Testing the limits
How a group of scientists has made UConn athletic seasons possible
The NCAA samples-only refrigerator sits in a controlled access area of UConn’s Engineering & Science Building at the heart of campus, a few hundred yards from the Werth Champions Center and other prominent athletic facilities.
On most days, it is filled with bags containing hundreds of vials of saliva by 10 a.m. That is generally the time of transition from collection to analysis in an elaborate COVID-19 testing program that allows UConn athletes to break some shackles of a pandemic and compete in the eerily empty arenas of 2020-21.
“We try to distinguish between spit and drool,” said Dr. Deena Casiero, UConn’s director of sports medicine. “We don’t want people to spit in the tube. That makes bubbles. You just drool. We teach kids all these tricks. Think about something delicious, something that makes you salivate. Or think about sucking on a lemon or lime. Then they bring the tube to their mouth and just let liquid pour out.”
That’s how this painstaking process begins, with UConn basketball players, hockey players, football players — you name it — simply drooling on cue to begin their program’s designated testing days. They can’t eat or drink for 30 minutes prior and when samples are tinted, say, orange, well … Reset the clock. Back in line. No Powerade, remember.
The saliva tubes move across campus all morning, the athletic training staff scrambling to collect and deliver. The fridge is the hand-off point to a lab of six scientists — doctors, professors, graduate students among them
10,000
How many student-athlete tests have been performed
300
The number of tests performed daily on UConn athletes
124
The number of total student-athlete positive tests
6
The number of scientists that run the lab
— who while wearing hoods and bio safety gear run a cost-effective, seven-day-a-week analysis that identifies the SARS-CoV-2 gene.
UConn’s COVID-19 lab conducts up to 340 individual tests a day for the athletic department alone, in addition to the 5,000 it runs daily through pool testing for the university population at large. More than 10,000 tests have been performed for the athletic department since the current protocol was put in place in October.
Without this process and the effort of those involved, UConn sports at this time would be impossible.
The cost of athletics testing in this system is under $100,000, with each test costing under $10. That is far less expensive, with a quicker turnaround time, than services offered by off-campus labs. Costs to the lab for testing the student population at large, university professor and lab coordinator Dr. Rachel O’Neill said, is hundreds of thousands of dollars versus the millions it would have been with the use of off-site labs.
The RT-qPCR test (quantitative reverse transcription) includes cycles of heating and cooling, the mixing of samples with fluorescent dyes and enzymes that turn RNA into DNA and so much more in areas not necessarily covered by Science 101. Clear your mind of Bunsen burners. The testing method begins with a machine receiving a 96-well plate of vials, which rests on an inversely shaped Peltier heating block so samples rise to just shy of a boil — 95 degrees Celsius.
There is enough involved to fill a textbook but the bottom line is this: Student-athlete saliva samples are tested for a human control gene, to make sure the sample is actually saliva, and for the COVID-19 gene. Samples are cycled through the machine 40 times over the course of about two hours. Results are automatically documented and assigned to student-athletes with a bar code system that begins with players labeling their tube and logging into a website before they drool.
“It does produce a cycle threshold,” Casiero said. “The lower the cycle threshold, the more positive the sample. The higher the cycle threshold, that means the longer it took to produce the positive, which translates to a lower viral load. That's an important piece of a data for me as a clinician, because what somebody’s cycle threshold tells me is how many copies of virus they have circulating in their system, which translates to how infectious they are and potentially how contagious they are. It's a high-level test. It’s the gold standard.”
Test results are usually returned to Casiero between 4-6 p.m., a manageable turnaround time for athletic endeavors dependent on timing nearly as much as accuracy. From there, Casiero shares results with administrators and program members. And she coordinates, when the need arises, the necessary response to any positive results.
This is the intersection of sporting ambition and medical judiciousness.
It is complicated.
“Just the other morning, someone’s sample was all blue,” said Howard, who works with the football team. “I was like, ‘Did you just brush your teeth?’ They said, ‘Yeah, Bob. I’m sorry.’ I said, ‘You know this isn’t going to work. Go dump that, rinse your mouth, wait 30 minutes. Let’s go.’”
‘It’s a struggle ... every day’
The pandemic has created a collision of hope and fear and reality. Science, and the light it sheds on student welfare and transmission risk for group activities, has seeped deep into an athletics world that, traditionally, runs largely independent from other campus divisions.
