Chemical and Electrophysiological Characterisation of Headspace Volatiles from Yeasts Attractive to Drosophila suzukii.

Chemical control of Drosophila suzukii (Diptera: Drosophilidae) based on the use of insecticides is particularly challenging as the insect attacks ripening fruits shortly before harvest. An alternative strategy may rely on the use of yeasts as phagostimulants and baits, applied on canopy as attract-and-kill formulations. The aim of this research was to identify the most attractive among six yeast species for D. suzukii: Saccharomyces cerevisiae, Hanseniaspora uvarum, Clavispora santaluciae, Saccharomycopsis vini, Issatchenkia terricola, and Metschnikowia pulcherrima. The volatile profile of C. santaluciae was described for the first time. Behavioural experiments identified H. uvarum and S. vini as the most attractive yeasts. The characterization of yeast headspace volatiles using direct headspace (DHS) and solid-phase microextraction (SPME) revealed several strain-specific compounds. With DHS injection, 19 volatiles were characterised, while SPME revealed 71 compounds constituting the yeast headspace. Both analyses revealed terpenoids including ß-ocimene, citronellol, (Z)-geraniol (nerol), and geranial as distinct constituents of S. vini. H. uvarum and S. vini were further investigated using closed-loop stripping analysis (CSLA) and electroantennography. Out of 14 compounds quantified by CSLA, ethyl acetate, isoamyl acetate, ß-myrcene, benzaldehyde and linalool were detected by D. suzukii antennae and might generate the strong attractiveness of S. vini and H. uvarum. Our results highlight a strong attraction of D. suzukii to various yeasts associated with both the flies and their habitat and demonstrate how different sampling methods can impact the results of volatile compound characterization. It remains to be demonstrated whether the distinct attraction is based on special adaptations to certain yeasts and to what extent the metabolites causing attraction are interchangeable.

A simple and portable method for on-line texture measurement of Italian "Speck Alto Adige".

Texture is a relevant parameter for the assessment of cured ham's quality. In this study a rapid on-line instrumental technique for the measurement of the texture of pieces of cured smoked ham intended for sale as "Speck Alto Adige" PGI was developed. Speck samples were subjected to a compression test using a portable Shore A tester, and instrumental data were compared with conventional texture analyses (texture profile analysis and stress relaxation test) and with sensory evaluations. First, a hardness range in which a threshold value could be identified for the eligibility of 120 speck samples for the "Speck Alto Adige" PGI indication was established; afterwards, a Shore A hardness threshold value of 48 was defined based on measurements of more than 1000 samples. These findings may help manufacturers to determine the textural properties of Speck, based on a simple and rapid instrumental analysis.

Behavioral manipulation of Drosophila suzukii for pest control: high attraction to yeast enhances insecticide efficacy when applied on leaves.

BACKGROUND: The invasive pest, Drosophila suzukii attacks fresh soft-skinned fruit. Broad-spectrum insecticides are implemented for control but there is a need to reduce environmental risks and insecticide residues on fruits. Hanseniaspora uvarum is a yeast frequently found on ripe fruits and associated with D. suzukii. We aim to exploit the ecological association and attraction of D. suzukii to H. uvarum by developing an attract-and-kill strategy, with spray-application on canopy but not fruit. We therefore investigated D. suzukii attraction, egg-laying and mortality when exposed to insecticidal yeast-based formulations. RESULTS: Hanseniaspora uvarum strongly attracted D. suzukii when applied on leaves of grapevine, Vitis vinifera. Notably, this attractiveness was competitive to ripe grape berries that were susceptible to D. suzukii infestation. Moreover, adding H. uvarum enhanced the efficacy of insecticidal formulations against D. suzukii. Flies exposed to leaves treated with yeast-insecticide formulations showed higher mortality and laid a lower number of eggs compared to flies exposed to insecticide alone. In a wind tunnel, all treatments containing H. uvarum alone or in combination with insecticides, caused similar upwind flight and landing at the odor source, which provides evidence that the addition of insecticide did not reduce D. suzukii attraction to yeast. CONCLUSION: Hanseniaspora uvarum can be used to manipulate the behavior of D. suzukii by attracting flies to insecticide formulations. Yeast attraction is competitive to grape berries and improves insecticide effectiveness, suggesting that sprays covering canopy only, could reduce residues on fruit without compromising management efficacy.

