It's just a black plastic box that looks like a cross between an office desk phone and a credit card machine.
But antigen testing machines like those in Nebraska Medicine's clinical laboratory in Omaha are being credited with helping the Huskers and the rest of the Big Ten get back to playing football this fall.
A newer version of the device set up inside Memorial Stadium could be used to run daily COVID-19 tests on Husker players, coaches and others in the coming weeks. The tests are part of the medical protocols the Big Ten will require during its shortened season.
Antigen tests, commonly used in doctor's offices for influenza, detect proteins known as antigens that have been collected on nasal swabs or in saliva. While they're less sensitive than the gold standard test — PCR, or polymerase chain reaction — they're faster and cheaper and can be conducted by a trained technician.
PCR tests detect and amplify viral genetic material. They must be done by laboratory professionals in high-tech labs. The largest of the PCR machines in the Nebraska Medicine lab measures roughly 10 feet long and more than 4 feet wide.
Antigen tests "offer a lot of flexibility," said Dr. Scott Koepsell, the clinical lab's medical director. "And widespread testing is going to be a key to containing this (virus)."
Indeed, some scientists nationally have called for rapid, more frequent testing to screen workers, students and others. The aim, they say, is to catch people who are contagious, including some who haven't yet developed symptoms — or never will have them. Some proponents even have promoted tests, which aren't yet available, that would be cheap and simple enough to use at home.
One concern driving such calls is the time it takes people to get PCR test results. Health officials have voiced concerns that some who get tested aren't isolating as they wait for the results, continuing with their usual activities instead.
According to the state's COVID-19 dashboard, the overall turnaround time on tests in Nebraska is running just under three days. One national lab is taking four days. TestNebraska's turnaround time is 3½ days on average. Labs operated by universities and health systems are returning results in one to two days.
Adi Pour, director of the Douglas County Health Department, said more rapid, point-of-care tests are needed.
Pour said this week that it's taking an average of nearly 3½ days for county residents to go and get tests after experiencing symptoms. From the time they get tested to the time the county gets the results is another 3½ days. By the time county health officials notify an infected person, more than 6 days have passed, as has much of the 10-day isolation period recommended by the federal Centers for Disease Control and Prevention.
People with concerns about the antigen tests say those less-sensitive tests might miss people who are infected with the virus, giving them a false negative and leaving them free to spread the virus.
Koepsell, who will serve as interim director of the NU testing lab, said that's the rationale for frequent testing. If the antigen tests are done often enough, they eventually will catch those who are infectious.
Just how often is enough isn't yet known. The Big Ten will require daily antigen testing. Athletes who test positive will have to be given a PCR test to confirm the results.
"I'd say several times a week is probably sufficient," Koepsell said, "but I know they're being cautious."
Meanwhile, more of the faster tests are beginning to make their way into use, and new types are being developed. Federal officials have pledged to significantly ramp up the availability of such point-of-care tests as early as this fall.
Koepsell said the federal government initially purchased large numbers of the three major antigen test platforms now available so they could be distributed to screen high-risk groups, such as nursing home staff and residents. The makers now have either filled those orders or will do so in the next couple of months, allowing them to fill other orders.
"It has a lot of potential," he said. "We have a bit to learn about it, how best to use it."
Point-of-care tests, in fact, already have begun arriving in Nebraska nursing homes. As of midweek, 135 of the 188 facilities scheduled to get them had received the machines, according to the Nebraska Department of Health and Human Services.
Two models, including the Sofia device purchased by the university, require machines to read them. But the third, expected in December, comes as a card. Like a pregnancy test, it displays two lines if positive and one if negative. It also can be read with a cellphone app.
Koepsell said the University of Nebraska-Lincoln bought its machine before the Big Ten came out with its recommendations. He said he doesn't know which platform the Big Ten will choose.
The antigen tests, similar to pregnancy tests, rely on what's known as lateral flow technology. With the Sofia, a patient's nasal swab is placed in a tube with a solution. A technician uses a pipette to drop a bit of the liquid into a well on a small cartridge that also holds a paper strip. The liquid moves across the strip, which contains an antibody that binds to the antigen. If viral antigens are present, a fluorescent indicator glows and the machine picks it up.
Such tests cost about $20 to $40 on average, Koepsell said. The machines themselves can cost several hundred dollars. The card version is being advertised for about $5 a test. PCR, on the other hand, costs from $60 to $100 per test and takes a few hours. Daily swabbing, Koepsell said, does not pose a risk of damage or infections, but it is uncomfortable and can cause nosebleeds, particularly in those who have nasal polyps or allergies. "But it's a small price to pay to be safe," he said.