Athletic goals are real. The games and experiences matter. Some semblance of a normal life is constantly pursued for student-athletes.
Disruptions are real, too. The UConn men’s and women’s basketball teams have had numerous games postponed due to COVID issues within their program, or within an opponent’s. Each program has been shut down for 10or 14-day periods for positive tests. The entire football season was canceled, due in part to coronavirus.
Casiero is at the heart of operations and conversations that affect every arm of the athletic department.
“It's a struggle, I think, every day,” Casiero said. “But what I lean on is, my job is to take care of the athletes. My job is to make the decisions that I think are best. The nice thing about what's been happening is that we haven't seen many kids get sick. You see athletes get diagnosed with COVID. But very few of them go on to severe disease.
“I will tell you, if that weren't the case, then things would be very different. If every kid I diagnosed with COVID, I had to send to the hospital because they were in respiratory distress, we would not be where we are in athletics right now. I wouldn't have worked so hard to keep this going if kids were getting sick. I think that would have changed the entire way I attacked this. But, luckily, kids are faring pretty well.”
The lives of 650 student-athletes are affected by data provided by the lab.
“David has been so wonderfully patient in understanding the complexities of what we have to do,” Casiero said of athletic director David Benedict. “I’ve had to make decisions that don't always make coaches and players and administrators happy. But at the same time, I believe David fully respects me and how I have handled this really difficult time.”
Every day for doctors, players, coaches and others is a tip-toed walk on COVID eggshells and yet UConn has managed to make it this far, nearly a year after the world changed, with its teams resilient and seasons largely intact. That speaks to the power of ingenuity and a campus-wide cooperation that demands so much of so many, and a vast communication network upon which the entire testing program is based.
“There are definitely times where we've all just hit a wall and been like, ‘This is so exhausting, and it's never stopping,” said O’Neill, a professor in UConn’s department of molecular and cell biology who is among the lab’s lead coordinators. “But at the end of the day, as soon as we get results and are reporting, and are reminded that they're people and students and we're doing this for the university, it's really hard not to be like, ‘It’s OK. This is great.’”
An incredible weight to carry
The testing program has required various members of the athletic and academic communities to double their pre-pandemic workload in efforts to keep student-athletes healthy and compliant with NCAA guidelines. Also, some scientists have had to put on hold various academic initiatives. Everyone involved is sacrificing, from student-athletes living bizarre lifestyles of constant testing and periodic isolation to the local delivery person who makes sure the lab has enough supplies.
Casiero and trainers haven’t stopped treating sprained ankles and concussions. But since midMarch, the lives of the UConn athletics medical and training staffs have been unimaginably strained.
Dealing with a virus with potential for long-term health implications or symptoms that aren’t yet fully understood, accepting responsibility for the health and safety of student-athletes and a campus community at large, setting courses of action that are supposed to carve a path to the next game through a pandemic … that is an incredible weight to carry.
“I always knew I was a strong person, but the past 11 months have proven even to myself how strong I am,” Casiero said. “Because this has been brutal. … It's definitely up and down for me. But if I had to summarize, the most difficult aspect is that we're dealing with a novel virus where we don’t have the data. As a medical professional, almost everything I do, the foundation is in sound medical data with years and years of data to support decisions. For the last 11 months, every healthcare provider in the country treating COVID or managing COVID has been operating in an area that we, as physicians, are not usually operating in. We do not have a [complete] set of data to back up decisions. You have the CDC and you have the local department of public health to lean on.
“I oftentimes feel that I just have to make the best decision I can with the data that I have, and when I go to people like David with an explanation for that decision — to a non-medical person the concept is foreign. When you talk to coaches and administrators, things are black and white, X’s and O’s, wins and losses. In medicine, things are not black and white. That has been the most difficult aspect of what I've been doing, navigating uncharted territories.”
A key assist from yale
The most important “roster” on the UConn campus is as follows: O’Neill; Dr. Kendra Maas, a facility scientist in microbial analysis; Dr. Lisa Nigro, a postdoctoral fellow in microbial analysis; Gabriel "Gabe" Salles and Lucy Owusu, graduate students in the health care genetics program; and Ben Robinson, an M.S. UConn graduate.
They run the lab that a university leans on.
Dr. Ellyssa Eror, the medical director of student health and wellness at UConn, heads care for the general student population. Casiero heads medical care for the student-athlete population. They work closely together in areas of COVID management and care.
