COVID-19 Mortality and Progress Toward Vaccinating Older Adults - World Health Organization, Worldwide, 2020-2022

After the emergence of SARS-CoV-2 in late 2019, transmission expanded globally, and on January 30, 2020, COVID-19 was declared a public health emergency of international concern.* Analysis of the early Wuhan, China outbreak (1), subsequently confirmed by multiple other studies (2,3), found that 80% of deaths occurred among persons aged ≥60 years. In anticipation of the time needed for the global vaccine supply to meet all needs, the World Health Organization (WHO) published the Strategic Advisory Group of Experts on Immunization (SAGE) Values Framework and a roadmap for prioritizing use of COVID-19 vaccines in late 2020 (4,5), followed by a strategy brief to outline urgent actions in October 2021.^† WHO described the general principles, objectives, and priorities needed to support country planning of vaccine rollout to minimize severe disease and death. A July 2022 update to the strategy brief^§ prioritized vaccination of populations at increased risk, including older adults,^¶ with the goal of 100% coverage with a complete COVID-19 vaccination series** for at-risk populations. Using available public data on COVID-19 mortality (reported deaths and model estimates) for 2020 and 2021 and the most recent reported COVID-19 vaccination coverage data from WHO, investigators performed descriptive analyses to examine age-specific mortality and global vaccination rollout among older adults (as defined by each country), stratified by country World Bank income status. Data quality and COVID-19 death reporting frequency varied by data source; however, persons aged ≥60 years accounted for >80% of the overall COVID-19 mortality across all income groups, with upper- and lower-middle-income countries accounting for 80% of the overall estimated excess mortality. Effective COVID-19 vaccines were authorized for use in December 2020, with global supply scaled up sufficiently to meet country needs by late 2021 (6). COVID-19 vaccines are safe and highly effective in reducing severe COVID-19, hospitalizations, and mortality (7,8); nevertheless, country-reported median completed primary series coverage among adults aged ≥60 years only reached 76% by the end of 2022, substantially below the WHO goal, especially in middle- and low-income countries. Increased efforts are needed to increase primary series and booster dose coverage among all older adults as recommended by WHO and national health authorities.

Evaluating newly approved drugs for multidrug-resistant tuberculosis (endTB): study protocol for an adaptive, multi-country randomized controlled trial

BACKGROUND

Treatment of multidrug- and rifampin-resistant tuberculosis (MDR/RR-TB) is expensive, labour-intensive, and associated with substantial adverse events and poor outcomes. While most MDR/RR-TB patients do not receive treatment, many who do are treated for 18 months or more. A shorter all-oral regimen is currently recommended for only a sub-set of MDR/RR-TB. Its use is only conditionally recommended because of very low-quality evidence underpinning the recommendation. Novel combinations of newer and repurposed drugs bring hope in the fight against MDR/RR-TB, but their use has not been optimized in all-oral, shorter regimens. This has greatly limited their impact on the burden of disease. There is, therefore, dire need for high-quality evidence on the performance of new, shortened, injectable-sparing regimens for MDR-TB which can be adapted to individual patients and different settings.

METHODS

endTB is a phase III, pragmatic, multi-country, adaptive, randomized, controlled, parallel, open-label clinical trial evaluating the efficacy and safety of shorter treatment regimens containing new drugs for patients with fluoroquinolone-susceptible, rifampin-resistant tuberculosis. Study participants are randomized to either the control arm, based on the current standard of care for MDR/RR-TB, or to one of five 39-week multi-drug regimens containing newly approved and repurposed drugs. Study participation in all arms lasts at least 73 and up to 104 weeks post-randomization. Randomization is response-adapted using interim Bayesian analysis of efficacy endpoints. The primary objective is to assess whether the efficacy of experimental regimens at 73 weeks is non-inferior to that of the control. A sample size of 750 patients across 6 arms affords at least 80% power to detect the non-inferiority of at least 1 (and up to 3) experimental regimens, with a one-sided alpha of 0.025 and a non-inferiority margin of 12%, against the control in both modified intention-to-treat and per protocol populations.

