Keeping Kids Alive
Child Death Review in the United States, 2020

June 2021

The National Center is funded in part by Cooperative Agreement Number
UG7MC28482 from the US Department of Health and Human Services(HHS), Health Resources and Services Administration (HRSA), Maternaland Child Health Bureau (MCHB) as part of an award totaling $799,998
annually with 0 percent financed with nongovernmental sources. The
contents of this guidance are solely the responsibility of the authors andshould not be construed as the official position or policy of, nor should
any endorsements be inferred by HRSA, HHS or the U.S. Government.

Status of CDR in the United States| 2

TABLE OF CONTENTS
Introduction ...................................................................................................................................................6
CDR in 2020: Effects of COVID-19………………………………………………………………………………………..7
Report Highlight Summary .........................................................................................................................8
Teams ........................................................................................................................................................... 10
Structure.................................................................................................................................................. 10
State vs. local models ................................................................................................................. 10
State advisory boards ................................................................................................................. 10
Statutes and rules that apply to CDR .......................................................................................... 11
Staffing ....................................................................................................................................... 11

Regions ................................................................................................................................................ 14
Lead Agency ............................................................................................................................................... 15
Case Selection ............................................................................................................................................ 16
Review Process .......................................................................................................................................... 18
Partners ................................................................................................................................................... 18
Coordination with other reviews ....................................................................................................... 19
The National Fatality Review-Case Reporting System ...................................................................... 21
Partner projects ..................................................................................................................................... 22
Prevention................................................................................................................................................... 23
Examples ................................................................................................................................................. 23
Conclusion .................................................................................................................................................. 25

Status of CDR in the United States| 3

Source of Information:
The National Center for Fatality Review and Prevention State Profile Database:
Reports from State Child Death Review Program Coordinators
State Child Death Review Coordinators are surveyed bi-annually on the status of theirprograms. In spring 2021, they were surveyed regarding their 2020 activities. Thirty-sevenprograms responded to the survey. For states that did not respond, their most recent
responses were used in compiling data for this report.
Citation:
The National Center for Fatality Review and Prevention. Keeping Kids Alive: Child Death Review
in the United States, 2020. Michigan Public Health Institute, 2021.

1-800-656-2434 | info@ncfrp.org | 2395 Jolly Road, Suite 120 Okemos, MI 48864
www.ncfrp.org©Michigan Public Health Institute, June 2020

Status of CDR in the United States| 4

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Status of CDR in the United States| 5

Keeping Kids Alive
Child Death Review in the United States, 2020

Introduction
Each year almost 40,000 children, ages 0-18, die in the United States. Child Death Review(CDR) is a process in which local or state-level multidisciplinary teams meet to share anddiscuss case information in order to understand how and why children die. Diverse agencies
send representatives to the case review meeting to share relevant records to help the teamcreate a complete picture of the factors that increased risk. Teams use this information tocatalyze action to make their communities safer.

The ultimate goal of a CDR team is to take action to prevent future deaths.
The National Center for Fatality Review and Prevention (National Center) is funded by theMaternal Child Health Bureau (MCHB) of the Health Resources and Services Administrations(HRSA), United States Department of Health and Human Services, to provide technicalassistance, training, and data support to CDR and Fetal and Infant Mortality Review (FIMR)
programs across the country.
There are CDR programs in every state, the District of Columbia, and several Native
American/Alaska Native tribes. These systems differ in their scope both at the state and local
level. They vary in composition of state and local teams, level of state support, placement ofadministrative leadership, supporting legislation, the types of deaths reviewed, and reporting
systems used. To better understand these similar but diverse programs, the National Center
conducts a bi-annual query of state-level CDR program leaders to assess program status. The
following report is a synopsis of the responses from 2021 and represent the status of the
programs in calendar year 2020.
The purpose of this report is to provide a summary of the status of child fatality review
programs across the United States in 2020: what agencies participate in and fund them; thelegal bounds within which they function; factors that guide case selection within states; howdata are collected and used; and actions teams take to decrease childhood fatalities.
The National Center provides this report to inform review teams, their partners, local, state,
and federal governments, and other concerned parties about the breadth, diversity, andimpact of the child death review process. The information in the following report is not static,
as states often make changes to their programs, adopt new legislation to support theirprograms, or build new teams; it provides a comprehensive snapshot of the status of CDR in
the United States in 2020. More complete information and links to individual state programs
can be found on the National Center website (www.ncfrp.org).