Through various testing methods in the 2020-21 academic year, 1,159 general student population tests (residential and off-campus Storrs, and residential Stamford) had returned positive according to data updated Wednesday. There were 124 positive studentathlete tests since March.
Thirteen days is the longest Casiero had to wait for a studentathlete’s tests results as the early stages of the pandemic raged and the medical community was overwhelmed. That is untenable in the world of athletics, particularly in season. UConn’s system of swab testing, in association with Quest Diagnostics, met basic needs for many months with campus virtually empty.
But with students set to return and sports seasons on the horizon, anything outside of consistent 24-hour turnarounds would be less than ideal — because the next practice or the next game is almost always the next day. Casiero needed a testing system that would be fiscally manageable and wouldn’t overburden her staff. And she needed fast results.
O’Neill’s lab had made progress with pool testing — where 10 samples are tested simultaneously, with individual tests to follow only if the pool is positive — and thought the approach could apply for athletics. It could not, Casiero concluded, even while in a desperate search of new approaches and considering partnerships with numerous labs across Connecticut and Massachusetts.
The fact that O’Neill’s operation was on campus was perfect. But with the pool testing that was being pitched, Casiero knew the additional time needed for follow-up individual tests triggered by any pool positive would only complicate athletic planning.
The situation changed with the introduction of SalivaDirect testing — developed at Yale and granted emergency use authorization by the FDA in August. That would work, Casiero knew. It was in line with NCAA
guidelines. O’Neill and Maas prepared their lab to run the protocol, all the while continuing with pool testing for the general student population that remains in use today, and were operational with a new testing model for the athletic department in October.
All in, the lab has conducted hundreds of thousands of COVID tests since the pandemic began.
A race to load up the fridge
For the athletics segment to play out properly, there is a race to get drool collected and delivered. If the samples are not delivered to the lab by 10 a.m., it’s asking a lot for scientists to produce results in the needed time frame.
So the collection process is a race to load up the fridge.
“The panic is when we send over a number to the lab, like, ‘We’re dropping off 289,’ and the lab lets us know an hour later they only have 284,” head athletic trainer Bob Howard said. “Everybody scrambles, goes back through their numbers. You counterbalance. ‘OK, everything is accounted for.’ But sometimes it isn’t. We work in synchronicity, very close with them. They’re rock stars over there at the lab. They have come through in such a way to help us.”
On testing days, trainers set up a table at the team’s facility. All Tier 1 program members – players, coaches, managers support staff, medical staff, members of the travel party, others – line up. The trainer has a bag of empty vials and a bag of labels, each of which features a QR barcode as part of a system designed by the UConn lab, primarily Maas.
A player is handed a label and scans the code with their phone, prompting a website. The player then enters their NET ID and a password, which identifies them in the UConn system, and the player confirms that the codes on the label and site match. They affix the label to the vial and they drool into it, being sure to fill it past the line marking 1 CC, or 1 milliliter.
“Just the other morning, someone’s sample was all blue,” said Howard, who works with the football team. “I was like, ‘Did you just brush your teeth?’ They said, ‘Yeah, Bob. I’m sorry.’ I said, ‘You know this isn’t going to work. Go dump that, rinse your mouth, wait 30 minutes. Let’s go.’”
Largely, though, it’s a relatively smooth process. It beats the invasive nasal swab, a process endured by athletes for months. It also beats waiting days for results.
Once the vials are filled and capped, a member of the training staff walks or drives the samples to the Engineering & Science Building, loads the fridge and sends a text message to scientists in the lab down the hall. And the analysis begins.
Testing takes place three times a week for basketball teams and hockey teams, twice a week for football and at least once a week for other sports (tests are added before and after road trips). Any positive tests are re-tested to confirm.
“If we weren't dedicated, we would have turned around and walked away a long time ago, but we're in it,” Casiero said. “And I'm so proud … of my medical staff, how vigilant they've been through this whole thing. And I think the athletes really appreciate it. I've gotten cards, messages, from athletes thanking me for doing what we've done to allow them to do what they love. To be honest, that's what makes this all worth it. You can be so stressed and so tired and so frustrated, and then I get an email from an athlete saying, ‘I was able to play hockey today because of how hard you worked.’ It's those types of things that make it worth it.”
7
The number of days per week the lab has to run
96
The number of samples that can be tested at a time
2 hours
The amount of time it takes to perform tests
10 a.m.
The time vials are filled by and sent to the testing lab
4 p.m.
The time around when the results are delivered