The CDC advises people who test positive to isolate for 10 days. After that, they're no longer considered infectious. But athletes and others who have had COVID-19 can't just be taken off the list for testing because they could become infected again.
Antibody tests, which detect proteins the immune system produces when it responds to an invader, can indicate whether someone has been exposed to the virus in the past. But Koepsell said researchers at the University of Nebraska Medical Center have documented cases, albeit infrequently, of people who have gotten COVID-19, produced antibodies and gotten infected again. A few such cases have been reported in medical literature.
In the future, he said, researchers hope to have antibody tests, like those available for hepatitis immunization, that will allow them to check whether a person is protected.
"I believe the daily testing will keep them safe," Koepsell said of the football players. "But we're also going to learn a lot."
All of the tests will produce a flood of results. Scott Holmes, manager of the Lincoln-Lancaster County Health Department's environmental public health division, said the data will be managed separately so that it doesn't dilute the county's test results. They will do the same with testing from nursing homes.
Koepsell, for his part, admitted that he, like many others, is ready for some football.
"I think they've done it in a safe way and a thoughtful way, and I just think we needed it at this time," he said. "So I'm very excited."
Louise Connelly has watched from her quaint home on the corner of 32nd and Harrison Streets as driver after unsuspecting driver turned off of Harrison and — clunk!— hit a crater at the top of 32nd Street.
For years, Connelly said, she and her roommate had called the city asking for an upgrade to the stretch of 32nd Street between Harrison and Polk — a small section of unpaved road.
Connelly's street is among an estimated 300 miles of unimproved roads in Omaha that decades ago were not built to city standards.
Until the passage of an unimproved streets policy in late 2018, the city wanted Connelly to help pay for improvements. That wasn't an option for the 69-year-old retiree and her roommate.
"We don't have the money to pay for a road," Connelly said. "As many taxes as we pay anyhow for roads, we shouldn't have to."
A recent change to the 2018 unimproved streets policy should make it even easier for Omahans like Connelly, who live in areas of higher poverty, to get their substandard roads fixed at no cost.
Under the 2018 policy championed by Mayor Jean Stothert, most Omaha property owners who live along unimproved roads split with the city the cost of upgrading their unimproved street to city standards, which would have them made of concrete. The property owners pay 50%, and the city pays 50%. To redo a street to a nonstandard level — made of asphalt — the city pays 25% and the property owners pay 75%.
In areas where at least 15% of households are below the poverty level, and at least 50% of housing units are owner-occupied, the city pays 100% of the cost of improvement.
The unimproved streets policy is not for general street repair. It targets only streets that were never built to city standards in the first place and have badly deteriorated.
Homeowners in economically distressed areas now don't have to go through the same process that applies in other areas with unimproved roads. Previously, people in those areas had to apply with the city and petition their neighbors to create an improvement district.
But the city law department earlier this summer determined those procedural steps aren't necessary because the city is footing the entire bill.
Stothert said not a single person in a high-poverty area went through the process of creating an improvement district since the 2018 policy was created. She said it didn't make much sense to ask those homeowners to go through that process when the city pays for the repairs anyway.
"I just think it's a much fairer policy to do it (this) way," she said. The city has estimated that of Omaha's 5,000 lane miles, about 300 are unimproved streets, many of which have rough surfaces and are riddled with cracks, ruts and potholes. Such streets have long been a problem in portions of North and South Omaha and the Elkhorn and Westside areas.
It would cost about $300 million to repair them all with concrete. Stothert said in practice, the amount is lower because some homeowners opt for an asphalt overlay, which is cheaper.
A mile-stretch of concrete road costs about $1.5 million, Stothert said. A mile of asphalt is about $150,000.
The number of unimproved lane miles in the city hasn't substantially changed over the last two years, said Heather Tippey Pierce, general services division manager of the city's Public Works Department.
That's partly because each improvement project addresses about a one-block stretch of road, so even a handful of projects don't make a huge dent, she said. The city also has been working on projects that started before the 2018 policy went into effect.
But city officials expect the number of projects to trend upward as more unimproved roads are brought up to standard. In 2019, the first year of the new policy, only a handful of neighborhoods formed districts to trigger repairs. This year, the city received more than 40 applications.
"As folks talk to each other, and they see projects getting completed, they're going to say, 'Hey, how do I get this done?' " Tippey Pierce said.
A $200 million streets bond issue approved by Omaha voters in May is directing more money to unimproved roads. The bond issue will give the city $40 million a year over the next five years to address all of the city's aging streets.
