
 Other important components of nosocomial infection control activities include hand washing, isolation, microbal agent control and immunization.
Hand washing by the healthcare personnel is one of the most effective means of preventing nosocomial infection in the healthcare facilities. The hands of health workers are always inhabited by normal flora organisms (e.g. Staphylococci species and micrococci) which can also extend to the deeper layers of the skin and transient organisms (like Klebsiella – Enterobacter and Acinetobacter). Normal flora organisms can be dangerous to immuno compromised patients or patients with inserted prolonged foreign object. Thorough hand wash with warm water and detergent substantially reduces microbal colonization of health workers hand. Facilities for hand washing should be located at proximate points as possible. Unfortunately health workers neglect this important procedure, and studies indicated the physicians are the most negligent professional group in this regard and compliance is about 40% of the time in most health institutions (Chotani et al., 2007, P.541). The reason for poor practice of hand wash is the fact that many health workers suffer from a complex Saloojee & Steenhoff described as “Omo-syndrome” – that is a feeling of being super neat and sterile (Saloojee & Steenhoff, 2001).
Isolation is meant to break the chain of transmission of pathogens from source to susceptible person. Health workers, patients or visitors could be source of infection. There are two types of isolation: standard and transmission based isolation. Under standard isolation everybody fluid or skin abrasion is considered infectious. Use of protective devices like masks, glove, cleaning equipment and linen, environmental control and cohorting patients are advised.
Transmission based isolation is implementation of standard precautions plus measures specific to the transmission mode. For airborne infection; private room isolation and negative pressure room and for droplet infection; private room isolation or cohorting of patients should be practiced, while private isolation or cohorting patients will be used for contact infection (Chotani et al., 2007, P.453).
Immunization of health worker is essential in some instances in the case of infection that is vaccine preventable. Some organisms can cause infection both at community level and at hospital level. Diphtheria, Hepatis A & B, influenza, measles and chickenpox immunization should be given to the health workers depending on the risk they face in their occupational setting.
Another important measure for the control of nosocomial infection is antibiotic control in health institutions. Antibiotic is the second most used class of drugs in hospital setting and study has shown that 40% of the times, antibiotics were not properly used. Improper use of these drugs leads to the emergence of anti-microbial bacteria and drug reaction. So it is important that an antibiotic policy that will control the use of the drug evolves in a hospital.

7.0 Conclusion:
Nosocomial infection cases are increasing throughout the world and the situation is more pronounced among developing countries. The rate of nosocomial infections in a hospital varies according to the unit, with intensive care units having the highest rate than other units in a hospital, present invasive medical devices, hospital environment, poor personal hygiene of health workers, age and immune level of patients are factors that predisposes people to nosocomial infection. Continuous integrated infection control activities, surveillance, immunization of health workers, isolation and antibiotic use control policies are vital measures towards the control of nosocomial infection in a health facility.








ENVIRONMENTAL HEALTH: THE KEY TO SUCCESSFUL PRIMARY HEALTH CARE SERVICES DELIVERY


BY: DR. NURUDEEN SOBOWALE OLANIRAN,
Ag. Head, Department of Public Health,
College of Medical Sciences,
University of Calabar,
Calabar.
 November 20, 2012


 Your Excellency, Ogbeni Rauf Adesoji Aregbesola, the Governor of the State of Osun; The Honorable Minister of Health; The Honorable Minister of Environment, Housing and Urban Development; The Honorable Commissioner of Health, State of Osun; The Honorable Commissioner of Environment, State of Osun; Special Advisers, Permanent Secretaries here present; Directors in the MDAs here present; The National President, Environmental Health Officers Association of Nigeria; The Secretary/Registrar, West African Health Examination Board; The Registrar, Environmental Health Officers Registration Council of Nigeria-EHORECON, Our Royal Fathers;  Gentlemen of the Press ladies and Gentlemen.
1.    INTRODUCTION
The environment is so critical to the survival or death of man so much so that any human society that ignores this scientific fact does so at its own peril. All advanced nations of the world continually pay attention to the potential impact (positive or negative) of the environment on the citizens’ health and socioeconomic wellbeing. The relationship between environment and health has been discussed in detail elsewhere (Olaniran et al., 1995). In Nigeria, there is an urgent need for conscientizing the political class, policy makers, programme managers, and the entire citizenry on the critical issue of Environment and Health, and its role in Primary Health Care (PHC). The paper will present this topical issue by going from the general to the particular. Brief overview of Health, Public Health, Environmental Health and PHC; Challenges and Opportunities will be discussed.



