Travel, Triage and Transmission: U.S. Healthcare and the 2026 World Cup

Hello and welcome to Transmission Interrupted.

My name is Jill Morgan.

I'm a nurse here at Emory University Hospital, and for those of you not yet

familiar with NETEC, our mission is to set the gold standard for special pathogens

preparedness and response across health systems in the U.S. with the goals of

driving best practices, closing knowledge gaps, and developing innovative resources.

NETEC works alongside and in cooperation with the CDC and is

funded by ASPR, the Administration for Strategic Preparedness and Response.

I am excited to talk to Dr. Alex Isakov today.

Alex joins me from here in Atlanta.

He is the medical director of the Emory Grady EMS Biosafety Transport Program.

He's also a Division Chief of Pre-Hospital and Disaster Medicine and

the Co-Lead of NETEC's EMS work group.

I think for today's topic we're gonna be talking about World Cup prep and there

has been nobody that I know of that's more embedded in this, than you Alex.

So welcome and I'm looking forward to hearing more about everything having

to do with World Cup and the worries of healthcare and healthcare workers.

Well, thanks for having me, Jill.

It's always great to get on Transmission Interrupted.

So let's start with a little bit about, like, this planning

has been going on now for literally years, and what is your place in that

planning, just as a quick overview?

I'm a frontline healthcare worker, as an emergency medicine

physician at Emory University Hospital.

And I run a division of physicians that focus on pre-hospital care.

And so because Atlanta is a host city our team has been working to

ready agencies for a large number of visitors coming to Atlanta.

And then, as you know, like you, I'm also active in the special pathogens community.

So,I also think it's important that our front line healthcare personnel,

whether they be first responders or first receivers, are best prepared

to manage a patient so that they can make best decisions for the

patient, but also good decisions about protections that are necessary.

Caring for them safely and preventing transmission to others.

I participate in Atlanta's host city medical committee and, you know, this

is among the things that have been considered in advance of World Cup.

How is World Cup prep different than anything else that

brings a lot of visitors to the city?

There are a few things that distinguish it, Jill.

I think the first is the duration of the games in any particular host city.

In Atlanta, for example, they will be host to eight of the matches.

If you look across the United States.

There are eleven host cities in the U.S. There are a total of

16 host cities in North America.

And there are 48 teams and their fans coming to North America to play matches

over the course of a month to six weeks, and it will be in the middle of summer.

It will be different than any other type of event that we've hosted here,

because the duration of the World Cup for over one month between June and July.

And it'll bring more visitors from different parts of the world to all of our

host cities than we might otherwise have had for a Super Bowl or a World Series

or other types of mass gathering events that cities are ready to respond to.

Yes, because it seems like most of the things that any big city might

prepare for like a sporting event or huge concerts and things like that, I can't

imagine even, you know, like following Taylor Swift around as its own, I'm

sure, mass casualty sort of prep thing.

But, you know, you think about those being largely U.S. based people.

You might get an influx of people, but they're largely

coming from the United States.

And I can't imagine how difficult it is to do this prep when right

up until the end you're not even sure which countries are coming.

I mean, is it decided even yet exactly who will be here?

They have 48 teams that are qualified from all over the world, and

of course the host cities are identified.

Now there are team home base cities that I think have yet to be finalized.

They know which 48 teams are coming, but the fan base may go beyond the

48 countries that are represented.

Sure.

and those 48 countries, some of them, I'm sure all of them, we

all have our own flu season.

We all have our own strains of things.

And then there are some countries that have some endemic diseases

that I know are of a concern to us.

Yeah, that's right.

You know, this is part of what makes World Cup unique in that regard is

that you'll have visitors from all over the world coming to eleven different

cities in the United States, and you're right, where there's different endemic

diseases in these various countries.

And the American healthcare enterprise knows how to assess patients, and does a

very good job at managing their illness all the way through severe critical care.

Frontline healthcare personnel, they do this in the United States every day,

but they have an increased likelihood of encountering, diseases that they

wouldn't routinely see because of the large number of international visitors

that'll be coming, to the United States.

Even if we pick one that's non-communicable, Jill, like malaria,

we're all trained as frontline healthcare personnel to consider malaria on

our differential diagnosis when we have somebody with a travel history,

and fever, and constitutional signs or symptoms, and it's important to

consider malaria in patients with a travel history, especially as they're

coming from a malaria-endemic area.