The bond issue, which already is helping the city take on new roads projects, filled a $34 million gap between what experts say the city should be spending on road maintenance compared to what the city was shelling out.
Stothert pledged that the extra $6 million a year — the difference between the $34 million need and the $40 million created by the bond issue — would go to unimproved roads.
The city's 2021-26 capital improvement program now includes $6 million a year for such roads. The city had been spending $820,000 a year.
The extra money allowed the city in August to schedule street repairs for 10 economically distressed areas, including the street by Louise Connelly's home.
Other upcoming projects in high-poverty areas: 14th from Fort to Browne Streets; 65th Avenue from Fowler to Ames Avenue; the eastern end of Monroe Street in South Omaha; 32nd between S and T Streets; and a handful of alleyways.
Work on those streets, which call for the roads to be repaired with concrete, is expected to be completed between 2021 and 2022.
Another six projects in high-poverty areas in 2020 had less than 50% owner-occupancy and thus don't qualify under the policy. Those are referred to the Planning Department, which considers them for inclusion with the city's Community Development Block Grant plan.
Councilman Vinny Palermo represents South Omaha, the location of many of the city's unimproved roads. He noted that not everyone wants the unimproved road running by their house to see repairs. Some people enjoy the way such roads discourage traffic.
But Palermo said he's pleased that residents in low-income areas now have an easier way to get the road improvements, if they want them.
"I'm happy with where we're at," Palermo said. "It's another path, it's another opportunity, for those who are interested in actually getting their unimproved roads taken care of to make it happen."
Sam Cooper and his neighbors, who live along Walnut Street north of Creighton University Medical Center-Bergan Mercy, are among the Omahans who have decided a better street is worth the cost.
Cooper, president of TitleCore National, a title and escrow firm, said neighbors began talking in summer 2019 about the possibility of forming an improvement district to upgrade Walnut between 76thAvenue and 78th Street, which was "a mess for years," he said.
The first step: informal talks among neighbors. Were people interested in splitting the cost of repairs with the city? Was it worth it? Should they opt for concrete or asphalt?
"You've got to live next to these people," Cooper said. "You don't want something like this to divide the neighborhood."
By fall, the 10 homes now included in the improvement district were comfortable moving forward, Cooper said. A simple majority of property owners is all the city requires for the formation of a district.
Once an area decides there's interest in pursuing repairs, a neighborhood representative can contact the city or visit the "Street Improvements" tab on the Public Works website. The city will supply residents with information about the process and the difference between a Street Improvement District, which brings roads up to full standard, and a Road Maintenance District, which consists of an asphalt overlay.
People can visit the city website Omaha PASER Rating Lookup and type in their address. Streets that are eligible for the city's unimproved roads policy are those that have a PASER rating of 4 or less. Those are shown in red on the map.
Cooper and his neighbors went with concrete. Walnut Street is currently under construction and may be completed by Thanksgiving. The 10 households in the area will each pay about $22,800 for their new road. Depending on the cost of repairs, payments, which come along with one's property tax bill, can stretch over a 20-year period.
Cooper said he's been pleased with the process and encouraged other neighborhoods with unimproved streets to look into the city's policy. While Walnut Street is currently torn up, he's excited for the final product.
Said Cooper: "It's got to get bad before it can get better."
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For months as the coronavirus pandemic raged coast to coast, Omaha's St. Joseph Villa nursing home remained a cheerful safe haven for its elderly residents.
But beginning in mid-July, COVID-19 gained a foothold within the halls of the care center just south of downtown. And despite the staff's life-and-death struggle to contain it, the virus proceeded to ravage St. Joseph's fragile population.
First, two residents died. The next week, four more succumbed. And week by week, deaths mounted.
As of early September, 16 residents had died — the second-highest coronavirus death toll of any nursing home in Nebraska. And St. Joseph is now among nine Nebraska nursing homes with double-digit COVID-19 fatalities.
Seventy-five-year-old Lily Rigatuso was among the victims at St. Joseph. Her son, Eli, kept a 10-day vigil outside his mother's window before she passed away July 26.
"I'm confident if COVID hadn't struck, she would still be here," Eli said of his generous and spirited mother.
Gov. Pete Ricketts and state health officials for months have rejected calls to release the names of Nebraska nursing homes with COVID-19 outbreaks, offering only statewide aggregate numbers of cases and deaths in long-term care facilities.
But the World-Herald recently mined a federal database to reveal COVID-19's toll on Nebraska's 200-plus nursing homes and their 11,500 residents.
