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Inspector General’s Office investigates in-custody suicides with Nebraska Department of Correctional Services

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Inspector General’s Office investigates in-custody suicides with Nebraska Department of Correctional Services


LINCOLN, Neb. (KOLN) – An inspector general is recommending changes in the Nebraska Department of Correctional Services after reviewing three in-custody suicides.

A report released Tuesday details successes and failures made by staff and infrastructure within NDCS in the wake of three suicides between 2021 and 2023. The inmates died by hanging in each incident, but all under different circumstances.

Inspector General Doug Koebernick said in his report that NDCS has spent time looking into suicides in its facilities. A suicide work group had been established in 2018, led by the department’s medical director.

The group made multiple recommendations for the department which include:

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  • Distributing suicide awareness pamphlets to inmates, friends and family
  • Adjusting the staff training manual
  • Streaming a suicide prevention video in all NDCS facilities
  • Using an additional screening tool during transfers and intakes
  • Advertising a phone number that friends and family can call should an inmate make alarming comments

During his investigation, Koebernick found that NDCS only implemented the phone number to report suicidal comments made by inmates. However, the number did not work, and NDCS eventually phased the program out.

A review of three suicides then revealed a handful of policy and infrastructure failures within NDCS that resulted in incomplete investigations. He found that internal critical incident reviews, mandated reports outlining specific details in suicides, were not be sufficiently completed.

Similarly, a mental health team member is required to complete a psychological autopsy following a suicide. Koebernick requested the psychological autopsies in each case, but NDCS did not provide him with any.

Individual A:

The first inmate, identified as Individual A, a 45-year-old man, died by suicide at the Tecumseh State Correctional Institution in 2022. He was serving a life sentence after murdering his cellmate and had been incarcerated for a variety of charges beginning in 2006.

In August, correctional staff found the inmate lying with his left arm hanging off his bed. He had cut himself, and a pool of blood was gathering on the floor. Staff brought him to the medical unit and gave him stitches.

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He told staff that he was not suicidal, but a suicide note that had been tossed in the trash was later found in his room. The inmate was put under “Plan A,” otherwise known as suicide watch, and was given a security blanket, paper clothes and extra supervision.

A few days later, behavioral health staff downgraded his plan before returning him to his regular unit. The inmate had denied any suicidal intent when spoken to by staff.

Staff then found the inmate unresponsive in his cell just 16 days after he cut his wrists with a razor blade, Koebernick wrote. He wrapped a bedsheet around his neck and tied it to the top bunk of his bed. Staff attempted life-saving measures, but the inmate was pronounced dead.

Koebernick reviewed phone call the inmate made in the days before his death, and he discovered that the man had spoken to his mother on several occasions. Five days before his death, the inmate told his mother about his self-harm and indicated that he wanted to die.

The inspector general then interviewed inmates familiar with the man and learned that he may have been abusing K2 and possibly owed another inmate money for the drug. He noted that the review of phone calls and the interviews were not completed in the ICIR.

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Individual B:

In June of 2023, another 45-year-old inmate took his life in a similar manner to Individual A. He had been incarcerated since May of 2023, and his release was expected by the next year.

An emergency response team was activated after the inmate was found unresponsive in his cell one night. He was found face-down with a sheet tied around his neck that had been attached to a locker. Staff performed life-saving measures, but a paramedic with Lincoln Fire and Rescue ultimately pronounced him dead.

Further investigation revealed that not all cameras in the area were operational at the time, eliminating any view of staff outside the cell. Intelligence staff noted the issue a day after the death, Koebernick wrote.

Koebernick discovered that the cameras were not working due to a software update. The cameras should have been working at the time, however, but nobody bothered to check if they were actually functioning.

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Prior to the death, Koebernick check the inmate’s call records and discovered he’d made 99 outgoing calls on the day of his death. He learned that the inmate would regularly call a woman and get into an argument. Only two of the calls connected that day, and both devolved into “a very vocal argument,” Koebernick wrote.