Field and greenhouse application of an attract-and-kill formulation based on the yeast Hanseniaspora uvarum and the insecticide spinosad to control Drosophila suzukii in grapes.

BACKGROUND: The invasive insect Drosophila suzukii (Matsumura) is an important pest of several red grape varieties. The yeast Hanseniaspora uvarum (Niehaus), which is associated with D. suzukii, strongly attracts flies and stimulates them to feed on yeast-laden food. In the present study, a formulation based on H. uvarum culture with spinosad insecticide was applied to the foliage of vineyards and control of D. suzukii was compared to applying spinosad to the whole plant. After successful H. uvarum and insecticide application in the vineyard, we tested additional H. uvarum-based formulations with spinosad in a greenhouse to determine their capacity to control D. suzukii. RESULTS: Application of the H. uvarum-spinosad formulation at 36.4 g of spinosad per hectare reduced the D. suzukii field infestation at the same rate as applying 120 g of spinosad per hectare and prevented spinosad residues on grapes. Leaves treated with H. uvarum and spinosad in the field and transferred to a laboratory assay caused high mortality to flies and reduced the number of eggs laid on fruits. Formulations with spinosad applied in the greenhouse showed that both H. uvarum culture and the yeast cell-free supernatant of a centrifuged culture increased fly mortality and reduced the number of eggs laid compared to the unsprayed control. CONCLUSION: In comparison to typical spinosad spray applications, the use of H. uvarum in combination with spinosad as an attract-and-kill formulation against D. suzukii reduces pesticide residues on the fruits by targeting the treatment to the canopy and decreasing the amount of insecticide per hectare without compromising control efficacy.

Effect of Processing and Storage on the Quality of Beetroot and Apple Mixed Juice.

In recent years, there has been a growing interest in the development of health-promoting and disease-preventing functional foods. Beetroot is a promising vegetable because of its outstanding antioxidant activity, vivid colour, and content of bioactive compounds. In the present study, the quality of pure beetroot and apple juices as well as that of their mixture was evaluated by measuring changes of colour, betalain content, and antioxidant activity during processing and storage. No perceivable colour changes of the beetroot juice were observed after adding apple juice up to 85% of the total amount. However, the antioxidant activity was proportionally reduced with the addition of apple juice. Pasteurization negatively affected the content of betalains but did not influence the antioxidant activity. Storage led to colour modifications and reduction of betalains and antioxidant activity. Through preliminary shelf-life studies, a durability of 65 days at room temperature for apple and beetroot juice blends was calculated. The novelty of this study lies in an extended description of physico-chemical characteristics of a fresh apple and beetroot blended juice obtained from local products, in the study of the effects of processing and storage on its quality, and in the estimation of its shelf-life after storage at different temperatures.

Persistence of a Yeast-Based (Hanseniaspora uvarum) Attract-and-Kill Formulation against Drosophila suzukii on Grape Leaves.

The production of phagostimulant and attractive volatile organic compounds (VOCs) by yeasts can be exploited to improve the efficacy of attract-and-kill formulations against the spotted wing drosophila (SWD). This study evaluated the persistence over one week of a yeast-based formulation under greenhouse conditions. Potted grape plants were treated with: (i) potato dextrose broth (PDB), (ii) PDB containing spinosad (PDB + S), and (iii) H. uvarum fermentation broth grown on PDB containing spinosad (H. u. + S). Laboratory trials were performed to determine the survival and the oviposition rate of SWD after exposure to treated leaves. Ion-exchange chromatography was performed to measure carbohydrates, sugar alcohols, and organic acids on leaf surfaces, while amino acids were assessed through liquid chromatography-mass-spectrometry. Additionally, the VOCs released by plants treated with H.uvarum were collected via closed-loop-stripping analysis and compared to those emitted by untreated leaves. A higher mortality was observed for adult SWDs in contact with H. uvarum containing spinosad compared to PDB containing spinosad. Generally, a decrease in the amounts of non-volatile compounds was observed over time, though numerous nutrients were still present one week after treatment. The application of the yeast-based formulation induced the emission of VOCs by the treated leaves. The concentration of 2-phenylethanol, one of the main VOCs emitted by yeasts, decreased over time. These findings describe the presence of potential phagostimulants and compounds attractive to SWD in a yeast-based attract-and-kill formulation and demonstrate the efficacy of the formulation over one week.