In all, through Sept. 6, 31 homes have reported fatal outbreaks, totaling 185 deaths. That's approaching half the state's total death count of 400-plus, underscoring the critical need to protect nursing home residents.
Nine homes had 10 or more deaths, including five in Douglas County. In Grand Island, one home saw 20 resident deaths.
And up until now, the vast majority of the deadly outbreaks have never been publicly disclosed.
"When you are concerned about your loved one in a facility, knowing what is happening is essential," said Todd Stubbendieck, state director for AARP Nebraska. "This transparency is important to people."
There's a strong correlation between nursing home deaths and communities in Nebraska where COVID-19 has spread most widely.
More than three-quarters of all nursing home deaths fall within three communities that have seen high virus levels: Douglas County, and the regions surrounding the meatpacking communities of Grand Island and Dakota County.
"The thing that we've learned is just how susceptible skilled nursing and assisted living facilities are to the community around them," said Heath Boddy, CEO of the Nebraska Health Care Association.
Nursing homes and their staff were hamstrung early on in the pandemic by limited ability to test. That shortfall made it difficult to identify asymptomatic carriers — staff members and others who unknowingly spread the virus without showing any symptoms.
Even when testing became more available, there were still often days-long waits for results — time for the virus to spread widely within a care facility.
"Sometimes it's just too late for those facilities," said Dr. Salman Ashraf, who as medical director of Nebraska Medicine's Infection Control Assessment and Promotion Program has consulted nursing homes on preventing and containing outbreaks.
The good news is the testing situation has improved — and could get considerably better in coming weeks.
The Trump administration, which has faced sharp criticism for its response to the pandemic, recently began distributing rapid point-of-care antigen testing devices to federally certified nursing homes across the country.
With this new ability to get back instant results, the federal government is now mandating that nursing facilities in communities with high rates of COVID-19 spread test all staff members at least once a week.
The figures also show most of Nebraska's deadliest outbreaks have occurred within homes with below-average performances in regulatory inspections, including many homes that have had a history of observed shortcomings in their infection control practices.
Even so, one of the state's most highly rated homes wound up with one of the deadliest outbreaks.
There's some positive news in the numbers, too. Considering that Nebraska homes have reported some 700 confirmed cases of COVID-19, it means almost three-quarters of nursing home residents infected survive. Even for the frail populations of such care facilities, COVID-19 is not a guaranteed death sentence.
Still, given the outsized role long-term care deaths play in Nebraska's total COVID-19 toll, it underscores the importance of home administrators, public health officials and regulators working to keep COVID-19 out.
New nursing home outbreaks and deaths continue to occur every week, offering ongoing proof of how quickly and lethally the virus can strike.
Until two months ago, all of Perkins County in southwest Nebraska had not seen a single coronavirus case. But then in mid-July, a local outbreak ensnared the small, county-run nursing home in Grant.
As of Sept. 6, 10 residents of Golden Ours Convalescent Home had died. Those deaths give Perkins County and its population of 2,900 the 10th-highest COVID-19 death rate in the nation — five spots ahead of New York City.
"If there's any lesson to be learned from this… it is absolutely what a damn grass fire it can become in a long-term care setting," Perkins County Health Services CEO Neil Hilton was quoted by the local paper telling the Perkins County board. "It's a grass fire."
Public records obtained by The World-Herald show a state inspection right around the time of the outbreak found the home in Grant failed to ensure two employees did not work when they were showing virus symptoms, and also failed to properly screen all staff members and residents for symptoms.
Two employees the week of the inspection tested positive for COVID-19. The following week, a dozen residents did.
It appears the Grant outbreak has claimed the lives of more than a third of the home's 26 residents. It's not uncommon for the deadliest Nebraska outbreaks to claim as much as 25% of a home's residents.
Chris Young, administrator at Westfield Quality Care of Aurora, said he hopes when people look at figures like that, they consider just how devastating it is not only for the families impacted, but the staffs of care homes, too.
For some residents, their caregivers become "their closest friends in the world," he said, and the bonds are mutual. It was extremely painful for his home early in the pandemic to endure 13 resident deaths.
"Westfield had a horrible experience," he said. "People have hearts in this profession. They care a lot."
* * *
Even before Nebraska had recorded its first confirmed case of COVID-19, nursing homes were on high alert.
They'd already seen the peril the virus posed for residents of long-term care facilities when a sustained outbreak at a Seattle area nursing home killed dozens.
COVID-19 was proving it could spread easily person to person and was most dangerous for people over age 60. Long-term care homes bring together in a group setting dozens, even hundreds, of people in that age group, many with health conditions that make them more vulnerable.
