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LOS ANGELES, When the United States, Canada and Mexico formally submitted their co-hosting bid to soccer governing body FIFA in 2018, they touted the safety of the region, noting “no major endemic infectious diseases across any of our Host Countries.”

Now, as the three countries prepare to welcome one of the largest international gatherings around the globe since the Covid-19 pandemic, infectious diseases are front of mind.

Of particular concern is an outbreak of Ebola that is ravaging parts of the Democratic Republic of Congo, whose team is scheduled to play matches in Houston, Atlanta and Guadalajara. Officials are also monitoring threats from hantavirus, a rare but serious infection that recently broke out on a cruise ship full of international travelers.

“We’re going to have people from all over the world coming into the city, into the county, for these games, and that’s great,” said Anish Mahajan, the deputy health director in Los Angeles County, which is introducing wastewater surveillance at a large sporting event for the first time. “But that’s a massive risk for various infections.”

The United States’ vast and fractured public health system is prepared to respond. The Centers for Disease Control and Prevention has taken on a high-level role gathering and reporting outbreak data, sharing guidance on testing and reporting symptoms. In recent weeks, CDC officials have convened weekly calls with public health offices in the 11 U.S. host cities and dispatched staff to assist them in person. Doctors nationwide are participating in simulations that anticipate the worst.

Those state, county and city health departments face a tricky challenge as they gird for Ebola: promoting tools and strategies forged through the response to Covid but without the pandemic-era funding that helped develop them.

Disease detectives in Atlanta

The Centers for Disease Control has long used the World Cup as an example of the types of mass gathering that “face unique risks” from both communicable diseases and non-communicable conditions like “temperature extremes, stampedes, environmental hazards, and challenging security situations,” as the center wrote in the latest edition of its Yellow Book guidance for health care professionals tending to international travelers. It also released a fan-facing website that includes guidance on avoiding infectious diseases.

That threat is now hitting close to home for the CDC, whose headquarters is around seven miles from Atlanta’s Mercedes-Benz Stadium, where the Congolese national team is scheduled to play its final group-stage match on June 27. After matches there, the Georgia Department of Public Health will monitor people who show up at local emergency rooms for symptoms of an outbreak, according to a department spokesperson.

“DPH maintains robust statewide surveillance systems to detect early signs of unusual disease activity,” Nancy Nydam Shirek, a spokesperson with the Georgia Department of Public Health, said in a statement. “These systems are supported by strong laboratory capacity and close coordination with healthcare providers and local health departments.”

Data collected by state and local agencies like Georgia’s will feed into a “syndromic surveillance” system maintained by the CDC, which can then map out trends in symptoms. A dedicated World Cup data dashboard will “give state and local health departments enhanced visibility into disease trends both within and beyond their jurisdictions,” an agency spokesperson told POLITICO.

Through programs known as the Epidemic Intelligence Service and Laboratory Leadership Service, more than a dozen CDC officers nicknamed “disease detectives and detectors” are assisting states hosting World Cup activity, including Kansas, Texas and Washington, as they scale up their wastewater monitoring and testing capacities.

The attempt to collect and analyze stadium wastewater in Los Angeles is supported partially by a CDC-funded pilot program, part of a $4 million World Cup defense being mounted by the county health department.

Los Angeles, which is hosting eight matches at SoFi Stadium, is running a pilot program to connect its local wastewater surveillance system to the outflows of sewage from the 70,000-seat facility. Before, during and after each match, public health workers will collect samples and drive them to a lab for genomic sequencing that can detect dozens of pathogens, including Covid and measles, although not hantavirus.

Just a few years ago, it would not have been possible, Mahajan said. Wastewater surveillance could only test for a few pathogens and the state didn’t have the lab capacity to process samples for the large array of diseases they do now. But an infusion of federal pandemic dollars built up the infrastructure to surveil the germs being flushed out of the stadium. This represents the first time that the city has deployed this Covid-era technology for a large-scale sporting event.

“Everything about our work is different since Covid,” said Los Angeles County Health Director Barbara Ferrer. “We’re very alert and aware that there’s always a possibility now that you could have an event that’s catastrophic in nature that requires rapid mobilization and deployment of lots of resources.”

“While we don’t anticipate any of that happening at the World Cup,” Ferrer went on, “we were no longer naive enough to say, you know, there’s no chance it will happen.”

Hazmat in New York

The patient had Ebola.

That was the conceit of an exercise conducted Tuesday by NYC Health + Hospitals department timed to a World Cup-specific threat: A patient with an infectious disease goes into cardiac arrest, and one of New York City’s public hospitals has to save the individual’s life while protecting the health care workers providing care.

Inside Bellevue Hospital’s Special Pathogen Unit, a medical training manikin lay on an operating table. In the scenario developed by city officials, it represented a 39-year-old man who had been diagnosed with Ebola and now required delivery of advanced cardiovascular life support.