2.    HEALTH
A popular dictum says ‘Health is Wealth”. However, in contemporary Nigerian society, it is self-evident that money, especially primitive accumulation of material wealth, is wealth. This misconception is primarily responsible for the nonchalant attitude of most Nigerians to preventive health care. Yet, it is generally accepted that “Prevention is Better than Cure.”
The World Health Organization (WHO, 1940), in the Preamble to the Constitution, defined Health as” a state of complete physical mental and social well-being and not merely the absence of disease or infirmity”. This WHO definition is utopian and unattainable by any person. Health of a person is so fluid and ever-changing. It largely depends on several environmental factors outside the control of a person, as well as complex personal genetic traits, socio-cultural attributes and negative behaviours. From the Environmental Health perspective, health is defined as a state of equilibrium between man and numerous, complex, physical, chemical, biological, psycho-social//socio-cultural factors in his environment. A state of disequilibrium (imbalance) results in disease or illness. This definition is less utopian and forms the basis of the epidemiological triad-Agent, Host and Environment. The Health profession comprises Public Health, Medicine, Pharmacy, Medical Laboratory Sciences, Nursing Sciences, Pharmacology, Radiography, Medical Statistics, etc. and their subspecialties/subfields.


2.1.                     POPULATION AND HEALTH ESTIMATES
Table 1 Population and Health Estimates for Selected Countries in West Africa.
S/N
Country
Population Health Estimates


Population (Mid 2012) x106
Births per 1000 popln.
Deaths per 1000 popln.
Infant Mortality Rate
% Popln Ages
Life Expectancy at Birth
Percent popln Urban
<15
65+
Male
Female
1.
Benin
9.4
40
12
81
44
3
52
56
44
2.
Cote d’Ivoire
20.6
35
12
73
41
4
54
56
50
3.
Ghana
25.5
32
8
47
39
4
63
65
44
4.
Liberia
4.2
40
11
83
43
3
55
57
47
5.
Nigeria
170.1
40
14
77
44
3
48
54
51
6.
Sierra Leone
6.1
39
16
109
43
2
47
48
40
Source: Population Reference Bureau (PRB), (2012)


Table 1 shows population and health estimates for six countries in West Africa. Benin, Liberia and Nigeria have estimated 40 births per 1000 population; Ghana has lowest number of deaths per 1000 population (i.e. 8) while Sierra Leone has the highest Infant Mortality Rate per 1000 live births (i.e. 109). The population in the six countries comprises mainly youths (39-44%) while only 2-3% are in the 65+ years age group. Females have higher life expectancy (i.e., live longer) than males in all the six countries. Nigeria has the highest percent of population in urban area (i.e. 51%). Nigeria Demographic and Health Survey –NDHS (2008) reported that 71.5 % and 45.3% of households used improved source of drinking water (potable water) in urban and rural areas, respectively. In the same survey, the proportions of household using improved sanitation facilities that were not shared were 31.4% in urban areas and 24.6% in rural areas. The NDHS findings are consistent with data from other studies indicating higher water supply and sanitation facilities coverage in urban than rural areas in Nigeria.