Comparative Lipidomics of Different Yeast Species Associated to Drosophila suzukii.

Yeasts constitute a dietary source for the spotted wing drosophila (SWD) and produce compounds that attract these flies. The study of the chemical composition of the yeast communities associated with SWD should therefore help to understand the relationship between the biology of the insect and the yeast's metabolism. In the present study, the lipidome of five yeast species isolated from grapes infested by SWD (three Hanseniaspora uvarum strains, Candida sp., Issatchenkia terricola, Metschnikowia pulcherrima and Saccharomycopsis vini) and a laboratory strain of Saccharomyces cerevisiae was explored using an untargeted approach. Additionally, the lipid profile of two species, S. cerevisiae and H. uvarum, which were reported to elicit different responses on SWD flies based on feeding and behavioral trials, was compared with a chemical enrichment approach. Overall, 171 lipids were annotated. The yeast species could be distinguished from each other based on their lipid profile, except for the three strains of H. uvarum, which were very similar to each other. The chemical enrichment analysis emphasized diversities between S. cerevisiae and H. uvarum, that could not be detected based on their global lipid profile. The information concerning differences between species in their lipidome may be of interest to future entomological studies concerning the yeast-insect interaction and could help to explain the responses of SWD to diverse yeast species.

Impact of Routine Point-of-Care Versus Laboratory Testing for Early Infant Diagnosis of HIV: Results From a Multicountry Stepped-Wedge Cluster-Randomized Controlled Trial.

BACKGROUND: Although the World Health Organization recommends HIV-exposed infants receive a 6-week diagnostic test, few receive results by 12 weeks. Point-of-care (POC) early infant diagnosis (EID) may improve timely diagnosis and treatment. This study assesses the impact of routine POC versus laboratory-based EID on return of results by 12 weeks of age. METHODS: This was a cluster-randomized stepped-wedge trial in Kenya and Zimbabwe. In each country, 18 health facilities were randomly selected for inclusion and randomized to timing of POC implementation. FINDINGS: Nine thousand five hundred thirty-nine infants received tests: 5115 laboratory-based and 4424 POC. In Kenya and Zimbabwe, respectively, caregivers were 1.29 times [95% confidence interval (CI): 1.27 to 1.30, P < 0.001] and 4.56 times (95% CI: 4.50 to 4.60, P < 0.001) more likely to receive EID results by 12 weeks of age with POC versus laboratory-based EID. POC significantly reduced the time between sample collection and return of results to caregiver by an average of 23.03 days (95% CI: 4.85 to 21.21, P < 0.001) in Kenya and 62.37 days (95% CI: 58.94 to 65.80, P < 0.001) in Zimbabwe. For HIV-infected infants, POC significantly increased the percentage initiated on treatment, from 43.2% to 79.6% in Zimbabwe, and resulted in a nonsignificant increase in Kenya from 91.7% to 100%. The introduction of POC EID also significantly reduced the time to antiretroviral therapy initiation by an average of 17.01 days (95% CI: 9.38 to 24.64, P < 0.001) in Kenya and 56.00 days (95% CI: 25.13 to 153.76, P < 0.001) in Zimbabwe. CONCLUSIONS: POC confers significant advantage on the proportion of caregivers receiving timely EID results, and improves time to results receipt and treatment initiation for infected infants. Where laboratory-based EID systems are unable to deliver results to caregivers rapidly, POC should be implemented as part of an integrated testing system.

HIV Mother-to-Child Transmission in Cameroon: EID Positivity Yields and Key Risk Factors by Health Service Points After Usage of POC EID Systems.