The inmate’s cellmate was interviewed, and he shared a harrowing story from the night of the suicide. Staff woke him up once they found his cellmate unresponsive and yelled at him to untie the bed sheet. But staff burst in and ordered him back to his bed. He was handcuffed as staff performed CPR and later moved to the holding area.

His cellmate’s corpse was then left in the same holding room in full view of the inmate. He asked to be taken out of the room three or four times but was told no each time. After some time, staff returned him to his cell and then transferred him to a new cell the next day.

The inmate reported suffering a breakdown the day after the suicide, and he reported that mental health staff did not contact him despite his suffering.

During the interview, the inmate told Koebernick that his deceased cellmate had been abusing his prescription drugs in the days leading up to his suicide and often stayed up all night.

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Individual C:

Finally, the inspector general’s office investigated the suicide death of a 25-year-old inmate in December of 2021. The man had been incarcerated since 2019, and he was expected to be released in early 2032.

The inmate was not a sex offender at the time of his death, but he was slated to be sentenced for a sex-related offense in federal court the week following his death.

Correctional staff discovered the inmate unresponsive on his bottom bunk early one morning. Like Individual A, Individual C wrapped a bed sheet around his neck and tied it to his top bunk. Chest compressions were attempted, but the inmate was pronounced dead a short time after he was found.

A suicide note showed that the inmate did not want to be a sex offender. The ICIR showed that staff handled the incident well, but the inmate had been checked at “substandard” 30-minute increments.

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Another suicide at Tecumseh’s prison in 2016 involved the use of a bed sheet tied to a top bunk, and the ICIR in this incident recommended staff remove the second bunk and cabinets from the prison’s cells.

In his findings, Koebernick concurred with the ICIR’s recommendation and encouraged NDCS to removed second bunks and cabinets from cells in Tecumseh.

He also wrote that body camera footage from the incidents proved helpful in his investigation, but noted that those cameras aren’t in use at the Reception and Treatment Center which primarily handles cases involving mental health.

He then recommended the following actions for NDCS:

  1. NDCS should review the recommendations from the 2018 suicide work group and determine if a special team should be created to focus on suicides and suicide attempts
  2. The department should review its policy regarding psychological autopsies and whether or not they have been completed or remain necessary
  3. The prison in Tecumseh should remove second bunks and cabinets from its cells
  4. Body cameras should be implemented with staff on each shift’s emergency response team
  5. The ICIR process should be amended to include more investigatory means, including interviewing inmates and reviewing additional information in each incident

Inspector General Koebernick shared his findings with NDCS Director Rob Jeffries on June 10. He concluded his report with Jeffries’ response on June 25.

The director wrote back with the following after signing a policy directive for NDCS:

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“The mental health director/designee will designate a psychologist who is not assigned to the affected facility to complete a psychological autopsy for all suicides and, as he/she deems appropriate for attempted suicides.”

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Nebraska Games and Park sets up wildlife display at State Fair

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Nebraska Games and Park sets up wildlife display at State Fair


GRAND ISLAND, Neb. (KSNB) – Nebraska Games and Park was well prepared for the Nebraska State Fair on Friday with a large exhibit showcasing many species of creatures native to the state.

A 6000 gallon aquarium was set up with dozens of fish to showcase many of the species of fish that swim in the Platte River and others.

There was also a display explaining water flow and currents that had demonstrations for kids to play with.

Nebraska Game and Parks also had a water fall display, with many (fake) creatures inhabiting it. It was adorned with creatures like a mountain lion, a wild turkey and a beaver.

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Throughout the day dozens of school groups and children toured the exhibit to learn more about the critters that call Nebraska home.

“It’s great to answer questions and tell people what’s going on,” said Emma Ebito, the Nebraska Game and Parks Marketing Coordinator.

Ebito and her team have been setting up this exhibit for many months now, starting in late January. They were proud that it was able to provide fun and knowledge to children.

“It means everything,” said Ebito “It’s so cool to be such a major attraction at the state fair as well as getting people to interact with us.”

