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Taylor ML, Kersh GJ, Salzer JS, Jones ES, Binder AM, Armstrong PA, Choudhary SK, Commins GK, Amelio CL, Biggerstaff BJ, Beard CB, Petersen LR, Commins SP. Intrinsic risk factors for alpha-gal syndrome in a case-control study, 2019 to 2020. Ann Allergy Asthma Immunol 2024; 132:759-764.e2. [PMID: 38341029 PMCID: PMC11318600 DOI: 10.1016/j.anai.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Alpha-gal syndrome (AGS) is an allergy to galactose-α-1,3-galactose (alpha-gal), a carbohydrate found in most mammals. Evidence indicates that AGS develops after a tick bite, and in the United States, AGS is most associated with bites from Amblyomma americanum (lone star tick); however, not all persons bitten by ticks develop clinical AGS. OBJECTIVE To investigate intrinsic risk factors associated with the development of AGS. METHODS We performed a case-control study among adults presenting for diagnosis or management of AGS at an allergy clinic in North Carolina during 2019 to 2020 and compared them with controls enrolled from 2 nearby internal medicine clinics. A questionnaire gathered epidemiologic and tick exposure data, and blood was obtained for alpha-gal-specific IgE and other testing. RESULTS The 82 enrolled case patients and 191 controls did not differ significantly by age or sex. Case patients were more likely than controls to have A or O blood types (non B-antigen), have experienced childhood allergies, and have a family history of AGS and other food allergies. Case patients were also more likely to report experiencing long healing times for insect bites or stings and a family history of allergy to stinging or biting insects. CONCLUSION This study suggested that intrinsic factors contribute to risk of developing AGS. Some traits are genetic, but common behaviors among households and family units likely also contribute. Identification of these risk factors can inform personal risk, aid health care providers in understanding susceptible populations, and contribute to ongoing understanding of AGS epidemiology.
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Affiliation(s)
- Marissa L Taylor
- Rickettsial Zoonoses Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Gilbert J Kersh
- Rickettsial Zoonoses Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Johanna S Salzer
- Rickettsial Zoonoses Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Emma S Jones
- Office of the Director, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado
| | - Alison M Binder
- Rickettsial Zoonoses Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Paige A Armstrong
- Rickettsial Zoonoses Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shailesh K Choudhary
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Grace K Commins
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Claire L Amelio
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Brad J Biggerstaff
- Office of the Director, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado
| | - Charles B Beard
- Office of the Director, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado
| | - Lyle R Petersen
- Office of the Director, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado
| | - Scott P Commins
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Miller MJ, Lee P, Lee BG, Flegel WA, West-Mitchell K, Conry-Cantilena K, De Giorgi V. Consideration for alpha-gal syndrome in two critically ill persons with group O blood who received group B plasma. Transfusion 2024; 64:949-951. [PMID: 38566573 PMCID: PMC11104486 DOI: 10.1111/trf.17811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The U.S. Centers for Disease Control and Prevention (CDC) has reported increasing rates of alpha-gal syndrome, an allergic response after meat ingestion (AGS). AGS has been associated with prior exposure to tick bites or other biologics characterized by a life-threatening immunoglobulin E (IgE)-mediated hypersensitivity to galactose-alpha-1,3-galactose (alpha-gal) an oligosaccharide structurally similar to the group B antigen on red blood cells (RBC) found in most non-primate mammalian meat and products derived from these mammals. In 2023, Transfusion reported 3 group O recipients of group B plasma in the Washington, D.C. metropolitan area with no history of meat allergy who had anaphylactic transfusion reactions compatible with AGS. AIMS We investigated allergic reactions in 2 additional patients who received ABO minor-incompatible blood products at 2 hospitals in the D.C. area during fall 2023. METHODS For both patients, a medical chart review was performed and IgE levels to alpha-gal were measured. RESULTS The first patient, a 64-year-old, O-positive patient status post heart transplant with no known allergies, was admitted with acute COVID-19 induced antibody-mediated transplant rejection and placed on extracorporeal membrane oxygenation (ECMO). While undergoing plasma exchange (PLEX) (50% albumin/50% fresh frozen plasma (FFP)), the patient tolerated 2 units of group O FFP and 1 unit of group A FFP before becoming hemodynamically unstable during transfusion of 1 unit of B-positive FFP. PLEX was stopped. The patient later died of sepsis from underlying causes. The second patient, a 57-year-old O-positive man with a history of melanoma and neuro fibromatosis type 1, was undergoing an abdominal resection including transfusion of 3 units of O-positive RBC when he suffered hypotension and ventricular tachycardia requiring intraoperative code after receiving 2 units of group B FFP. Hiveswere noted after resuscitation. The patient had a history of tick bites but no known allergies. He is alive 5 months after the possible allergic event. Both patients had full transfusion reaction evaluations and immunology testing results above the positive cutoff for anti-alpha-gal IgE. DISCUSSION AND CONCLUSION Two patients with O-positive blood and no known allergies experience danaphyl axis after transfusion with group B FFP. The symptoms cannot definitively be imputed to an allergic transfusion reaction, but the presence of IgE against alpha-gal supports an association. Medicating patients with antihistamines and IV steroids pre-transfusion may prevent allergic reactions. Restricting group B plasma-containing products (plasma, platelets, cryoprecipitate) for patients who experience AGS-like symptoms may be considered.