A nurse, donned in protective gear, grabbed a bag-valve mask, then abandoned it as he realized the patient had gone into cardiac arrest. Another nurse rushed in with defibrillator pads while a mechanical CPR device took over compressions. Observers from Bellevue and the National Emerging Special Pathogens Training and Education center, which operates under the Department of Health and Human Services’ Administration for Strategic Preparedness and Response, tracked each step against a checklist to evaluate the readiness of the facility.

Outside, a physician suited up, multiple layers of gloves, taped at the wrists; doubled shoe covers; a full-body hazmat suit; and a helmet-like hood to shield her face.

Observers tracked the time. Clinicians knew communication would be difficult once inside their suits, so they slipped on Bluetooth earpieces before sealing themselves into the gear.

By the time the doctor reached the patient’s bed, the monitor showed he had no pulse, despite electrical activity in the heart. Compressions continued for several minutes before a pulse returned and the patient was stabilized and intubated. The procedure took about 45 minutes, a timeline staff described as a success.

But the most dangerous moment came after the patient had been stabilized. To leave the room, there were three divided warm and hot zones where clinicians exit slowly, removing contaminated gear step by step. One misstep while doffing their gear can risk cross-contamination.

Erin McGuire, medical director of the Special Pathogens Unit, said the approach is rooted in routines developed long before the World Cup was imminent.

“It’s important for us to always do these drills, regardless of what’s going on with the rest of the world,” McGuire said. “It gives us a chance to test our protocols, to practice putting on PPE, to work together as a team, to work on our communication.”

It is one of a series of exercises that New York officials have conducted to prepare for high-risk scenarios. Other simulations run by Bellevue, a regional hub that trains hospitals across New York, New Jersey, Puerto Rico and the U.S. Virgin Islands, have focused on power outages, extreme heat and outbreaks of measles, swine flu or other respiratory illnesses. In March, working with the FBI and NYPD, they conjured an anthrax attack. The National Special Pathogen System, which operates under the Department of Health and Human Services, a collaboration with hospitals across the country that NYC Health + Hospitals helped launch out of the West Africa Ebola outbreak a decade ago, recently role-played a World Cup emergence of Middle East Respiratory Syndrome, or MERS.

“The big thing we have here is time,” said Alister Martin, commissioner of the New York City Department of Health and Mental Hygiene. “We didn’t have that with Covid. We can plan and simulate as many different outcomes and scenarios as possible, which has been very helpful for us.”

Food trucks in LA

But much of what now preoccupies public health officials about the World Cup is indistinguishable from what would have concerned their predecessors in 1994, the last time a World Cup was hosted in the United States.

“It’s the less interesting things, not the global outbreak,” said Martin. “It’s talking about, are the foods people are eating safe? Are the ways we’re crowding and gathering safe?”

These are the bread-and-butter responsibilities of public health departments around any large event, only expanded to deal with the unusual scope and duration of the World Cup. Bay Area authorities will draw on their experiences hosting the Super Bowl at Santa Clara’s Levi’s Stadium in February, but the World Cup will entail six gamedays with fans from at least eight countries. And while Florida welcomes 140 million tourists each year, state officials rarely have to plan for having a stadium full of travelers packed into a confined space as they will be at Miami’s Hard Rock Stadium.

Officials there have been stockpiling an arsenal of relevant gear, from barricades and portable work lights to box trucks, utility trailers and resources to treat people who have been overcome by Miami’s summer heat. The Florida Emergency Operations Center, which manages the logistics of major events and natural disasters, will operate with more staffers to help monitor the event, and also quickly deploy them from Tallahassee if asked by local officials.

The Florida Department of Health “continuously monitors domestic and international public health developments and remains prepared to adjust coordination efforts as needed based on evolving public health conditions and guidance,” said spokesperson Brian Wright.

In Los Angeles, nearly half of the county health workers assigned to the World Cup will be checking food safety among vendors expected to proliferate around SoFi and other fan gathering spots. The county is putting out public notices to unfamiliar visitors that they should look for the official letter grades that indicate a food venue has been inspected. Other bouncy public messaging campaigns advise fans to carry fentanyl test strips and opioid reversal medication and travel by taxi if drinking.

Local health officials have been able to apply for grants from a $625 million World Cup fund managed by the Federal Emergency Management Agency, but competition among state agencies has been fierce. Of the $46 million awarded to Massachusetts, which will host matches at Foxborough’s Gillette Stadium, just $310,800 went to the state department of public health.

Los Angeles just received word on Thursday that it will be reimbursed $961,424 for World Cup-related costs. That amount is less than one-quarter of what it expects to spend, largely on overtime for 240 employees who have been dedicated to preparation and on game days.

The department, which has had to recently close six health clinics due to federal budget cuts, has yet to come up with a plan for how it will make up the difference.

“It’s going to create a problem down the road,” said Ferrer.

Carmen Paun contributed to this report.