Because, if you miss that diagnosis, for some patients it

can have serious consequences.

And so, being in a World Cup host city, or in a city that will attract

visitors from around the globe, it's important to increase your vigilance

for those types of illnesses that you might not routinely see day-to-day..

Yeah.

I think about even some of the other ones, you mentioned malaria, doesn't

have person to person spread.

Dengue, yellow fever, even some of the other ones that I think

we think of as Caribbean, like Chikungunya and things like that.

We have the mosquitoes to transmit an awful lot of things here, even if we

don't typically have those pathogens.

And I guess, if you're coming a really long way to a host country and to a host

city, I'm willing to bet that some of the people coming also may travel to

other places that have nothing to do with World Cup, like our national parks.

Like, Disney World and Disneyland and, you know, the Grand Canyon.

So there isn't a place in the country that really is excluded from needing

to think about the concept of travel, and symptoms, and keeping our eye out.

You're right on target that the people that are visiting the United

States, Canada, and Mexico, for World Cup, are not going to limit themselves to

the host cities where the stadiums are.

This is something that while you may have a concentration of people in

those host cities, there'll be people that'll be traveling all over the

United States who've come, to the U.S. Because of World Cup, but are not gonna

limit themselves to that geography.

So, everyone has to be a little bit more vigilant.

I wanna pivot for just a second, because normally, of course,

we're talking about transmissible diseases here and infectious diseases,

but there are a lot of other things that I think could cripple a healthcare

system if we had some other things that can happen during these large events.

Some of those, of course, Atlanta is very familiar with the Olympic Park

bombing,s I mean, that's still way too fresh in many minds here in Atlanta.

But also, I think just what happens when you get lots of people together.

We have people coming from the southern hemisphere where it's flu season.

We have people coming with their own pathogens from wherever, but also

enthusiastic fans, and fireworks, and just the kind of rivalry stuff that we

would worry about with other injuries.

And I just wonder, what does this look like in other world Cup events?

I'm gonna separate Qatar because I know that was a completely dry

World Cup and probably a little different than perhaps typical of

fan activities and things like that.

I think all World Cups are different in many ways, Jill.

In the way that you say Qatar was unique, if you were hosting World

infrastructure there, it's just distinct from what it is in the United States.

And so every World Cup host country is going to have unique,

elements that need to be managed.

But there are also things that are common, like what we're talking about

here as it relates to communicable and non-communicable diseases, and readying

the health system and the public health enterprise to Be ready to detect those

illnesses and to respond if needed, not just to clinically manage a patient, but

if there's need to isolate someone with a communicable disease or conduct a case

investigation and subsequent contact tracing, that those measures are in place.

You mentioned some issues as it related to security concerns, risk for violence,

risk for injury, consequences from alcohol consumption, and that's all real

and needs to be anticipated as well.

There's not a tremendous amount of data that's been available for us to

review as it relates to increased demand for health services during World Cup.

So there's some planning assumptions that have been made to anticipate

increased numbers of people seeking care.

I think for us in the United States, and because of the time of year that

we're hosting the games, I think heat injury is something that we

really should be on the lookout for and have mitigation plans in place.

And maybe review protocols among first responders and first receivers about how

to manage the most serious consequences of heat injury, heat stroke for example.

I think that would be worthwhile.

In terms of consequences of alcohol consumption or violence, most

U.S. cities are prepared to manage patients with trauma and intoxication.

We have robust health systems in all the U.S. host cities that

should be able to manage that.

If we start to consider issues around mass casualty management that will challenge

really any city, but it'll be important then for first responders to have their

patient triage guidelines top of mind.

Reminded how to perform lifesaving interventions for patients in the

field that need them and then look at their patient distribution plans.

And also recognize that in the history of mass casualty incidents there's always a

large proportion of people that self-refer to the nearest hospital for care, and so

that's all part of the consideration for hosting mass gathering events as well, and

cities take measures to prepare for that.

I'm wondering about some of the details of that.

I think this idea of moving people around, like if need be.

Certainly hospitals outside of Atlanta or outside of any of the

host cities would then be responding.

And I assume that essentially the conops that you might have in place

for other things really get brought to bear with these kind of situations

where if you need to offload patients somewhere else, EMS becomes just this

incredibly strong network of agencies that can respond and move people around.

It sounds like it would be a logistical, I mean, I'm grateful that there are

people who are focused on just those logistics because I think to the rest of

us, that sounds like just a nightmare.