DISCUSSION

The lack of a safe and effective regimen that can be used in all patients is a major obstacle to delivering appropriate treatment to all patients with active MDR/RR-TB. Identifying multiple shorter, safe, and effective regimens has the potential to greatly reduce the burden of this deadly disease worldwide.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02754765. Registered on 28 April 2016; the record was last updated for study protocol version 3.3, on 27 August 2019.

Examining the Association Between States of Consciousness and the Coma Recovery Scale–Revised: A Rasch Analysis

Date Presented 04/9/21

OTs use the Coma Recovery Scale–Revised (CRS–R) to evaluate and make treatment decisions for individuals with disorders of consciousness (DoC) after a brain injury. This session will describe psychometric properties of the assessment and examine the association with state of consciousness. State of consciousness influences how therapists think about the patient’s prognosis, plan of care, and rehabilitation outcomes.

Primary Author and Speaker: Jennifer Weaver

Additional Authors and Speakers: Sara Stephenson

Collapse

A Retrospective Analysis on Clinical Practice-Based Approaches Using Zolpidem and Lorazepam in Disorders of Consciousness

This is a retrospective study to investigate the results of using zolpidem and lorazepam in persons with disorders of consciousness (DoC) and to provide practical information for clinical application and further studies. The cohort included 146 patients (11 hemorrhagic stroke, 87 traumatic brain injury (TBI), 48 anoxic brain injury (ABI)) admitted to a specialized DoC rehabilitation program. A positive trial indicated a patient responded to either zolpidem or lorazepam with prominent functional improvements necessitating routine use of the medication. Non-responders had equivocal or negative (i.e., went to sleep) responses. Eleven patients with a stroke who had either medication were all non-responders. Of the remaining 135 patients, 95 received at least one medication trial. The overall positive rate was 11.6% (11/95), with 6.3% (5/79) for zolpidem and 14.0% (6/43) for lorazepam. Among TBI patients, the positive rate of the zolpidem trial (10.2%, 5/49) was slightly higher than that of the lorazepam trial (6.9%, 2/29; p > 0.05). Among ABI patients, the positive rate of the lorazepam trial (28.6%, 4/14) was significantly higher than that of the zolpidem trial (0%, 0/30; p = 0.007). Following a positive trial, most patients were continued on the medications on a regular basis before eventual discontinuation. Our results suggested the etiology of DoC, considering traumatic vs. anoxic injuries, may serve in guiding the clinical application of these medications in the treatment of DoC and in future prospective studies. We advocate for screening all patients with DoC using zolpidem and/or lorazepam.

Many Faces of the Hidden Souls: Medical and Neurological Complications and Comorbidities in Disorders of Consciousness

Early and goal-directed management of complications and comorbidities is imperative to facilitate neurorecovery and to optimize outcomes of disorders of consciousness (DoC). This is the first large retrospective cohort study on the primary medical and neurological complications and comorbidities in persons with DoC. A total of 146 patients admitted to a specialized inpatient DoC rehabilitation program from 1 January 2014 to 31 October 2018 were included. The incidences of those conditions since their initial brain injuries were reviewed per documentation. They were categorized into reversible causes of DoC, confounders and mimics, and other medical/neurological conditions. The common complications and comorbidities included pneumonia (73.3%), pain (75.3%), pressure ulcers (70.5%), oral and limb apraxia (67.1%), urinary tract infection (69.2%), and 4-limb spasticity (52.7%). Reversible causes of DoC occurred very commonly. Conditions that may confound the diagnosis of DoC occurred at surprisingly high rates. Conditions that may be a source of pain occurred not infrequently. Among those that may diminish or confound the level of consciousness, 4.8 ± 2.0 conditions were identified per patient. In conclusion, high rates of various complications and comorbidities occurred in persons with DoC. Correcting reversible causes, identifying confounders and mimics, and managing general consequences need to be seriously considered in clinical practice.