Status of CDR in the United States| 6

CDR in 2020: Effects of COVID-19
The majority of CDR programs are led by state health departments, and all of them rely on
multidisciplinary teams meeting in person to review cases. Prior to the pandemic, many teams
were prohibited from meeting virtually due to confidentiality concerns and legislativerequirements. During the pandemic, states and agencies were impacted in different ways, andCDR programs responded differently.

While in-person review meetings continued in some jurisdictions, mostteams responded by meeting remotely or temporarily halting reviews.
In addition to stay-at-home orders and new remote work requirements, some state and local
teams faced reassignment of key staff in support of the COVID-19 response—to activities
such as surveillance, contact tracing, or COVID testing. Even after the worst of the pandemic
had passed, some staff continued to be reassigned to support mass vaccination efforts. In
many jurisdictions, teams’ ability to conduct reviews was a moving target throughout the year,
as some were early adopters of virtual platforms. COVID-19 did not impact each jurisdiction
similarly, and state policies related to COVID-19 varied.

State and local programs displayed creativity and resilience in the face of thechallenges of 2020. They shared effective strategies in regional networking
opportunities and through the National Center’s listserv.
Not surprisingly, there were fewer cases entered into the National Fatality Review-Case
Reporting System in 2020, compared to the previous year. In 2019, CDR programs entered
1180 cases per month on average; in 2020, they entered 980 cases per month on average.
Even when CDR systems continued to review cases or resumed reviews, the pandemicpresented challenges to completing case reviews, including:▪

Team member/staff deployments▪

Lag in access to death certificates▪

Delay in receiving records from other agencies▪

Building capacity for remote meetings▪

Challenges with case identification▪

Records had less information than usual

Status of CDR in the United States| 7

Report Highlight SummaryChild Death Review (CDR) is a multidisciplinary, preventionfocused process where teams meet to discuss case information
to better understand how and why children die.

There are CDR teams in all 50 states, the District ofColumbia, and within tribes.

55%of these teams are led by state healthdepartments. Others are led by social service
agencies, medical examiners offices, attorneys
general or departments of justice.

71%

of states mandate a state CDR program.

16%of states permit CDR based on legislation or administrative rules.

37%of states mandate local CDR teams.

Another 26%
43

permit local CDR.

states have CDR state advisory boards.

Status of CDR in the United States| 8

Cases are reviewed by local and state-level teams.

18

19

programs
only review
cases locallyreviewcases
at state& locallevels14
programs
only review
cases at thestate level

10 states also review selected near-fatal injuries. Near-

fatal injuries and fatalities can be studied together tobetter support injury prevention efforts.

46 states use the National Fatality Review-Case
Reporting System (NFR-CRS) to collect datafrom CDR reviews.

There were more than

239,000 cases in the NFR-CRS by the end of 2020.
CDR teams commonly collaborate with otherreview processes, including:• Citizen Review Panels• Fetal and Infant Mortality Review• Domestic Violence Fatality Review• Maternal Mortality Review• Suicide Fatality Review• Homicide Fatality Review• Other Child Abuse and Neglect Reviews• Overdose Fatality Review

Status of CDR in the United States| 9

TeamsComposition of state and local CDR teams vary, but standard participating
professional representation includes:▪ Child welfare• More than 1,350 CDR Teams▪

Public health• All 50 states▪

Pediatrics▪

Law enforcement• Washington, D.C. and Tribal
Nations▪

Prosecutors▪

Medical examiners or coroners▪

Injury prevention professionals▪

Mental health professionals▪

Suicide prevention professionals▪

First responders

Team participants bring relevant case records from their respective agencies to case review
meetings to help create the full picture of the child’s life environment and factors contributing
to how and why a child died. Teams identify risk factors, protective factors, systems gaps androot causes contributing to the deaths. This information is used to catalyze prevention actions
at the local and/or state level to prevent similar deaths in the future.