I think it'll be challenging for any US community, depending on the

number of casualties and the nature of the injuries that they need to manage.

That's not an easy day for anyone if you have a large number of

casualties that need management.

You're right, the EMS community have a role in trying to mitigate

the challenges, the consequences of that type of an incident, and there

are frameworks that help to have those procedures Better, placed.

Like the healthcare coalitions that are funded by the federal government through

the HPP or Hospital Preparedness Program, contribute to a community's readiness

and engagement of health systems.

This concept of medical operations coordination, to try and redistribute

patients to where the resources are and away from health systems that

are operating under surge conditions is an important concept to try and

get best outcomes for patients.

We know that health systems operating under surge conditions, there's a greater

likelihood of having bad outcomes in health systems that are operating

beyond capacity, so that those load balancing techniques are important.

But bringing it back to infectious and communicable diseases, Jill.

For the Transmission Interrupted crowd.

I think podcasts like this are important to increase awareness about some of

those illnesses that we talked about that we don't more routinely see, which

is one of the risks of having a large number of international travelers come.

And you'd mentioned a number of them.

We talked about malaria, we talked about dengue, I mentioned

c hikungunya as an example.

Then there are also illnesses that are just perhaps more impactful

because of the concentration of people that you have in places.

And so, while they may not seem that exotic, they certainly can be disruptive.

And when we think about norovirus and the importance of safe food and safe

water, and how disruptive a neurovirus outbreak can be, and how important it

will be to have cleaning and disinfection protocols in place, and isolation

recommendations in place to mitigate that.

And we rely heavily on our public health partners for that type of guidance.

Also as you'd mentioned, there are people coming from the southern

hemisphere where flu season is active.

And so, in close quarters you're more likely to have transmission of

respiratory illnesses, and that can include influenza and it can include

COVID-19, and we can't say measles is eradicated in the United States anymore.

And so, there's risk whether they're travelers from a neighboring state

or travelers from another country.

If they have been in infected with the virus that causes measles, then

they're at risk for transmitting.

It's the most contagious disease that we know, and so when you have people at mass

gathering events in close quarters, and here in Atlanta, Mercedes-Benz Stadium,

that's an example, is an indoor venue.

But it's not just the stadiums, it's going to local restaurants, and going

to bars, and going to other places where if you have measles, you can

increase the likelihood of transmission.

And so that's something for us to consider.

Absolutely.

So along those lines, Alex, and I guess just thinking about sort of, to wrap

this up with some good advice from you.

I know that you have done a fair amount of traveling for this preparation.

What's your advice to travelers?

Whether they're traveling for the World Cup or whether they happen

to be traveling when everybody else is traveling around the country, or

internationally, during this event.

Do you feel like people should take more precautions or be extra careful?

Whether that's masking or hand hygiene, or what do you suggest?

Probably a few things.

One, for vaccine preventable diseases, try to be vaccinated.

I think that's good advice for all of us day to day.

Certainly good advice for people that routinely go into areas where

you're in close quarters with others.

I think it's especially important if you have some underlying medical

conditions that would put you at risk for more serious illness, even for

influenza, because of age or some other underlying medical conditions.

So, get vaccinated for vaccine preventable diseases is one

great way to prevent transmission of infection and consequences.

I think the second is that if you are ill don't go to crowded

rooms and mass gathering events.

If you have a fever and a cough then you should just stay home until

those symptoms improve and you can look to the public health authority

about guidance when you're less likely to be shedding the virus or

whatever it else that made you ill.

People come to enjoy the games and they're going to wanna participate

in all the social engagement, whether it's in the stadium or outside.

If you're sick, probably stay home until you feel better.

If you do have underlying medical conditions then I think you have to

also just follow the advice of your doctor about the wisdom of going into

a crowded space where the likelihood of illness transmission is higher.

Those are broad and general recommendations.

I think if you have hand sanitizer available, always good

to exercise good hand hygiene.

I won't go as far as to say you should wear a procedural mask

going into a mass gathering event.

I think that's a personal choice for many.

I think it's a great answer and I think you're absolutely right.

Vaccine preventable.

Get vaccinated.

Absolutely number one.

And I think hand hygiene, the number of times we touch our face,

the number of times we touch other things and then touch our face.

The odds of probably getting a direct inoculation from another human, of

course, they're gonna go up in a confined space, in closed quarters.