Nursing homes are also staffed by workers who, of necessity, must move from resident to resident giving care. And those staffers at the end of the day return to their own families, perhaps stopping at the store or a gas station on the way home.
In doing their critical work, caregivers also serve on the front lines of the pandemic, putting their own health at risk.
"My heart goes out to all the front-line workers," the AARP's Stubbendieck said. "I can only imagine the worry they have about spreading the virus at work or home."
Before Nebraska saw its first COVID-19 case in early March, the state's nursing homes were already getting advice from federal officials, Nebraska Medicine's infection control program and state regulators on strategies to keep the virus out and prevent spread.
For example, they encouraged homes to look for ways to care for residents in cohorts, limiting the number of staff members going in and out of rooms. Proper hand hygiene was also stressed.
At the time, testing had yet to ramp up in Nebraska or across the country. So the best advice they could give was to take workers' temperatures and screen them for other symptoms using a questionnaire.
Even when the virus broke out in homes, there still often wasn't enough testing capacity to screen all workers. Boddy said early on there were also "awful" shortages of personal protective equipment, with caregivers frequently forced to reuse masks.
At the onset of the pandemic, scientists also still had much to learn about the virus, including how easily it could be spread by those who don't show any symptoms.
"We didn't know it, but early on, we were fighting it with one and a half arms behind our back," Boddy said.
One of the first big nursing home outbreaks to make headlines in Nebraska was at the Life Care Center of Elkhorn, part of the same national chain as the doomed Seattle home. The Elkhorn home disclosed in May that more than half of its residents contracted the virus, and that 11 of them died.
Also in Omaha, the county-run Douglas County Care Center reported six resident deaths.
However, most such outbreaks in Nebraska never came to light. Ricketts and the Nebraska Department of Health and Human Services established a policy of leaving it to the homes and county health officials to decide what to disclose.
The AARP has called on the state to publicly release the outbreaks, in real time. DHHS officials say disclosing the names of those homes risks violating the privacy of residents.
But inmid-May, the federal Centers for Medicare and Medicaid Services began requiring federally certified skilled nursing facilities to file weekly reports with the federal Centers for Disease Control and Prevention on their coronavirus cases and deaths.
Homes were to report each resident who died and had a laboratory positive test or was suspected of having the virus. It's a given that nearly all also had underlying health conditions that contributed to their deaths. After all, that's why they were in a skilled care facility.
The reporting requirement does not apply to 10 nursing homes in Nebraska that aren't federally certified. And it does not include other types of long-term care like assisted living facilities. But it offers the clearest picture of how care homes in Nebraska have been impacted by COVID-19.
Overall, the figures suggest Nebraska has been more successful than most states in protecting its nursing home residents.
Nebraska ranks 41st among the states and Washington, D.C., in coronavirus cases per 1,000 nursing home residents, and 38th in deaths.
Another grim way to look at it: The coronavirus has killed more than 4% of nursing home residents nationally. In Nebraska, though, only about 1.5% have died.
"We know every death is a tragedy," said Dr. Gary Anthone, Nebraska's chief medical officer. "But one of the reasons I think we have done so well on our mortality rate is our success in managing long-term care outbreaks."
Standing out from the data are the nine outbreaks where 10 or more residents have died.
They include 20 residents at Emerald Nursing and Rehabilitation Lakeview in Grand Island, the 16 residents at St. Joseph Villa, 14 at the Life Care Center of Elkhorn, 13 at Westfield in Aurora, 12 at the Life Care Center of Omaha (another affiliate of the same national chain), 11 at Good Samaritan Society-Millard and 10 each at Omaha's Florence Home, Golden Ours in Grant and Plainview Manor, a small rural home in northeast Nebraska's Pierce County.
The outbreaks at St. Joseph, Life Care Center of Omaha, Florence and Plainview have never before been disclosed. And most of the others became more severe than was revealed at the time — in some cases, much more.
In all, those nine double-digit death outbreaks account for almost two-thirds of all reported nursing home deaths in Nebraska.
Douglas County stands out as home to five of the nine deadliest outbreaks, more than one-third of all deadly outbreaks and almost half of all deaths.
Most nursing home deaths can be found within Douglas County and two well-known Nebraska hot spots: a five-county area surrounding Grand Island, where a major outbreak fueled largely by a local meatpacking plant rippled through the region; and Dakota County, another meatpacking community that still ranks in the top 10 nationally in per-capita coronavirus cases.
While the exact cause of outbreaks is almost never known, it's likely nearly all involved