BACKGROUND: Most HIV-exposed infants access early infant diagnosis (EID) through the prevention of mother-to-child transmission (PMTCT) service points. However, there are limited data on HIV positivity in non-PMTCT health care settings (pediatric wards, emergency departments, outpatient departments, tuberculosis clinics, etc.). The introduction of point-of-care testing provided an opportunity to describe HIV positivity at alternative health service points and associated risk factors. METHODS: We performed a cross-sectional subanalysis with data from 58 health facilities in Cameroon. The risk of a child being HIV positive at a health service point was considered as a dependent variable, and exploratory variables were assessed using multivariate models with a significance level of 0.05. RESULTS: Overall, 2254 HIV-exposed infants identified by clinical or biological screening were tested by polymerase chain reaction using point-of-care EID. Approximately 74.3% of the infants were tested at a PMTCT entry point, whereas 25.7% were tested at non-PMTCT service points. The positivity yield was 5.7% (95 of the 1674) at the PMTCT service point and 17.6% (102 of the 580) at non-PMTCT service points. Non-PMTCT service points [adjusted odds ratio (aOR): 1.95; 95% confidence interval (CI): 1.36 to 2.80] and vaginal delivery (aOR: 2.56; 95% CI: 1.25 to 5.25) were independently associated with HIV positivity. In a separate analysis (infants aged 0-6 months), mixed feeding mode (aOR: 3.68; 95% CI: 2.00 to 6.77) was also associated with HIV positivity. CONCLUSIONS: More than half of children newly identified as HIV-positive were tested at non-PMTCT service points. The highest EID positivity yields were found in non-PMTCT service points. Strengthening HIV testing in non-PMTCT service points may help to identify additional infected children and improve timely initiation of treatment and care.

Acceptability of Routine Point-of-Care Early Infant Diagnosis in Eight African Countries: Findings From a Qualitative Assessment of Clinical and Laboratory Personnel.

BACKGROUND: The Elizabeth Glaser Pediatric AIDS Foundation introduced point-of-care (POC) testing for early infant diagnosis (EID) of HIV in 8 African countries. Understanding experiences and opinions of users can help facilitate introduction and sustainability. SETTING: Cameroon, Côte d'Ivoire, Eswatini, Kenya, Lesotho, Mozambique, Rwanda, and Zimbabwe. METHODS: Structured interviews with health care workers (HCWs) providing EID services and semistructured interviews with national and regional laboratory managers or EID program managers were conducted before and after the implementation of POC EID. Survey responses were analyzed and compared; open-ended responses were analyzed by theme. RESULTS: In total, 234 and 175 interviews with HCWs and 28 and 14 interviews with laboratory or program managers were conducted before and after the introduction of POC EID, respectively. In preintervention interviews, challenges identified with laboratory-based EID testing included distance from patients' residence to the health facility, time-consuming sample transportation to central laboratories, stockout of testing kits, and long wait times for results. Postintervention data revealed that HCWs found POC EID easy to use and were very satisfied with the fast turnaround time and ability to initiate treatment for HIV-infected infants sooner. Laboratory managers were also supportive of scaling-up POC testing although cautious of the need for reliable infrastructure to operate platforms. The recommendation was that POC EID be integrated within the national diagnostic testing network. CONCLUSIONS: Support for POC EID from key stakeholders is essential for sustainability. Overall, participants supported the rollout of POC testing for EID, noting challenges and opportunities for scaling-up POC EID and recommending integration into the overall EID system.

Evaluation of a routine point-of-care intervention for early infant diagnosis of HIV: an observational study in eight African countries.

