The ‘diseases of crowds’ experts say could be at the World Cup
In early April, Krutika Kuppalli, MD, gave a presentation on infectious diseases Texas doctors might encounter during the 2026 FIFA World Cup, which takes place tomorrow through July 19 in the United States, Canada, and Mexico.
As co-director for the Texas Department of State Health Services World Cup Infectious Diseases Consultation Hotline, Kuppalli must anticipate which infectious diseases could be at the World Cup.
Kuppalli knew that Dallas was hosting the Argentinian soccer team, so she briefly mentioned the Andes hantavirus. At the time, she had no idea it would soon make headlines for sparking a cruise ship outbreak.
“Hantavirus was on my list of things to think about,” Kuppalli, an associate professor of infectious diseases in the School of Public Health at UT Southwestern, told CIDRAP News. “Would it be on the differential [diagnostic list] if I had a patient from Argentina who was from an area that we know where the vector is found? Yes. But it’s not the most common thing I think about.”
While hantavirus can’t be ruled out as a possibility, she and hundreds of other public health experts from across the United States are bracing for more quotidian illnesses such as flu, COVID-19, chlamydia, and norovirus as more than 6.5 million fans converge on 16 cities —and share pathogens with each other.
Measles a top concern
Forty-eight national soccer teams will compete in 104 games across the 16 cities in 11 metro areas. Atlanta, Boston, Dallas, Houston, Kansas City, Los Angeles, Miami, New York/New Jersey, Philadelphia, Seattle, and the San Francisco Bay Area will host the US games.
Public health professionals in the 11 US host metros have been planning how to protect fans from these diseases during the World Cup. Over the past 18 months, James Garrow, MPH, has been working with colleagues in Philadelphia on how to tackle public health readiness and response during the tournament. In many ways, the health department will do what it usually does.
“Disease surveillance is disease surveillance every day of the week,” Garrow, Philadelphia deputy health commissioner, told CIDRAP News. “What is changing in terms of the World Cup is how intense that disease surveillance is going to look.”
While Garrow worries about heat-related illnesses and air quality, there’s one infectious disease he’s most concerned about. “Measles is probably our top worry,” he said. “We’ve already put out communications to our regional healthcare providers about what to look for.”
With recent outbreaks in the United States, lower vaccination rates, and people traveling, it seems more likely than ever that a fan with measles could be in the stands at the World Cup. This year, stadiums and Fan Festivals packed with cheering people could make it easy for measles to thrive.
“Measles tends to hang around in the air. It’s very small particles and it just floats there for up to two hours after someone with measles has been in the space,” Garrow said. “How many people could potentially have gone through that particular site in two hours after the person left?”
Risk of Ebola very low
Even in years without newsworthy infectious disease outbreaks such as Ebola and Andes hantavirus, public health experts know that infectious diseases flourish in large crowds.
“You have to think of the World Cup as a mass gathering event,” said Amesh Adalja, MD, a senior scholar at the Johns Hopkins Center for Health Security. “It’s going to be diseases of crowds or what we call crowd diseases that spread.”
Infectious diseases that thrive in crowds fall into four categories: respiratory ailments, sexually transmitted infections (STIs), vector-borne infections, and gastrointestinal (GI) illnesses. “We have to think of the gamut of infections,” Kuppalli said.
With the Ebola outbreak in the Democratic Republic of the Congo making headlines, many fans wonder what that might mean for them, but doctors don’t anticipate seeing cases during the World Cup.
“The entire global health community is watching the Ebola outbreak with deep concern,” Rebecca Katz, PhD, MPH, professor and director of the Center for Global Health Science and Security, said. “When we talk about the World Cup, the threat to the general public in North America is really quite low.”
Ebola spreads when people come in contact with bodily fluids, which is why it often infects healthcare workers and people involved in burial rituals. “You could be sitting next to somebody in a stadium, and you’re not going to get Ebola from them,” Katz said.
Gonorrhea, chlamydia ‘will definitely be attending’
Experts expect they’ll see more common types of infections, such as COVID-19 or respiratory syncytial virus (RSV). While most Americans aren’t thinking about flu in the summer, it’s infuenza season in the Southern Hemisphere, meaning teams and fans from that part of the world could arrive with it.
“You can even see outbreaks of flu,” Bernard Camins, MD, professor of infectious diseases at the Icahn School of Medicine at Mount Sinai, said. “Theoretically, [fans] can get on the plane while they’re still not sick and land and be contagious.”
GI infectious diseases such as norovirus often spread during big sporting events, including the 2026 Milan Cortina Winter Olympics in Italy and the 2018 Pyeongchang Winter Olympics in South Korea.
“We know that norovirus can cause pretty substantial outbreaks in mass gathering types of setting,” Adalja said. “It all depends on the environment and how many people are interacting with each other in a way that allows these pathogens to transmit.”
Enjoying food outdoors, such as at a festival, could increase the likelihood of contracting a foodborne illness, as well.
“People in public areas may not have access to hand sanitizers or soap and water as much,” Camins said. “They’re more likely to eat contaminated food or even contaminate themselves by touching surfaces and then eating.”
For many attending the World Cup, it’s a time to celebrate. For some, that might mean having sex, which could increase their risk of contracting an STI.
“Gonorrhea and chlamydia will definitely be attending the World Cup,” Adalja said. “When these mass gathering events occur, there are a lot of people doing different activities, including having multiple sexual encounters.”
People are also more likely to be drinking alcohol and taking drugs, “which then lowers their inhibition, so they’re more likely to contract a sexually transmitted disease,” he added.
Public health practitioners also wonder if they might see arboviruses, which are transmitted by arthropods such as insects. Mosquitos that carry dengue and chikungunya are in some places in the United States, but most cases have been imported, Katz said.
“We now have a lot of people potentially coming into the country from regions of the world experiencing dengue and chikungunya,” she explained. “It’s really important to be monitoring for those arboviruses as well.”
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