2213. Etiology of Community-Acquired Pneumonia (CAP) in Hospitalized Native American Adults

Background

Methods

Results

Conclusion

Disclosures

1835. High Burden of Invasive Staphylococcus aureus Disease Among Native Americans on the White Mountain Apache Tribal Lands

Background

Native Americans in the southwestern United States (US) have a higher risk of many infectious diseases than the general US population. The objective of this study was to determine the burden of invasive Staphylococcus aureus disease among Native Americans on the White Mountain Apache (WMA) Tribal lands.

Methods

Prospective population and laboratory-based surveillance for invasive S. aureus infections was conducted from May 2016 through April 2018. A case was defined as a Native American individual living on or around the WMA Tribal lands with S. aureus isolated from a normally sterile site. Incidence rates were calculated using the Indian Health Service User Population as the denominator. Age-standardized incidence rates were calculated by direct standardization methods using US Census data from 2015 as the reference.

Results

Fifty-three cases were identified (Year 1: 24; Year 2: 29). Most cases were adults (90.6%; median age: 47.4 years) and had ≥1 underlying medical condition (86.8%), of which the most common were obesity (50.0%) and diabetes (50.0%). 26.4% of cases were categorized as community acquired. Most infections were methicillin-resistant (MRSA; 75.5%). 88.7% of cases were hospitalized, 7.5% required amputation, and 7.7% died within 30 days of the initial culture. The overall incidence of invasive S. aureus was 156.3 per 100,000 persons (95% confidence interval [CI]: 119.4, 204.5) with no significant difference in the incidence by year (Year 1: 141.5; Year 2: 171.1; incidence rate ratio: 1.21; 95% CI: 0.70, 2.08). The overall incidence of invasive MRSA was 118.0 per 100,000 persons (95% CI: 86.5, 160.8) with no significant difference by year (Year 1: 106.1; Year 2: 129.8; incidence rate ratio: 1.22; 95% CI: 0.66, 2.28). The incidence of invasive S. aureus and MRSA increased with age and was highest among individuals 50–64 years of age. The overall age-adjusted incidence of invasive MRSA was 138.2 per 100,000 persons (Year 1: 125.2; Year 2: 150.9, for comparison US 2015 general population: 18.8 per 100,000 persons).

Conclusion

The WMA community has one of the highest reported incidence rates globally of invasive MRSA. Interventions are urgently needed in this community to reduce the morbidity and mortality associated with these infections.

Disclosures

All Authors: No reported Disclosures.

555. The Burden of Invasive Staphylococcus Aureus Disease Among Native Americans on the Navajo Nation

Background

Native Americans in the southwestern United States (US) may be at higher risk for invasive infections due to Staphylococcus aureus. The objective of this study was to determine the burden of invasive S. aureus among Native Americans on the Navajo Nation.

Methods

Prospective population and laboratory-based surveillance for invasive S. aureus infections was conducted from May 2016 through April 2018. A case was defined as a Native American individual living on or around the Navajo Nation with S. aureus isolated from a normally sterile body site. Incidence rates were calculated using the Indian Health Service User Population from 2016 and 2017 as the denominators for Years 1 and 2, respectively. Age-standardized incidence rates were calculated using US Census data from 2015 as the reference group.