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Family fights for continued awareness of dyslexia, grateful for eight years of Nebraska legislation • Nebraska Examiner

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Family fights for continued awareness of dyslexia, grateful for eight years of Nebraska legislation • Nebraska Examiner


LINCOLN — Norah Schmidt loves reading, particularly dystopia and romance novels, but the high school senior recalls when that wasn’t always the case because of a learning disability: dyslexia.

Norah Schmidt, 17, is pictured Aug. 15, 2024, during her final first week of her senior year of high school in Lincoln. (Courtesy of Heather Schmidt)

Norah, 17, remembers being pulled out of class for timed readings where staff would hold a stopwatch and track how quickly she could read and if she was close to her peers.

“The first six years of school, K through 5, were hard,” Norah told the Nebraska Examiner this summer. “I didn’t know what I was doing, reading in fifth grade at a third grade level, reading my first book in fifth grade. It’s improved since but still hard.”

Close to graduation and looking ahead to college, Norah said she reads whenever she gets the chance now, after years of an uphill climb of interventions in part aided by legislation and advocacy from Norah’s parents in Lincoln Public Schools.

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Legislation back to 2017

State lawmakers have passed multiple bills since 2017 to improve services for students with dyslexia and require intensive reading interventions in each of Nebraska’s 244 school districts. 

“I do hope that with all this going through, students who are coming into schools don’t have to go through things I did,” Norah said of the legislation.

State Sen. Lou Ann Linehan of Elkhorn. Aug. 17, 2024. (Zach Wendling/Nebraska Examiner)

State Sen. Lou Ann Linehan of Elkhorn has been heavily involved in legislative efforts regarding dyslexia, including her support this year for Fremont State Sen. Lynne Walz’s Legislative Bill 1284. That package contained two reading proposals from Linehan, which she said was her last “rah rah” before being term-limited out of the Legislature:

  • LB 1253, to award up to $500,000 in grants to Nebraska companies researching artificial-intelligence-based writing assistance models for students with dyslexia.
  • LB 1254, to set aside $2 million over three years for reading improvement mentorship programs and to employ regional coaches to train teachers in K-3 how to teach reading.

Linehan, who has dyslexia, introduced LB 651 in 2017 during her first year as a state senator to provide accelerated reading interventions for students in grades K-3. 

Known as the Nebraska Reading Improvement Act, any student who exhibited a reading deficiency would have received an individual reading improvement plan. Students would have needed to show sufficient reading skills to move on to fourth grade or be held back for a year.

Linehan said that extra support is critical, partially to prevent behavioral issues for students who will “hate school because they don’t want to be embarrassed.”

“They don’t want to have to stand up and be asked to read a book, and they can’t, so they throw the book because ‘I’d rather be in trouble than be embarrassed and have my friends make fun of me,’” Linehan said.

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School tour informed legislation

At LB 651’s hearing, superintendents, teachers and school members from various school districts expressed concern, particularly with retaining students in the third grade.

Then-State Sen. Patty Pansing Brooks of Lincoln, who sat on the Education Committee along with Linehan, also opposed the measure, which later stalled during floor debate for the year.

But a separate bill, LB 645 from Pansing Brooks, did pass in 2017 to define dyslexia in state law. Linehan supported the change. 

Pansing Brooks brought the bill on behalf of her brother and cousin, who have dyslexia, and her mother, a former Lincoln Board of Education member who pushed for dyslexia-related services.

Linehan and Pansing Brooks have opposing political ideologies, but they sought to find a path forward in the fall of 2017 by touring more than a dozen schools together statewide to gather additional perspectives from educators and students, which informed new legislation to improve literacy.

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“The education community could blow me off because I was not a supporter of the teachers union. I was a very conservative member. They could have run me over,” Linehan said. “They could not run over Patty — her willingness, my determination, and just keep going back.”