3.     PUBLIC HEALTH
Public Health is “the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals (Winslow, 1920). This classic definition of public health is all-encompassing and still subsists. Public health is multidisciplinary and multi sectoral as shown in subfields/subspecialties which include Environmental Health, Epidemiology, Biostatistics, Public Health Sociology, Health Education and Promotion, Occupational Health and Safety, Sanitary Engineering, Public Health Administration, Public Health Nutrition, Public Health Nursing, Family and Reproductive Health (Maternal and Child Health), Veterinary Public Health, School Health, Care of the Aged and Physically Challenged, International Health, History of Public Health and Public Health Law. Public Health comprises many professionals with varied but related complementary educational, technical and professional trainings. Public Health is therefore the umbrella profession for the 17 distinct subfields.
Public Health is as old as human history. From the beginnings of human civilization, it was recognized that polluted water and lack of proper waste disposal spread communicable diseases. Early religions attempted to regulate human behavior that specifically related to health, from types of food eaten to, regulating certain indulgent behaviours such as drinking of alcohol, or sexual relations. The establishment of governments placed responsibility on political leaders to develop public health policies and programmes to prevent disease as much as possible to ensure social stability and economic prosperity. The World Health Organization (WHO) is the international agency that coordinates and acts on global public health issues. In the United States of America, the front-line of public health initiatives are state and county (local) departments. The United States Public Health Service (PHS) coordinates most of its intervention activities through the Centers for Disease Control and Prevention (CDC) headquartered in Atlanta, Georgia.

In Canada, the Public Health Agency of Canada is responsible for public health, emergency preparedness and response, and infectious and chronic disease control and prevention. The Public Health system in Nigeria is subsumed under the Federal Ministry of Health whose major focus is curative health care instead of preventive health care. It is high time the Federal Government of Nigeria established a Public Health Agency to provide sharper focus and better funding for public health programmes to reduce the unacceptably high number of preventable deaths in the country.

4.     ENVIRONMENTAL HEALTH
Environmental health is the science and art of preventing, controlling and abating physical, chemical, biological, psychosocial//socio-cultural hazards in the environment that may adversely affect public health and the environment. A hazard is any substance, condition or factor that has the potential for adversely affecting public health and the environment. A hazard may be physical, chemical, biological socio-cultural or psycho-social.
Public health is endangered whenever hazards get to man through environmental pathways such as the air we breathe, the water we drink, the food we eat, the house we live in, the soil used for planting, and fomites, contaminated inanimate objects (e.g. disposable gloves and overalls of medical doctors and nurses).
The National Environmental Sanitation Policy (Federal Ministry of Environment-FMENV., 2005) defines Environmental Sanitation, a major component of Environmental Health, as “the principles and practice of effecting healthful and hygienic conditions in the environment to promote public health and welfare, improve quality of life, reduce poverty and ensure a sustainable environment”.
The Policy lists fourteen essential components of Environmental Sanitation as follows:
i.                   Solid Waste Management;
ii.                 Medical Waste Management;
iii.              Excreta and Sewage Management;
iv.              Food Sanitation;
v.                 Sanitary Inspection of Premises;
vi.              Market and Abattoir Sanitation;
vii Adequate Potable Water Supply;
viii. School Sanitation;
ix) Pest and Vector Control;
x)                  Management of Urban Drainages;
xi)              Control of Reared and Stray Animals;
xii)           Disposal of the Dead (man and Animals);
xiii)         Weed and Vegetation Control; and
xiv)         Hygiene Education and Promotion.
The components listed above are all essentially, subspecialty areas of Environmental Health. An experienced, well trained Environmental Health Officer (EHO) is expected to have acquired relevant knowledge, skills and technical know-how to initiate, execute and supervise Environmental Health programmes, activities and interventions in any of the fourteen components of the Policy. It is noteworthy that the Federal Ministry of Environment has also developed Policy Guidelines on Sanitary Inspection of Premises, Excreta and Sewage Management, Market and Abattoir Sanitation, Pest and Vector Control and Solid Waste Management.