But even if you're out in open air stadiums or traveling, or in streets

and restaurants that are open.

You're still touching things, and then unfortunately what we do is

we shove these pathogens right into our own nose, mouths and eyes, and

that's probably just as responsible as anything else for how we get sick.

So, it's a great warning to remember your hand hygiene.

Take some hand sanitizer with you, and then at least wash your hands

please, when given the opportunity.

Yeah, I think that's right.

You know another thing we haven't talked about, but I think it's

important in readiness for mass gathering events and for FIFA World

You can learn more about that at NETEC.org.

But I think it's important for all of us as frontline healthcare providers to be

familiar with illnesses that are among those that the public health department

wanna know about, the reportable diseases.

So we wanna be able to identify them.

We also wanna be able to identify illnesses that would pose a risk

to other patients, or to us as healthcare personnel, as clinicians

or to visitors and bystanders.

And so going back to the discussion around measles would be a good example of that.

We want to be able to identify a case of measles as a frontline healthcare

provider, In addition to other illnesses, so that we can take steps

to properly isolate that patient and apply an appropriate hierarchy

of controls and personal protective equipment for our own safety.

And then alert the public health authority that we have a case of suspected measles.

They wanna know about that.

On this show, Jill, we often talk about Ebola Virus Disease.

Marburg Virus Disease, Middle East Respiratory Syndrome, all

high-consequence infectious diseases.

But really, while it's important for us to be ready for them, we're far

less likely to encounter a patient with one of those HCID's than we would

be a case of measles, and so it's important for us to just be reminded.

That's a great reminder, and I will say, in adult medicine, adult

emergency medicine, we may not be used to asking a vaccination history, right?

Because unless somebody's got an injury for which they might need a

tetanus shot, we kind of can skip over vaccination sometimes, and we're

more likely to ask that of children.

But we have a lot of adults around the world who might be un, or under

vaccinated, and not immune to measles.

And so it becomes something that we have to keep in a list of things that

we're at least considering for them.

Yeah.

Just increased awareness about that and travel history.

Dengue, for example, It's a vector-borne disease.

So, if we miss warning signs of a patient that presents with dengue, or maybe didn't

even consider it in our differential because we didn't consider that the

patient recently traveled, even from a place like Puerto Rico or the USVI, we

may miss an opportunity to intervene early and get a better result for the patient.

Absolutely.

Absolutely.

Alright, well, Alex is there something else you definitely want to get across?

Otherwise I will thank you and we'll wrap this up.

I'll underscore a few of the things that we talked about before.

I think Getting vaccinated against vaccine preventable diseases is important for

all of us as healthcare professionals, but just in the general population for

our own safety, safety of our kids, safety of our friends and neighbors, and

those that may have underlying medical conditions that may get a lot sicker.

Two, I think Identify, Isolate, Inform is a great tool for frontline healthcare

personnel to recognize illnesses that pose a risk to them, not just the patient,

but to the healthcare provider, other patients, the visitors, and bystanders.

And then the third is there's probably some value in reviewing some of these

non-communicable diseases just to increase your awareness and your being alert to

them as a frontline healthcare provider.

And that includes things like  chikungunya and dengue as examples, or malaria so

you're better ready to recognize them.

I think we should all be prepared to have a great summer, and enjoy

the World Cup in North America.

I know I'm really excited about World Cup.

I've gotten more excited over this spring.

I think it's gonna be fun.

I'm looking forward to it and I'm also hoping that everyone will remain well.

So, thanks, Alex.

It's been a pleasure to talk to you.

We're gonna be doing several episodes about World Cup prep

and things that people should be concerned about or looking out for.

So I really appreciate you kicking this off with some very

reasonable, doable warnings.

Like if you can get vaccinated against it, go ahead.

Absolutely.

And you know, don't forget to have fun.

That's right.

That's right.

Well thank you so much.

We really appreciate all of you joining us today for another

episode of Transmission Interrupted.

We hope you'll join us for future episodes on this and a wide range of

other topics from healthcare worker safety to personal protective equipment

and infectious diseases of all kinds.

If you have any questions for NETEC or ideas for future shows, please feel

free to contact us at info@netec.org.

That's info@netec.org.

You can also find us on the web at NETEC.org/podcast where you can

also subscribe to future episodes.

So, thank you all for joining us and we'll see you next time

on Transmission Interrupted.