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Affiliation(s)
- Maureen J. Miller
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Patricia Lee
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Brian G. Lee
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Willy A. Flegel
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- Department of Pathology, Georgetown University Medical Center, Washington, DC, USA
| | - Kamille West-Mitchell
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Kathleen Conry-Cantilena
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Valeria De Giorgi
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
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3
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Edlow JA. Alpha-Gal Syndrome: A Novel and Increasingly Common Cause of Anaphylaxis. Ann Emerg Med 2024; 83:380-384. [PMID: 37831041 DOI: 10.1016/j.annemergmed.2023.08.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/14/2023]
Abstract
The alpha-gal syndrome is a recently described cause of anaphylaxis to red meat that has been increasing in frequency over time. It is related to Lone Star tick bites in the United States and occurs in many other parts of the world. It is especially common in the southeastern United States. In addition to the usual symptoms of anaphylaxis, gastrointestinal symptoms are prominent. Another unusual feature is the delay of several hours between eating meat and the development of symptoms. Diagnosis can be made by a blood test for the immunoglobulin E antibodies to a specific oligosaccharide. As many as 10% of patients diagnosed with idiopathic anaphylaxis have alpha-gal syndrome in some parts of the United States. The only current treatment is a meat-free diet. Clinician awareness of alpha-gal syndrome is low, and because severe recurrent life-threatening episodes can occur, it is an important condition for emergency clinicians to be aware of.
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical School, Boston, MA; Emergency Medicine, Harvard Medical School, Boston, MA.
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Perusko M, Grundström J, Eldh M, Hamsten C, Apostolovic D, van Hage M. The α-Gal epitope - the cause of a global allergic disease. Front Immunol 2024; 15:1335911. [PMID: 38318181 PMCID: PMC10838981 DOI: 10.3389/fimmu.2024.1335911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/02/2024] [Indexed: 02/07/2024] Open
Abstract
The galactose-α-1,3-galactose (α-Gal) epitope is the cause of a global allergic disease, the α-Gal syndrome (AGS). It is a severe form of allergy to food and products of mammalian origin where IgE against the mammalian carbohydrate, α-Gal, is the cause of the allergic reactions. Allergic reactions triggered by parenterally administered α-Gal sources appear immediately, but those triggered via the oral route appear with a latency of several hours. The α-Gal epitope is highly immunogenic to humans, apes and old-world monkeys, all of which produce anti-α-Gal antibodies of the IgM, IgA and IgG subclasses. Strong evidence suggests that in susceptible individuals, class switch to IgE occurs after several tick bites. In this review, we discuss the strong immunogenic role of the α-Gal epitope and its structural resemblance to the blood type B antigen. We emphasize the broad abundance of α-Gal in different foods and pharmaceuticals and the allergenicity of various α-Gal containing molecules. We give an overview of the association of tick bites with the development of AGS and describe innate and adaptive immune response to tick saliva that possibly leads to sensitization to α-Gal. We further discuss a currently favored hypothesis explaining the mechanisms of the delayed effector phase of the allergic reaction to α-Gal. We highlight AGS from a clinical point of view. We review the different clinical manifestations of the disease and the prevalence of sensitization to α-Gal and AGS. The usefulness of various diagnostic tests is discussed. Finally, we provide different aspects of the management of AGS. With climate change and global warming, the tick density is increasing, and their geographic range is expanding. Thus, more people will be affected by AGS which requires more knowledge of the disease.