5.     PRIMARY HEALTH CARE (PHC)
At an International Conference held at Alma Ata, WHO/UNICEF (1978) defined PHC as “… essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in a spirit of self-determination; it forms an integral part of both the country’s health system of which it is the central function and main focus of the overall social and economic development of the community; it is the first level of contact of the individuals, the family and the community with the national health system, bringing health care as close as possible to where people live and work and constitutes the first element of continuing health care process.’
This comprehensive definition is quite explicit; however, Egwu (2006) has provided other dimensions of PHC in Nigeria. Arising from this definition of PHC are some fundamental principles (National Open University of Nigeria – NOUN, 2008). The principles are:
i.                   Absolute responsibility of the government for the health of the people.
ii.                 The right and duty of people (individual and collectively) to participate in their own health activities.
iii.              Emphasis on preventive measures.
iv.              Equitable distribution and accessibility of health services
v.                 Application of appropriate technology through well-defined health programmes integrated into the national health system.
vi.              The social orientation of health workers of all cadres to serve the people.
vii.            A multi sectoral, multidisciplinary approach.
Under the dynamic leadership of the late Minister of Health, Professor Olikoye Ransome-Kuti, PHC as a strategy of Health for All by the year 2000 reached its zenith with adequate funding and high immunization coverage for the six childhood killer diseases. Nigeria also produced its first National Health Policy (FMOH, 1988). PHC service coverage, accessibility, etc have since nose-dived in many rural communities. Adeyemo (2005) has identified problem areas in PHC implementation in Ife-East Local Government Area, State of Osun.
Primary Health Centres are the last (lowest) level of health care in the Nigerian Health Care System. The next higher level is the Secondary Health Care (General Hospitals) while the apex level is Tertiary Care (Teaching Hospitals, Specialist Hospitals, etc). The National Primary Health Care Development Agency (NPHCDA) set up in 1992 is the apex body for coordinating PHC services in Nigeria. It has six zonal offices and operates in all the 36 states and 774 local governments – in theory. In practice, most rural dwellers do not have access to PHC services and many have no choice but to consult quacks or traditional healers for their urgent health needs (Bakare, 2012).
Components of PHC are:
i.                   Education concerning prevailing health problems and the methods of preventing and controlling them;
ii.                 Promotion of food supply and proper nutrition;
iii.              Adequate supply of safe (potable) water and basic sanitation;
iv.              Maternal and child care including family planning;
v.                 Immunization against the major infectious diseases;
vi.              Prevention and control of locally endemic and epidemic diseases;
vii.            Appropriate treatment of common diseases and injuries;
viii.         Provision of essential drug;
ix.              Community mental health care; and
x.                 Dental (oral) health.

6.     NEXUS OF PRIMARY HEALTH CARE (PHC) AND ENVIRONMENTAL HEALTH (EH).
The rationale for the link between PHC and EH is the fundamental principle and philosophy guiding the training of an Environmental Health Officer: Prevention and Control through Hygienic Practices and application of the Principles of Sanitation.  Hygiene, the science of Health and its maintenance, comprises a system of principles for the preservation of health and the prevention of disease. In practical terms, it comprises personal (individual) and community actions taken to preserve heath and prevent disease. An example is simple hand washing with water and soap after using the toilet. By contrast, Sanitation is the effecting of healthful and hygienic conditions in the environment by using measures such as drainage, ventilation, potable water supply, sewage treatment, medical waste management, air pollution control, etc.
Environmental Health Officers Registration Council of Nigeria – EHORECON (2007) has adopted WHO’s identified functions of Environmental Health Officers. The listed functions are:
i.                   Waste management;
ii.                 Food hygiene and control;
iii.              Pest and vector control;
iv.              Environmental health control of housing and sanitation
v.                 Epidemiological investigation and control;
vi.              Air quality management;
vii.            Occupational health and safety;
viii.         Water resources management and sanitation;
ix.              Noise control;
x.                 Protection of recreational environment;
xi.              Radiation control and health;
xii.            Control of frontiers, air and sea ports and border crossing;
xiii.         Pollution control and abatement;
xiv.         Educational facilities (health promotion and education);
xv.            Promotion and enforcement of environmental health quality and standard ;
xvi.         Collaborative efforts to study the effects of environmental hazards (research);
xvii.       Environmental health impact assessment (EHIA).
This elaborate list of EHO’s functions is quite ambitious and presumes that the current quality of training of EHOs in Nigeria with respect to scientific, technical and professional content, can meet the current complex challenges of Public Health in Nigeria. However, the identified functions above are controvertible evidence that Environmental Health is key to successful PHC services delivery in Nigeria. Furthermore, an EHO’s training stands him/her in good stead to implement health programmes and activities related to components i, ii, iii, v, vi, and x (over 50%) of the PHC components. Indeed, an EHO is a multivalent professional.
7.     CHALLENGES
The Environmental Health profession in Nigeria currently faces some challenges, like many other professions all over the world. Some of the challenges are:
i.                   The profession MUST put its house in order because a house divided against itself cannot stand. Struggle for supremacy must be jettisoned for the profession to grow and earn the respect of other health professions.
ii.                 Efforts should be made to train and retrain EHOs to enhance their skills and promote professional growth in line with global best practices.
iii.              Employment of more qualified EHOs at the Federal, State and Local Government and the private sector should be vigorously pursued by EHORECON.
iv.              A hungry officer is an angry officer. EHORECON should put political pressure on States and Local Governments that fail to pay salaries of EHOs as at when due.
v.                 Local Government authorities should always provide a stand-by waste evacuation vehicle so that solid waste accumulated on Environmental Sanitation days will not be washed back into the drainage system.
vi.              Climate change: Flooding and its serious public health challenges such as cholera, typhoid and other disease epidemics; pneumonia, venomous snake bites, general poor sanitation conditions,  lack of potable water supply, etc cannot be ignored. Environmental Health Officers must liaise with National Emergency Management Agency (NEMA) and relevant State Emergency Management Agency (SEMA) to manage public health emergencies arising from flooding and other natural or man-made disasters.
8.       OPPORTUNITIES
1. About eight Nigerian Universities now offer Public Health/Environmental Health courses at the Bachelor’s degree level. A few others offer Masters while one offers training up to PhD level. EHOs should seize this opportunity to strengthen and enhance their carrier.
2. The National Association should seek linkages with Pan American Health Association, American Public Health Association, Environmental Health Associations in the U.S and elsewhere. Canadian Public Health Association and others for sponsorship of many of your activities including short post graduate courses.
3. Contributions to the new Occupational Health Bill currently being debated in the National Assembly.
9.     CONCLUSION
Environmental Health is a crucial component of Public Health. Functions of an experienced Environmental Health Officer are quite extensive so much so that his role in PHC services is indisputable and indispensible. Environmental Health is indeed the key to effective PHC services delivery.
I thank you for your attention.