Structure
State vs. local models
While every state and the Districtof Columbia has a CDR system,
these systems differ in theirscope at both the state and local
level. Every state conducts
review
reviews, but they vary in terms of
only review
only review
cases
how and where the reviews arecases locallycases at theat state
conducted. Some states conduct
state level& localfatality reviews in a state-level
levelscontext; others conduct locallevel reviews, often at the county
level, contributing their data to alarger, state-level dataset tosupport broader prevention efforts. In some states, reviews take place at both the local level
and the state level. Some state programs select certain cases to review for quality assurance,

35% 37% 27%

Status of CDR in the United States| 10

or to inform the state team and contextualize the data from local programs. States’
approaches vary based on several factors, including state statutes, geography, population sizeand density, funding, and program staffing.

Annual CDR training was provided by 47% of state programs in 2020, while 33% ofstate programs provided training on use of the National Fatality Review-Case
Reporting System.
State CDR programs provided broad programmatic support to stateand local review teams in 2020.
100%

98%
90%

84%

80%

73%

67%

60%

51%
41%

40%
20%
0%

Other functions of state programs included:▪ Generating reports▪

Collaborating with other partners or programs for prevention▪

Providing investigative assistance to local agencies upon request▪

Analyzing findings, recommendations, and fatality review data

State advisory boards

43 states had a state-level

Most states convene a state-leveladvisory board for CDR.
advisory board, regardless of which
agency leads the effort or whether
reviews take place in state or local contexts, Advisory boards work to:▪

Understand case review findings, data, and recommendations▪

Craft and advance state-level recommendations
Status of CDR in the United States| 11▪

Write annual reports▪

Conduct state-level reviews when appropriate

It is common for state advisory teams to have subcommittees focused on specific causes ofdeath, such as sleep-related infant death, child abuse and neglect, and suicide. They often
produce required reporting to state legislatures, governors, or other specific agencies; partnerwith other fatality review processes; and provide guidelines and protocols for local casereview teams.
Statutes and rules that apply to CDR
Most states (44) havelegislation or administrative
In 2020, 44 states had laws or rules thatrules that mandate or permit
mandated or permitted state CDR processes.
a state CDR program. These
statutes may make it easierfor teams to access caserecords for review, create a14%reporting mechanism forteams to inform specificagencies, the governor, or
Mandated
16%
legislature of their findings
and recommendations, orPermitted
require agencies to respondNot addressedto or act on CDR
70%
recommendations. Language
mandating fatality review
generally facilitates
improved records sharing
with CDR teams. Permissive
language generally facilitates a more responsive programmatic approach. In general, whether
mandated language or permissive language, a higher level of specificity in legislative language
can sometimes limit program flexibility.

Local CDR teams are mandated under state statute/rules in 19 states andpermitted under similar policies in 13 states.