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Affiliation(s)
- Marija Perusko
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Innovative Centre of the Faculty of Chemistry, University of Belgrade, Belgrade, Serbia
| | - Jeanette Grundström
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Maria Eldh
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Carl Hamsten
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Danijela Apostolovic
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marianne van Hage
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
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5
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Vaz-Rodrigues R, Feo Brito F, Guzmán Rodríguez R, Mazuecos L, de la Fuente J. Allergic reactions associated with medically relevant arthropods. Ann Med 2023; 55:2286531. [PMID: 38010429 PMCID: PMC10836243 DOI: 10.1080/07853890.2023.2286531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/16/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE Vector-borne diseases are a growing burden worldwide. In particular, the risks of allergic reactions to bites are associated with growing arthropod populations in contact with the public. The diversity of allergic reactions associated with host and arthropod factors difficult disease diagnosis, prognosis and prevention. Therefore, arthropod-associated allergies are underdiagnosed and require better surveillance of arthropod populations and disease diagnosis and management. METHODS To face these challenges, in this study, we describe five cases to illustrate arthropod-associated allergies with different symptomatology, including alpha-gal syndrome (AGS) associated with anti-alpha-gal IgE antibody titres. Information on symptoms in response to arthropod bites was collected from patients and medical doctors. RESULTS The five cases included patients bitten by a robber fly and different tick species. Cases were in Spain or U.S.A. Two cases were diagnosed with AGS and one case was diagnosed with anaphylaxis in response to tick bite with high anti-alpha-gal IgE levels. The symptoms in response to arthropod bites vary between different cases. CONCLUSION Allergic reactions and symptoms in response to arthropod bites vary in association with host and arthropod factors. Herein we propose recommendations to control allergic symptoms, associated disease risk factors and the way forward to advance in the prevention and control of arthropod-associated allergies.
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Affiliation(s)
- Rita Vaz-Rodrigues
- SaBio, Instituto de Investigación en Recursos Cinegéticos IREC-CSIC-UCLM-JCCM, Ciudad Real, Spain
| | - Francisco Feo Brito
- Medicine School, Universidad de Castilla la Mancha (UCLM), Ciudad Real, Spain
| | | | - Lorena Mazuecos
- SaBio, Instituto de Investigación en Recursos Cinegéticos IREC-CSIC-UCLM-JCCM, Ciudad Real, Spain
| | - José de la Fuente
- SaBio, Instituto de Investigación en Recursos Cinegéticos IREC-CSIC-UCLM-JCCM, Ciudad Real, Spain
- Department of Veterinary Pathobiology, Center for Veterinary Health Sciences, OK State University, Stillwater, OK, USA
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de la Fuente J, Estrada-Peña A, Rafael M, Almazán C, Bermúdez S, Abdelbaset AE, Kasaija PD, Kabi F, Akande FA, Ajagbe DO, Bamgbose T, Ghosh S, Palavesam A, Hamid PH, Oskam CL, Egan SL, Duarte-Barbosa A, Hekimoğlu O, Szabó MPJ, Labruna MB, Dahal A. Perception of Ticks and Tick-Borne Diseases Worldwide. Pathogens 2023; 12:1258. [PMID: 37887774 PMCID: PMC10610181 DOI: 10.3390/pathogens12101258] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
In this comprehensive review study, we addressed the challenge posed by ticks and tick-borne diseases (TBDs) with growing incidence affecting human and animal health worldwide. Data and perspectives were collected from different countries and regions worldwide, including America, Europe, Africa, Asia, and Oceania. The results updated the current situation with ticks and TBD and how it is perceived by society with information bias and gaps. The study reinforces the importance of multidisciplinary and international collaborations to advance in the surveillance, communication and proposed future directions to address these challenges.
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Affiliation(s)
- José de la Fuente
- SaBio, Instituto de Investigación en Recursos Cinegéticos, IREC-CSIC-UCLM-JCCM, Ronda de Toledo 12, 13005 Ciudad Real, Spain;
- Department of Veterinary Pathobiology, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK 74078, USA
| | - Agustín Estrada-Peña
- Department of Animal Health, Faculty of Veterinary Medicine, University of Zaragoza, 50013 Zaragoza, Spain
- Research Group in Emerging Zoonoses, Instituto Agroalimentario de Aragón-IA2, Universidad de Zaragoza-CITA, 50013 Zaragoza, Spain
| | - Marta Rafael
- SaBio, Instituto de Investigación en Recursos Cinegéticos, IREC-CSIC-UCLM-JCCM, Ronda de Toledo 12, 13005 Ciudad Real, Spain;
| | - Consuelo Almazán
- Facultad de Ciencias Naturales, Universidad Autonóma de Querétaro, Avenida de las Ciencias S/N Juriquilla, Querétaro 76230, Mexico;
| | - Sergio Bermúdez
- Medical Entomology Research Department, Gorgas Memorial Institute for Health Research, Panama City 0816-02593, Panama;
| | - Abdelbaset E. Abdelbaset
- Laboratory of Parasitology, Graduate School of Infectious Diseases, Faculty of Veterinary Medicine, Hokkaido University, Kita-18, Nishi-9, Sapporo 060-0818, Hokkaido, Japan;
| | - Paul D. Kasaija
- National Livestock Resources Research Institute (NaLIRRI/NARO), Kampala P.O. Box 5704, Uganda; (P.D.K.); (F.K.)
| | - Fredrick Kabi
- National Livestock Resources Research Institute (NaLIRRI/NARO), Kampala P.O. Box 5704, Uganda; (P.D.K.); (F.K.)