State Sen. Lou Ann Linehan of Elkhorn, left, kneels on the ground next to an elementary school student in fall 2017. In a second picture, to the right, then-State Sen. Patty Pansing Brooks of Lincoln watches a young student completing a worksheet on spelling words. The two senators led the literacy-based tour in part to inform legislation to combat dyslexia ahead of the 2018 legislative session
State Sen. Lou Ann Linehan of Elkhorn, left, and then-State Sen. Patty Pansing Brooks of Lincoln led a tour to more than a dozen schools in 2017 to meet with educators and students about reading literacy. Oct. 17, 2017. (Photos courtesy of Sen. Lou Ann Linehan and former Sen. Patty Pansing Brooks)

Pansing Brooks returned in 2018 with LB 1052, to update a dyslexia-focused guide for educators and require teacher training. And Linehan amended a revised version of her previous bill into LB 1081, which didn’t include holding students back. Both passed overwhelmingly.

Linehan’s proposal established three reading assessments for all students in grades K-3 each academic year, as well as supplemental interventions for those young students who have a reading deficiency.

“I felt like we could really work stronger together, and she’s a force, there’s no question,” Pansing Brooks said this summer.

In 2023, Linehan proposed LB 298, which also passed. It requires schools to track how many students have been tested for a specific learning disability and how many have a reading issue.

Districts must report that information annually by July 1 to the Nebraska Department of Education, which must compile the information and send a public report to the Legislature each year no later than Sept. 1.

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I do hope that with all this going through, students who are coming into schools don’t have to go through things I did.

– Norah Schmidt of Lincoln, a high school senior who has dyslexia

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‘I felt like Alice in Wonderland’

Heather Schmidt, Norah’s mother, recalled some of her own frustrations prior to that legislation, when Norah was in elementary school. School staff would show Norah’s parents charts “of why everything’s fine.” When Heather told them that everything wasn’t fine and that Norah was struggling, she said she was told to look at the chart in a different way.

“When we first started down this path, I honestly, in the meetings, felt like Alice in Wonderland just trying to figure out how to get home, and everybody was telling me about eight, nine other things that didn’t make sense,” Heather Schmidt recalled.

Norah Schmidt, right, a high school senior who has dyslexia and has fought to improve her education in Lincoln Public Schools stands next to her mother, Heather Schmidt.
Norah Schmidt, right, a high school senior who has dyslexia and has fought to improve her education in Lincoln Public Schools alongside her mother, Heather Schmidt. June 11, 2024. (Zach Wendling/Nebraska Examiner)

For some of Norah’s classes, she would have a sheet to track how many books she read each week. Though she spent hours reading, she couldn’t reach the goal, yet her mom would still sign the assignment, knowing the effort that Norah had put in.

Norah said she is still learning to cope with dyslexia and how to study, but an AI-focused tool created by local university students, Dyslexico, is helping to cut her study time in half.

“Instead of getting frustrated and shutting her Chromebook and pushing it away, she just kept going and writing, kept studying,” Heather Schmidt said. “You’d see her just kind of wilt as if she was defeated [before].”

Support with artificial intelligence

Dyslexico started in the University of Nebraska-Lincoln’s Raikes School. Key team members Bridget Peterkin and Tristan Curd, who graduated in May, testified at a legislative hearing in February in support of Linehan’s grant program in LB 1253.

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The online program is powered through AI but finds what its creators have described as a middle ground compared to other grammar check software.

Members of the Dyslexico team at the University of Nebraska-Lincoln that is working to combat dyslexia with AI-based tools sit on a bench in early February 2024. From left: Tristan Curd, Bridget Peterkin and Nick Lauver.
Members of the Dyslexico team at the University of Nebraska-Lincoln that is working to combat dyslexia with AI-based tools. From left: Tristan Curd, Bridget Peterkin and Nick Lauver on Friday, Feb. 9, 2024, in Lincoln. (Zach Wendling/Nebraska Examiner)

Peterkin said when Dyslexico began, it all felt very theoretical, but support and excitement from Linehan and others left the team “blown away.”

Curd said this summer that Dyslexico was looking to start new pilot programs with schools. He said getting a grant could help the team improve its services for the community.

“It’s super exciting because at its core, it will help us keep Dyslexico going,” Curd said.