Staffing
Programs have diverse levels of funding and staffing to support state
CDR activities. These are significantly impacted by state budgets. Statelevel full time equivalent staff positions (FTEs) dedicated to CDR ranged
from 0 to 6 across states; the median FTE for state programs was 1.5
FTE, and the average was 1.8. At the local level, FTEs ranged from 0 to
10 FTEs; the median was 1 FTE, and the average was 2.14.
State-level funding amounts ranged from $0 per year—relying heavily on
in-kind support from partnering programs—to $1.2 million per year. The
Status of CDR in the United States| 12median funding amount was $150,000; the average amount was $247,708. This diversity ofstaffing and financial support can influence program capacity, caseloads and case selection
criteria. Several states provide funding to support local CDR teams.
Federal grants were the most commonly reported source of funding to state-level programs;
state general funds and agency funds were the most commonly reported source of local CDR
funding. The most common sources of federal funding that states allocate to support CDR at
the state level are Health Resources and Services Administration (HRSA)-administered Title V
Block Grants—or Maternal Child Health (MCH) Block Grant funds; Sudden Unexpected Infant
Death/ Sudden Death in the Young Case Registry (SUID/SDY) funds; Child Abuse Prevention
and Treatment Act (CAPTA) funding; and Children’s Justice Act funds.

20

Federal funds were the most common source of funding tostate CDR programs in 2020. State funds were the mostcommon source of local CDR funding.
18

NUMBER OF STATES

15

10

10

5

Funding to support state CDR

8Funding to support local CDR

500
Title V
Funds

5

4

3
0

SUID/SDY Children's
Case
Justice Act
Registry

0

0

0

CAPTA

State
general
funds

State
agencyfunds

Status of CDR in the United States| 13

Regions

Fatality review is a unique function within states, and coordinators often do not have local
colleagues who can share lessons learned, provide input, or give advice from a place of indepth programmatic understanding.
The National Center for Fatality Review and Prevention (National Center) supported five
regional collaboratives for state CDR program participation, divided into West, Midwest,
Southeast, Mid-Atlantic, and Northeast. State coordinators participated in regional
collaborative opportunities, including regional coordinator community of practice calls in
2020. Each region has a coordinator from one of the participating states who works closelywith the National Center to plan and execute regional activities.
The regional networks provide opportunities for state CDR coordinators to interact withprofessional peers, share resources, learn from colleagues, and provide professional support
on a regular basis. These opportunities for shared problem solving were particularly valuable
in 2020, as state programs responded to the pandemic.

Status of CDR in the United States| 14

Lead Agency
Like many other aspects of CDR, the agency that leads coordination of programs varies bystate. The lead agency can influence diverse aspects of CDR teams including teamcomposition, natural program partnerships, types of cases reviewed, and the type ofrecommendations that result from reviews. Child death review began as a response to theunderreporting of child abuse and neglect-related fatalities, and as such, its roots are in childwelfare and social services disciplines. During the last decade, more CDR program
coordination has migrated to health departments.

While more than half of state programs were coordinated by the state healthdepartment in 2020, some were coordinated by social service agencies, medical
examiner’s offices, attorneys general, or departments of justice (DOJ).
In 2020, 3/4 of teams were coordinated by the state healthdepartment or social services agency.

14%
4%

Health department
Social services

8%
55%

Medical examiner

Attorney general/DOJ

19%

Other

Status of CDR in the United States| 15

Case selection
The selection of cases to be reviewed also varies by state. Throughout
the country, state-level teams are reviewing deaths from sudden andunexplained infant deaths (SUID), unintentional injuries, suicide,
homicide, abuse and neglect, and the deaths of children who were wardsof the state or had a history with child protective services. In 2020, there
was an increase in the number of states that reviewed SUID deaths,
deaths due to undetermined cause, child abuse and neglect deaths,
homicides, suicides, and deaths where the child had a history with social
services. There was a notable increase in the number of states reviewing cases where thechild was a ward of the state, from 75% to 92%. Case selection criteria are influenced bymultiple factors including:▪

Statutory requirements▪

Lead agency▪

Program capacity▪

Residency▪

Cause/manner of death▪

Medical examiner jurisdiction▪

AgeThis diversity of case selection criteria creates important context when examining
CDR data from the state level or aggregated at the national level.
Most states review cases with diverse causes of death.
100%
80%

100%

98%

98%

98%

96%

96%

96%

92%

90%
69%

60%
40%
20%
0%

Status of CDR in the United States| 16

Teams also use different age ranges for inclusion in fatality review. One state only reviews
deaths to children age 12 and younger. Seventy-eight percent of teams review deaths ofchildren and youth up to and including age 17 years. Four states include deaths occurring toyouth and young adults older than 18 years.
In addition to reviewing fatality cases, 10 states review some serious injuries or near fatalities
at either the state or local level. These cases provide important information to inform injury
prevention efforts.