| | - Foluke Adedayo Akande
- Department of Veterinary Parasitology and Entomology, College of Veterinary Medicine, Federal University of Agriculture, Abeokuta 111101, Ogun State, Nigeria;
| | - Dorcas Oluwakemi Ajagbe
- Department of Pure and Applied Zoology, College of Biological Sciences, Federal University of Agriculture, Abeokuta 111101, Ogun State, Nigeria;
| | - Timothy Bamgbose
- Department of Biological Sciences, Microbiology Unit, Faculty of Science, Kings University, Ode-Omu City 221102, Osun State, Nigeria;
| | - Srikant Ghosh
- Entomology Laboratory, Indian Veterinary Research Institute, Izatnagar, Bareilly 243122, Uttar Pradesh, India;
- IVRI-Eastern Regional Station, 37, Belgachia Road, Kolkata 700037, West Bengal, India
| | - Azhahianambi Palavesam
- Translational Research Platform for Veterinary Biologicals, Centre for Animal Health Studies, Tamil Nadu Veterinary and Animal Sciences University, Chennai 600051, Tamil Nadu, India;
| | - Penny H. Hamid
- Department of Animal Science, Universitas Sebelas Maret, Surakarta 57126, Indonesia;
| | - Charlotte L. Oskam
- School of Medical, Molecular and Forensic Sciences, Murdoch University, Perth, WA 6150, Australia; (C.L.O.); (S.L.E.)
- Centre for One Health and Biosecurity, Harry Butler Institute, Murdoch University, Perth, WA 6150, Australia;
| | - Siobhon L. Egan
- School of Medical, Molecular and Forensic Sciences, Murdoch University, Perth, WA 6150, Australia; (C.L.O.); (S.L.E.)
- Centre for One Health and Biosecurity, Harry Butler Institute, Murdoch University, Perth, WA 6150, Australia;
| | - Amanda Duarte-Barbosa
- Centre for One Health and Biosecurity, Harry Butler Institute, Murdoch University, Perth, WA 6150, Australia;
- School of Veterinary Medicine, Murdoch University, Perth, WA 6150, Australia
| | - Olcay Hekimoğlu
- Division of Ecology, Faculty of Science, Hacettepe University, Beytepe, Ankara 06800, Turkey;
| | - Matias P. J. Szabó
- Laboratório de Ixodologia, Faculdade de Medicina Veterinária, Universidade Federal de Uberlândia, Av. Pará, 1720/Campus Umuarama-Bloco 2T, Uberlândia 38400-902, Brazil;
| | - Marcelo B. Labruna
- Faculty of Veterinary Medicine and Animal Science, University of São Paulo, Sao Paulo 05508-220, Brazil;
| | - Ananta Dahal
- Department of Microbiology and Parasitology, Faculty of Animal Science, Veterinary Science and Fisheries, Agriculture and Forestry University, Chitwan 44200, Nepal;
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Tanne JH. US doctors are told to look for emerging, potentially life threatening allergic tickborne disease. BMJ 2023; 382:p1775. [PMID: 37527842 DOI: 10.1136/bmj.p1775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
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Thompson JM, Carpenter A, Kersh GJ, Wachs T, Commins SP, Salzer JS. Geographic Distribution of Suspected Alpha-gal Syndrome Cases - United States, January 2017-December 2022. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2023; 72:815-820. [PMID: 37498787 PMCID: PMC10390090 DOI: 10.15585/mmwr.mm7230a2] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Alpha-gal syndrome (AGS) is an emerging, tick bite-associated allergic condition characterized by a potentially life-threatening immunoglobulin E (IgE)-mediated hypersensitivity to galactose-alpha-1,3-galactose (alpha-gal), an oligosaccharide found in most nonprimate mammalian meat and products derived from these mammals. Specific symptoms and severity of AGS vary among persons, and no treatment or cure is currently available. During 2010-2018, more than 34,000 suspected cases of AGS were identified in the United States, but current knowledge of where cases occur is limited. This study examined alpha-gal-specific IgE (sIgE) antibody testing results submitted to the commercial laboratory responsible for nearly all testing in the United States before 2022 to assess the geographic distribution and magnitude of this emerging condition. During January 1, 2017-December 31, 2022, a total of 357,119 tests were submitted from residences in the United States, corresponding to 295,400 persons. Overall, 90,018 (30.5%) persons received a positive test result in the study period, and the number of persons with positive test results increased from 13,371 in 2017 to 18,885 in 2021. Among 233,521 persons for whom geographic data were available, suspected cases predominantly occurred in counties within the southern, midwestern, and mid-Atlantic U.S. Census Bureau regions. These data highlight the evolving emergence of AGS and can be used to help state and local health agencies initiate surveillance and target public health outreach and health care provider education to high-risk localities.
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