BACKGROUND: In 2017, there were 180 000 estimated new HIV infections in children aged 0-14 years. Without early diagnosis and treatment, half of infants with HIV die by age 2 years, with peak mortality around age 8-10 weeks. Conventional early infant diagnosis (EID) systems have not consistently returned results in a timely manner. However, point-of-care (POC) EID devices, which are new to market, could improve outcomes. In December, 2016, POC EID testing was introduced in eight sub-Saharan African countries as part of routine service delivery. We aimed to compare key service delivery and clinical outcomes and costs of POC versus conventional EID. METHODS: In our observational study, we compared service delivery and clinical outcomes in eight countries (Cameroon, Côte d'Ivoire, Kenya, Lesotho, Mozambique, Rwanda, Swaziland, and Zimbabwe), before and after a POC intervention was introduced for EID of HIV. For the baseline, pre-intervention sample, we sampled 30 consecutive tests for HIV-exposed infants who had a documented date of blood collection for EID within Ministry of Health registers in a subset of Elizabeth Glaser Pediatric AIDS Foundation (EGPAF)-supported sites that would be enrolled in POC. For the post-intervention sample, all infants who were tested with POC EID for HIV at an EGPAF site were included in the sample. For both conventional and POC EID testing, we did not specify an age range, but used national EID guidelines for EID eligibility. A range of sites for conventional data collection were selected to represent both primary testing sites (where POC EID instruments would be placed) and spoke sites, rural and urban environment, and high throughput and low throughput sites. In all countries, except Mozambique, we developed a POC EID test request form in conjunction with the Ministry of Health. In Mozambique, EGPAF-trained staff extracted data from health facility registers and other sources using a data collection form. Certain specific indicators were required for all countries, but countries could collect additional variables, as the POC EID test request form was used for patient management for the duration of the project. These forms were filled in by health-care providers at the facility. Once the form was completed it was collected by EGPAF staff and entered into a project-specific database. The cost per test result returned was approximated by use of the Global Fund's total cost of ownership estimates. FINDINGS: Retrospective collection of data on clinical and service delivery outcomes of conventional testing began on Nov 14, 2016, and was completed on Nov 26, 2017, for tests done between March 3, 2014, and March 30, 2017, at 96 health-care facilities using conventional testing. POC tests were done at 339 health-care facilities between Dec 1, 2016, and Dec 31, 2017. We evaluated data from 2875 infants exposed to HIV who were tested with conventional testing methods (2899 tests) and 18 220 infants tested with POC testing (19 071 tests). Several EID outcomes were significantly improved with POC testing relative to conventional testing. The return of results to caregivers within 30 days (in 18 737 [98·3%] of 19 058 infants receiving POC testing vs 542 [18·7%] of 2898 infants receiving conventional testing; p<0·0001), the median time from sample collection to return of results to caregivers (0 vs 55 days; p<0·0001), the number of infants with HIV initiating antiretroviral therapy (ART) within 60 days of sample collection (639 [92·3%] of 692 infants vs 42 [43·3%] of 97 infants; p<0·0001), the median time from sample collection to ART initiation among infants with HIV (0 vs 49 days; p<0·0001), and the median age at ART initiation among infants with HIV who were tested at 6-8 weeks (1·6 vs 3·3 months; p<0·0001) were all improved with POC testing compared with conventional testing. The cost per test result returned within 30 days was less for POC (US$27·24, range 21·39-33·10) than conventional testing ($131·02, 96·26-165·76). INTERPRETATION: POC EID improves the speed of return of HIV test results and enables earlier ART initiation; this approach could potentially reduce morbidity and mortality in infants with HIV. National programmes, funders, and implementing partners should consider POC EID as a preferred testing strategy for implementation. FUNDING: Unitaid.

Exposure of Owned Dogs and Feeding Ticks to Spotted Fever Group Rickettsioses in Central Italy.

Dogs may be useful sentinels for public health monitoring of spotted fever group rickettsioses (SFGR). The aim of this study was to determine the exposure to SFGR among dogs and feeding ticks in central Italy. A total of 344 dogs and 607 adult ticks (395 Rhipicephalus sanguineus and 212 Ixodes ricinus specimens) collected from the coats of sampled animals were included in the study. Canine serum samples were analyzed by indirect fluorescent antibody technique (IFAT) for IgG antibodies against Rickettsia conorii and Rickettsia rickettsii. All the ticks and buffy coats were processed by a PCR targeting a fragment of gltA followed by sequencing. Overall, 56 dogs (16.3%) tested positive for one or both rickettsial antigens by IFAT with endpoint titers ranging from 1:64 to 1:2048; 38 (11%) serum samples reacted against R. conorii, 46 (13.4%) reacted against R. rickettsii, and 28 (8.1%) reacted simultaneously against both rickettsial agents. All buffy coats were PCR negative. Rickettsial DNA was revealed in 39 (18.4%) I. ricinus and in 10 (2.5%) R. sanguineus specimens. The amplicons sequencing showed three SFGR, that is, R. conorii detected in 10 R. sanguineus specimens and Rickettsia helvetica and Rickettsia monacensis detected in 7 and 32 I. ricinus ticks. Nine out of the 10 R. conorii isolates were obtained from ticks collected from seronegative dogs, and one specimen from a dog tested positive for both R. rickettsii and R. conorii by immunofluorescence assay. Among the seven ticks tested positive for R. helvetica, six were recovered from the coats of seronegative dogs and one from a dog having antibodies against R. conorii; the 32 isolates of R. monacensis were obtained from 28 seronegative and 4 R. conorii/R. rickettsii-positive dogs. The results highlight the non-negligible exposure of the canine population to SFGR in the sampled areas.