In 2020, all reviews conducted at the state level were retrospective or
periodic in nature, while 10% of states also conducted some reviews
within 48 hours of the death at the local level.

Status of CDR in the United States| 17

Review ProcessStandardizing the fatality review process leads to better data, which
ultimately leads to more effective prevention and systems-improvement
efforts. Eighty-six percent of states have legislation or administrative
rules that mandate or permit the CDR process at the state level. Similar
statutes or rules permit or mandate local CDR reviews in 63% of states.
These regulations can determine or require such features as:▪

Confidentiality of CDR meeting records and discussions▪

Access to records▪

CDR program reporting▪

Designation of required state and local team members▪

Required review protocols▪

Protection of reviews from subpoenas/discovery and Freedom of Information Act (FOIA)
requests

Partners
The unique, multidisciplinary nature of fatality review is what makes it so effective. In
particular, the impact of teams’ prevention work is increased throughstrategic partnerships with injury prevention, maternal child health publichealth programs, child welfare agencies, and injury prevention coalitions.

Every state and the District of Columbia
reported formal coordination with their child welfare
agency in 2020.
Additionally:▪ 46 jurisdictions coordinated with their state maternal child health program▪

44 jurisdictions coordinated with their state injury prevention program▪

13 jurisdictions indicated that the state’s Safe Kids coordinator was on their advisory board,up from 9 in 2018▪

11 jurisdictions indicated that the state’s suicide prevention coordinator served on theiradvisory board, up from 9 in 2018

Status of CDR in the United States| 18

Coordination with other reviews
A commonly recognized best practice within CDR is programmatic coordination with othertypes of fatality reviews. It is common that a case that falls under the purview of CDR will also
be selected for review in a different fatality review process, such as a suicide or overdose
fatality case review. Additionally, CDR teams serve as the Child Abuse Prevention andTreatment Act (CAPTA) Citizen Review Panel (CRP) in 18 states, up from 16 in 2018. Under
CAPTA, states are required to convene CRPs to provide ongoing monitoring and annual
reporting on state efforts to meet child protection requirements1. Several states coordinate
their CDR and Fetal and Infant Mortality Review (FIMR) programs out of the sameadministrative office, sharing staff and other resources.

CDR coordinates with:•Child protective services review system in 27 states• Fetal & Infant Mortality Review (FIMR) in all 27 FIMR states• Citizen Review Panels (CRPs) in 25 states and D.C.
• Maternal Mortality Review (MMR) in 25 states• Domestic Violence (DV) fatality review in 20 states and D.C.
• Other SUID review in 15 states• Overdose review in 14 states• Suicide fatality review in 7 states• Homicide fatality review in 6 states

In 35 states, there is separate child abuse and neglect death review system in addition to
CDR. These are often conducted at the agency level to improve agency processes orprotocols; it is common for these agencies to be members of a CDR team. Overall, forty-sevenstates conduct internal agency-level reviews of child deaths.

Coordination with other fatality review processes has increased over time.
Between 2011 and 2020, based on state-level programmatic reporting:1▪

Programs coordinating with Maternal Mortality Review increased from 15 to 25.

▪

Programs coordinating with CRPs increased from 19 to 26.

▪

Programs coordinating with FIMR programs increased from 23 to 27.