Linehan said the student team amazed her because they understood dyslexia and that people who have it are capable and intelligent, but just struggle to read or write.

The grant applications are due to the Nebraska Department of Education by Sept. 6.

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‘We need to be proactive’

Elizabeth Tegtmeier, president of the State Board of Education, which oversees the Education Department, said that all students need to be supported. She said the State Board should expect struggling students to receive interventions but doesn’t need to wait for legislation.

“We’re in harmony as far as student literacy, and I just think that this particular facet of literacy needs to rise to the surface,” Tegtmeier said of the State Board.

State Board of Education President Elizabeth Tegtmeier, left, and state Education Commissioner Brian Maher. March 8, 2024. (Zach Wendling/Nebraska Examiner)

Tegtmeier said she also has a child who struggles to read and found herself, like Heather Schmidt, supplementing the assistance her school provided and seeking additional resources.

“We need to be proactive, not wait until students have failed,” Tegtmeier said. “That affects their self-esteem. It affects their ability to work in the classroom if we wait for them to fail before we offer them assistance.”

‘Swimming upstream’

Heather and Norah Schmidt haven’t always been successful in finding advocates within Lincoln Public Schools, they said, but they recently found support in Sara Jones, LPS’ student services supervisor, and Adriana Martinez, Lincoln Southeast High School’s English Department chair, who was one of Norah’s teachers last year.

Norah said Martinez gave her as much time as she needed on assignments and would break lessons down in a way she could understand, tailored to her learning style.

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Martinez said that she regularly tailors support to her students’ needs and that the “bare minimum” for teachers is to read and understand a student’s learning accommodations as part of their Section 504 plan or individualized education plan.

“Once I have a good understanding of my kids, we have pretty open conversations with what they need to feel successful,” Martinez said.

Adriana Martinez, English Department chair at Lincoln Southeast High School, right, and Sara Jones, student services supervisor for Lincoln Public Schools. (Photos courtesy of Adriana Martinez and Sara Jones)

Jones said that everyone at LPS wants students to succeed and that accommodations are available to students, but she acknowledged it’s a “tough avenue to fight, like swimming upstream,” at times.

“When you find that one little gem that might work, it’s such a good feeling,” Jones said.

Throughout her 12 years in special education, Jones said, it’s almost hard to describe how students change once the right tool is put in front of them. She said she sometimes runs into former students in the community and is able to see how the interventions have paid off.

“It’s just so heartwarming,” Jones said. “Even if it’s just one kid.”

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Martinez said teachers should “walk with humility” and understand that they don’t know everything and need to be lifelong learners.

Since the COVID-19 pandemic, teachers have seen that policies don’t always catch students’ needs, Martinez explained. She said many teachers are adapting and being more accessible.

“I think the more that students see teachers as collaborators for their learning,” Martinez said, “the better that we can make their education.”

‘We need to keep pushing harder’

State Sen. Lou Ann Linehan of Elkhorn, back left, and then-State Sen. Patty Pansing Brooks of Lincoln, right, meet with three students during one of many tours of schools in fall 2017
State Sen. Lou Ann Linehan of Elkhorn, back left, and then-State Sen. Patty Pansing Brooks of Lincoln, right, met with dozens of students and educators during a school reading tour about reading literacy and dyslexia. Oct. 17, 2017. (Photo courtesy of Sen. Lou Ann Linehan and former Sen. Patty Pansing Brooks)

Norah said more education for teachers on dyslexia will be helpful, as some don’t know what it is. She hopes future students don’t have to wait for help as long as her family did.

“I’m glad it’s happening now rather than 10 years down the line,” Norah said.

Her mother worries that momentum surrounding dyslexia needs could slow down with Linehan leaving the Legislature after this year. 

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“I hope we’re not going to be left without moving forward,” Heather Schmidt said. “I feel like they’ve made a lot of inroads, just even with the awareness level, but we need to keep pushing harder.”

Linehan said that with the accountability measures in place and a bigger focus on phonics and reading comprehension, she sees the work continuing.