Hipertireoidismo neonatal / Neonatal hypertireoidism

O hipertireoidismo neonatal é uma condição rara, porém com elevada morbi-mortalidade e com diagnóstico nem sempre claro. Este artigo tem o objetivo revisar as causas, manifestações clínicas, diagnóstico e tratamento das diferentes formas de hipertireoidismo neonatal.

Although neonatal hyperthyroidism is a rare condition, it has high morbidity and mortality rates and a not always easy diagnosis. This article reviews causes, clinical manifestations, diagnosis and treatment of the different forms of neonatal hyperthyroidism.

Manejo dos tumores do estroma gastrointestinal / Management of gastrointestinal strobe tumors

Os tumores estromais gastrointestinais são neoplasias mesenquimais do trato gastrointestinal que expressam a proteína tirosina quinase KIT. Ressecção cirúrgica é o tratamento de primeira linha para GISTs operáveis e localizados, além de contribuir para aumento de sobrevida em metastáticos e recorrentes. Novas linhas de drogas estão surgindo para modificar os padrões clássicos de tratamento.

Gastrointestinal stromal tumors are mesenchymal neoplasms of the gastrointestinal tract that express protein tyrosine kinase KIT. Surgical resection is the first-line treatment for localized and operable GISTs, and contribute to increased survival in metastatic and recurrent disease. New lines of drugs are emerging to modify the classic patterns of treatment.

Comparing academic performance of medical students in distributed learning sites: the McMaster experience.

BACKGROUND: In 2004, the Michael G. DeGroote School of Medicine at McMaster University in Hamilton, Ontario, developed the McMaster Community and Rural Education program (Mac-CARE), to coordinate core rotations for undergraduate and post-graduate medical learners in communities in Southern Ontario. AIMS: The purpose of this study is to compare the academic performance of medical clerks learning at distributed sites to students who remained in Hamilton using four measures of academic performance. METHODS: Progress test, OSCE, clerkship scores, and pre-clerkship tutorial-based evaluations were collected and Mac-CARE students were compared to non-Mac-CARE students on each performance measure using ANOVA. RESULTS: Outcomes are based on the first cohort to engage in Mac-CARE rotations. There were no statistically significant differences in academic performance between the 2 groups before the intervention rotation (pre-clerkship and clerkship evaluations, progress tests, or an inaugural OSCE). Mac-CARE students, however, scored higher on their post-clerkship OSCE than did non-Mac-CARE students. CONCLUSION: This study has shown that academic performance among students was at least comparable across all learning sites. To our knowledge, this is the first such study to be published within a Canadian context.

The risk of enteric diseases in young children and environmental indicators in sentinel areas of Mexico City.

The overall objective of this study is to promote the development of environmental health indicators in Mexico City. Specific examples focused on water quality, household characteristics e.g., sanitation and risk of enteric diseases. A geographic information system (GIS) was used in order to identify eligible wells and their surrounding homesteads (0.5 km around each well). A pilot study was conducted during the rainy season (1999), and a total of 1, 250 eligible households were visited on a random sample basis; only those having children under 5 years of age were interviewed. Data on diarrheal disease (i.e. occurrence in the previous two weeks) were obtained from 950 children, and their guardians provided information on their water supply, sanitation and socioeconomic variables. A total of 320 water samples were obtained from 40 wells, and tested for Total coliforms (TC/100 ml), Fecal coliforms (FC/100 ml). Escherichia coli (EC) and Fecal streptococci (FS). Bacterial indicators were detected in 40% of the wells in the western zone and in 32% of the southern zone (p = 0.01). The rate of diarrheal diseases was higher for children from the southern areas than in the west (OR = 1.7 and 95% CI: 0.99, 2.86). The final analysis showed a higher risk of diarrhea in children from rented homes than those living in owned dwellings (OR = 1.7 and 95% Cl: 1.04, 2.77): the risk was also highest for children living in houses with poor sanitation facilities (e.g., latrine) than those connected to a sewerage (OR = 1.7 and 95% Cl: 1.00, 2.93). Children from households perceiving unpleasant taste of water showed a higher risk than those without complaints (OR = 2.2 and 95% Cl: 1.28, 3.75). Linkages between environmental factors and health risk were created from spatially distributed information, and the proposed environmental health indicator (EHI) summarized the most significant predictors of diarrheal diseases. This baseline information may contribute to further environmental health investigation and policy making analysis.