Results

363 cases were identified (Year 1: 159; Year 2: 204). Most cases were adults (96.9%; median age: 56.0 years) and had ≥1 underlying medical condition (94.5%), of which the most common were diabetes (63.2%), hypertension (39.1%), and obesity (37.2%). 38.0% of cases were categorized as community acquired and 28.7% of infections were methicillin-resistant (MRSA). 83.2% of cases were hospitalized, 10.7% required amputation, and 6.5% died within 30 days of the initial culture. The overall incidence of invasive S. aureus was 74.4 per 100,000 persons (95% confidence interval [CI]: 67.1, 82.4) with a significantly higher incidence in the second year (Year 1: 64.9; Year 2: 84.0; incidence rate ratio: 1.29; 95% CI: 1.05, 1.59). The overall incidence of invasive MRSA was 21.3 per 100,000 persons (95% CI: 17.6, 25.8) with no significant difference by year (Year 1: 21.2; Year 2: 21.4; incidence rate ratio: 1.01; 95% CI: 0.69, 1.48). The incidence of invasive S. aureus and MRSA increased with age and was highest among individuals ≥65 years of age. The overall age-standardized incidence of invasive MRSA was 25.9 per 100,000 persons (Year 1: 26.0; Year 2: 25.7; for comparison US 2015 general population: 18.8 per 100,000 persons).

Conclusion

The Navajo Nation has a higher burden of invasive MRSA than the general US population. Further research is needed to evaluate trends over time and identify prevention strategies and opportunities for intervention.

Disclosures

All authors: No reported disclosures.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Global invasive bacterial vaccine-preventable diseases surveillance--2008-2014

Meningitis and pneumonia are leading causes of morbidity and mortality in children globally infected with Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis, and Haemophilus influenzae causing a large proportion of disease. Vaccines are available to prevent many of the common types of these infections. S. pneumoniae was estimated to have caused 11% of deaths in children aged <5 years globally in the pre-pneumococcal conjugate vaccine (PCV) era. Since 2007, the World Health Organization (WHO) has recommended inclusion of PCV in childhood immunization programs worldwide, especially in countries with high child mortality. As of November 26, 2014, a total of 112 (58%) of all 194 WHO member states and 44 (58%) of the 76 member states ever eligible for support from Gavi, the Vaccine Alliance (Gavi), have introduced PCV. Invasive pneumococcal disease (IPD) surveillance that includes data on serotypes, along with meningitis and pneumonia syndromic surveillance, provides important data to guide decisions to introduce PCV and monitor its impact.

Treatable childhood neuronopathy caused by mutations in riboflavin transporter RFVT2

Childhood onset motor neuron diseases or neuronopathies are a clinically heterogeneous group of disorders. A particularly severe subgroup first described in 1894, and subsequently called Brown-Vialetto-Van Laere syndrome, is characterized by progressive pontobulbar palsy, sensorineural hearing loss and respiratory insufficiency. There has been no treatment for this progressive neurodegenerative disorder, which leads to respiratory failure and usually death during childhood. We recently reported the identification of SLC52A2, encoding riboflavin transporter RFVT2, as a new causative gene for Brown-Vialetto-Van Laere syndrome. We used both exome and Sanger sequencing to identify SLC52A2 mutations in patients presenting with cranial neuropathies and sensorimotor neuropathy with or without respiratory insufficiency. We undertook clinical, neurophysiological and biochemical characterization of patients with mutations in SLC52A2, functionally analysed the most prevalent mutations and initiated a regimen of high-dose oral riboflavin. We identified 18 patients from 13 families with compound heterozygous or homozygous mutations in SLC52A2. Affected individuals share a core phenotype of rapidly progressive axonal sensorimotor neuropathy (manifesting with sensory ataxia, severe weakness of the upper limbs and axial muscles with distinctly preserved strength of the lower limbs), hearing loss, optic atrophy and respiratory insufficiency. We demonstrate that SLC52A2 mutations cause reduced riboflavin uptake and reduced riboflavin transporter protein expression, and we report the response to high-dose oral riboflavin therapy in patients with SLC52A2 mutations, including significant and sustained clinical and biochemical improvements in two patients and preliminary clinical response data in 13 patients with associated biochemical improvements in 10 patients. The clinical and biochemical responses of this SLC52A2-specific cohort suggest that riboflavin supplementation can ameliorate the progression of this neurodegenerative condition, particularly when initiated soon after the onset of symptoms.