“I may no longer be in the Legislature, but I will still pay attention. It is too important,” Linehan said. “We can’t let bright, capable people not get an education because they struggle to read at an early age.”

A legislative history on dyslexia and reading

At least five new laws have taken effect related to dyslexia since 2017, led by former State Sen. Patty Pansing Brooks of Lincoln and State Sen. Lou Ann Linehan of Elkhorn.

  • 2018: LB 1081 (Education Committee, with LB 651 from Linehan) — Established the Nebraska Reading Improvement Act, which encouraged school boards to develop reading instruction and intervention policies and required approved reading assessments to be given to students three times each school year plus supplemental interventions for students who have a reading deficiency. Passed 46-1.
  • 2023: LB 298 (Linehan) — Required school districts to report how many students have been tested for a specific learning disability (including characteristics of dyslexia), are identified as having a reading issue and who have shown improvement. Passed 44-0.
  • 2024: LB 1284 (State Sen. Lynne Walz of Fremont, with LB 1253 and LB 1254 from Linehan) — Established the $500,000 Dyslexia Research Grant Program for Nebraska companies researching the use of artificial-intelligence-based writing assistance for students with dyslexia. The Nebraska Department of Education is also required to develop and implement a professional learning system for evidence-based reading instruction for teachers who teach children up to third grade how to read. Passed 42-0.
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Nebraska immunization task force advocates for better vaccine access, education

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Nebraska immunization task force advocates for better vaccine access, education


OMAHA, Neb. (WOWT) – A volunteer task force, made up of healthcare providers across Nebraska, is getting the support of Governor Jim Pillen in bolstering awareness for immunizations.

This week, the Chair of Nebraska’s Immunization Task Force, Andrew Raduechel, joined Governor Pillen as he signed a proclamation for National Immunization Awareness Month in August.

It’s a show of support for the coalition, which has spent more than 30 years working to improve access to vaccines by combatting educational and financial barriers in Nebraska communities.

“Vaccines are really safe and effective. There’s a lot of misinformation out there about vaccines,” said Raduechel, who is also the Director of Pharmacy at Boys Town National Research Hospital.

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Nebraska Governor Jim Pillen recognizes
August as National Immunization Awareness Month with the signing of a proclamation on August 19, 2024.
(Andrew Raduechel)

Boys Town is one of various healthcare providers, such as Children’s Nebraska, CHI Health, Methodist Health System, and other community groups, agencies, and medical scientists on the task force.

“Really, we’re looking for outreach across the state. We’re slowly adding more and more folks from central and western Nebraska,” said Raduechel.

Raduechel said routine vaccination rates are slowly coming back after falling during the pandemic, but they’re still seeing some hesitancy.

“The risks side of it has been largely overblown. A lot of people are scared to get the vaccines, because they think they’re going to have some adverse event, when it just simply isn’t true and it’s incredibly rare,” told Raduechel.

Raduechel added that feeling a little sick after getting a COVID or influenza shot is normal and common. “It means it’s creating a response in your body, that’s a good thing. Having that protection is much better than actually experiencing that disease at some point,” said Raduechel.

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He said COVID still poses a significant health risk. “We just saw some statistics where the fatality from COVID is three-times that of flu still with the new strain,” explained Raduechel.

Chair of Nebraska’s Immunization Task Force, Andrew Raduechel, speaks with 6 News' Erin...
Chair of Nebraska’s Immunization Task Force, Andrew Raduechel, speaks with 6 News’ Erin Sullivan about National Immunization Awareness Month.(WOWT)

The FDA approved updated COVID-19 vaccines on Thursday that protect against new strains. A combination COVID-flu shot will not be available this year, but Raduechel said it’s likely on the horizon.

“We don’t have anything for the 2024-25 season. We’re hopefully though that certainly will help with rates of people getting the vaccine. One less decision, one less shot,” said Raduechel.

If you’re unsure about a vaccine, it’s recommended that you have a conversation with a healthcare professional you trust.

For those who are uninsured or underinsured, the Douglas County Health Department hosts an immunization clinic for children every Tuesday morning and also offers appointments for adults.

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