REFERENCES
Adeyemo, O.O. (2005). Local Government and Health Care Delivery in Nigeria: A case study”. J. Hum. Ecol., 18(2): 149-160.
Bakare, B. (2012). Improving Primary Health Care. Sunday Punch, Nov. 11, 2012. P 13.
Egwu, I. N. (2006). Primary Health Care System in Nigeria-Theory, Practice and Perspectives. Lagos: Elmore Publishers.
Environmental Health Officers Registration Council of Nigeria-EHORCON (2007). National Guidelines on Environmental Health Practice in Nigeria. FMENV, Abuja. Pp 4-5.
Federal Ministry of Environment-FMENV (2005). National Environmental Sanitation Policy. FMENV., Abuja.
FMENV. (2005). Policy Guidelines on Excreta and Sewage Management. FMENV., Abuja.
FMENV. (2005). Policy Guidelines on Market and Abattoir Sanitation. FMENV., Abuja.
FMENV. (2005). Policy Guidelines on Pest and Vector Control. FMENV., Abuja.
FMENV. (2005). Policy Guidelines on Sanitary Inspection of nPremises. FMENV., Abuja.
FMENV. (2005). Policy Guidelines on Solid Waste Management. FMENV., Abuja.
National Open University of Nigeria-NOUN (2008). Primary Health Care and HIV/AIDS. Pp 1-123.
National Population Commission (NPC) (Nigeria) and ICF Macro (2009). Nigeria demographic and Health Survey, 2008, Abuja, Nigeria. Pp. 21-22.
Olaniran, N.S., Akpan, E.A.; Ikpeme, E.E. and Udofia, G.A. (1995). Environment and Health-Module Eleven. Nigerian Conservation Foundation-NCF. Lagos: Macmillan Nigeria Publishers Limited.
Population Reference Bureau-PRB (2012). 2012 World Population Data Sheet, WashingtonD.C. USA.
Winslow, C.E.A. (1920). The Untitled Fields of Public Health: Science, 51 (1306): 23-33.
World Health Organization (1946). “Preamble to the Constituition of the World Health Organization”.