A phase I study of CNTO328, an anti-interleukin (IL)-6 monoclonal antibody combined with docetaxel in subjects with metastatic castration-resistant prostate cancer (CRPC)

5063

Background: IL-6 is a potential mediator of prostate cancer morbidity and mortality and may protect prostate cancer cells from chemotherapy-induced apoptosis. CNTO328, a chimeric anti-IL-6 antibody, has been shown to inhibit prostate tumor growth in xenograft mouse models. Methods: Chemotherapy-naïve patients with metastatic CRPC were administered CNTO328 in combination with T (75 mg/m2 q3w) in 3 dose-escalation cohorts (6 mg/kg q2w, and 9 and 12 mg/kg q3w) following an initial run-in cycle of T alone to examine the effect of CNTO328 on T pharmacokinetics (PK). Safety was evaluated prior to each dose escalation. Prostate specific antigen (PSA), radiological response, and C-reactive protein (CRP), the best-known surrogate of serum IL-6 bioactivity, were also assessed. Results: This study is fully enrolled December 2008 with 38 patients. 36 patients with KPS ≥70, median age 66 (range 43–82) received 6 (median) cycles of T (range 1–37). 32 patients received at least one dose of CNTO328 in combination with T and are evaluable. Baseline patient characteristics included: median PSA of 59 ng/mL (range 12–1430) and median CRP was 3.85 mg/L (range <1 to 91.3). One DLT was observed in each cohort (grade 4 neutropenic infection, grade 3 syncope and dehydration, grade 3 GI bleeding), though MTD for the combination was not reached. Most frequent ≥grade 3 adverse events (AE) were neutropenia (69%); leukopenia (63%); lymphopenia (31%); dyspnea (19%); fatigue (16%). One patient died due to AE (sepsis) reported as possible related to T and unlikely related to CNTO328 by investigator. Preliminary data show CNTO328 does not appear to have a major effect on T PK. Preliminary efficacy data is shown in the table . Ongoing evaluation indicates 3/12 partial responses in patients with measurable disease reported thus far. Conclusions: CNTO328 with T is well tolerated and demonstrates biological and clinical activity in CRPC that warrants further study.

[Table: see text]

[Table: see text]

Phase II study of the farnesyl transferase inhibitor tipifarnib plus fulvestrant in postmenopausal patients with hormone receptor-positive breast cancer: New York Cancer Consortium Trial P6205

1037

Background: Tipifarnib and fulvestrant both have single agent activity in hormone receptor-positive (HR+) metastatic breast cancer (MBC), and tipifarnib enhances the activity of anti-estrogens in HR+ breast cancer cell lines. Methods: Eligibility criteria: measurable HR+ MBC, postmenopausal status, ECOG PS of 0–2, and no prior chemotherapy for MBC. Treatment: fulvestrant 250 mg IM on day 1 plus oral tipifarnib 300 mg BID on days 1–21 every 28 days (defined as one cycle). Response was evaluated by RECIST criteria every 3 cycles. The study was suspended for efficacy/futility analysis after 33 of 46 patients were accrued. It was designed to detect an improvement in clinical benefit rate (CBR; defined as objective response or stable disease for at least 24 weeks) from 50% to 70% (90% power, type I error 10%), and would require at least 26 of 42 eligible/evaluable patients to have clinical benefit (CB). The expected CBR for fulvestrant alone is 30% in aromatase inhibitor (AI) resistant disease (Ingle, 2006), 45% in tamoxifen (tam)-resistant disease (Osborne, 2002), and 60% when used as first line endocrine therapy (ET) (Howell, 2004). Results: Of 33 patients enrolled, 28 are currently assessable for CBR (2 were ineligible, and 3 have stable disease for < 6 months and remain on treatment). Grade 3/4 toxicity: neutropenia (15%), pain (11%) and gastrointestinal toxicity (11%). Tipifarnib was either reduced in dose (N=10) or discontinued (N=8) due to toxicity or non-compliance. The overall CBR is shown; should accrual continue, all 14 evaluable patients must have CB in order to meet the pre-specified efficacy objective. For the ET-resistant group, 18 were resistant to AI therapy (or AI plus tam in 5) and 2 to tam. * Number eligible/evaluable for CBR. Conclusions: The tipifarnib-fulvestrant combination is not likely to produce a CBR of at least 70%. The 45% CBR in ET-resistant disease may merit further evaluation in this setting.

[Table: see text]

No significant financial relationships to disclose.

Phase II trial of FOLFOX6, bevacizumab and cetuximab in patients with Colorectal Cancer

4075

Background: Bevacizumab (B) + FOLFOX is widely accepted as a standard first-line therapy for metastatic colorectal cancer (mCRC). Recent treatment strategies have included the use of targeted therapies combined with chemotherapy to improve efficacy and to reduce chemotherapy-related toxicities. This Phase II study assesses first-line mFOLFOX6 + B + cetuximab (C), a monoclonal antibody approved for use in irinotecan-refractory mCRC. Methods: All pts had ECOG PS = 1, normal bone marrow, hepatic and renal function. Pts received mFOLFOX6 + B (5mg/kg) biweekly and C weekly (initially at 400 mg/m2, then subsequent doses at 250 mg/m2). Tumor assessment by imaging was done every 8 weeks. Primary endpoints are response rate, progression free-survival (PFS), overall survival (OS), and safety. The regimen would be considered promising if there were = 32 responses, or if = 60% of pts were progression-free for at least 8 months. Results: 67 pts (37 males, 30 females) were enrolled from 12/04–11/06. Median age was 57. Toxicities included Grade 4: neutropenia (6%), thrombosis/embolism (5%). Grade 3: neutropenia (13%), rash (13%), fatigue (11%), diarrhea (11%), abdominal pain (6%), neuropathy (5%), infection with ≤ Grade 2 ANC (4.5%). There were 2 deaths, 1 due to neutropenia and diarrhea and 1 to pulmonary fibrosis. As of 12/06, 9 pts were too early to evaluate. Of the remaining 58 pts, there were 32 responses (55%; 95% CI: 42%, 68%), including 3 CRs and 29 PRs; Median PFS was 9.6 months (95% CI: 8.8, 13.9 months), 71% were progression-free for at least 8 months, and median OS was not reached after a median follow-up of 11.4 months (range 1.5–25.2 months). Conclusions: Treatment with mFOLFOX6+ B + C met the pre-specified criteria for objective response and PFS to be considered promising. This regimen is associated with an acceptable toxicity profile and merits further evaluation. Supported by N01-CA-62204.

No significant financial relationships to disclose.

Detection of Escherichia coli Enterotoxins by Using Mouse Adrenal Cell and Suckling Mouse Assays: Collaborative Study

The ability of 10 Escherichia coli strains to produce heat-stable enterotoxin (ST) and heat-labile enterotoxin (LT) was determined by 8 analysts in a collaborative study. The suckling mouse model and the mouse adrenal cell line (Y-l) tests were used to detect ST and LT, respectively. Cultures for assay were grown 24 h in casamino acid-yeast extracttrace salts broth at 37°C in a shaker incubator at 250 rpm. Cell-free culture broth prepared by centrifugation and filtration was divided into 2 portions: One was heated for 30 min and used both for ST assay and as a heated control for LT assay; the other was used unheated for LT assay. Results were expressed as positive for ST, positive for LT, positive for ST and LT, or negative for both ST and LT; percent of correct estimates was calculated for each culture for each analyst. At the 95% confidence interval, the overall correct results were 96.3 ± 2.9 and 95.0 ± 3.4% for ST and LT, respectively. The test performances thus were satisfactory for detecting ST and LT produced in vitro by E. coli. The method has been adopted official first action.