Child Welfare Information Gateway.

https://www.childwelfare.gov/topics/management/administration/partnerships/oversight/cit
izen/
Status of CDR in the United States| 19

Programs coordinating with Sudden Unexpected Infant Death (SUID) reviews other than CDR
have increased 150%, from 6 to 15 from 2011 to 2020. In addition to reviews focused on
different types of deaths, military communities conduct their own child death reviews. Six
states partner with military CDR teams at either the state or local level, and 14 states havemilitary participation in their state or local CDR process, up from 11 in 2018.

Status of CDR in the United States| 20

National Fatality Review-Case Reporting System
In 2005, the National Center initiated its web-based National Fatality
Review Case Reporting System (NFR-CRS) and made it available at no
cost to all local and state CDR teams. In 2020, 46 states contributed
CDR data to the NFR-CRS, up from 44 states in 2018. There were over
239,000 cases in the NFR-CRS by the end of the year.
The data collected through fatality review is a rich data source thathighlights risk factors not available from other data sources. The natureof in-depth multidisciplinary case review through record sharing and deliberation provides
more contextual data, family history data, data on underlying health or psychosocial
vulnerability, and community systems to inform robust prevention planning.
In 2020, 43 states reported that they used their CDR data to produce Annual Reports.
Audiences for these reports include state governors, legislatures, state agencies, local teams,
and the general public. State and local teams also use the data to:▪

Identify risk and protective factors in child deaths▪

Inform prevention recommendations▪

Improve community systems

Partner projects
In 2020, 22 CDR states/jurisdictions were funded by the Centers for Disease Control andPrevention (CDC) to participate in the Sudden Unexpected Infant Death (SUID) Case Registry.
Through a collaboration with the National Institutes of Health (NIH), 13 of these awardees
were also funded to participate in the Sudden Death in the Young (SDY) expanded
component. Through these cooperative agreements, states or jurisdictions use NFR-CRS andexisting CDR programs as the foundation for reporting 100% of their SUID and/or SDY
deaths into the registry, providing population-level surveillance for those participating. For
more information on the SUID/SDY Case Registry, visit https://www.cdc.gov/sids/caseregistry.htm.

Status of CDR in the United States| 21

SUID and SDY Case Registry Jurisdictions

Status of CDR in the United States| 22

Prevention
The transition of state CDR program coordination from social service agencies to publichealth agencies likely influenced the evolution of CDR toward a prevention model.

Child death review teams have a strong focus on primary and secondary prevention
and systems-level improvements.
Examples of state-level prevention recommendations are highlighted below to illustrate thediverse actions CDR teams identified in 2020 to help prevent future deaths of children andyouth in their communities. This is in no way an exhaustive representation, as CDR teams arefunctioning to prevent childhood fatalities across the country.

ExamplesTennessee
Based on broad-ranging fatality reviews of 929 deaths by 34 local teams
in 2018, Tennessee’s Child Fatality Review system made key prevention
recommendations in 2020 focusing on prevention of suicide deaths;
motor vehicle crash fatalities; infant deaths due to premature birth, birthdefects, and unsafe sleep; and drowning2.
▪

Increase suicide prevention and mental health services in high-risk areas identified by the
Tennessee Department of Health suicide prevention program▪

Increase the number of schools in high-risk counties implementing evidence-based motor
vehicle safety programs in local high schools▪

Prioritize funding to reduce unintended pregnancies, reduce smoking during pregnancy, andincrease enrollment in group prenatal care, evidence-based home visiting, and carecoordination.

▪

Increase prevention of the leading drivers of birth defects including diabetes, substance use,high blood pressure, and high body mass index.

▪

Partner with state and community agencies to promote safe sleep, with a particular focus onintergenerational caregivers, to provide consistent, culturally appropriate messaging toaddress disparities.

2

Tennessee Department of Health. 2020 Child Fatality Annual Report: Understanding and Preventing Child
Deaths in Tennessee, 2020. https://www.tn.gov/content/dam/tn/health/documents/child-fatalityreports/2018-Child%20Fatality-Review-report%20.pdf
Status of CDR in the United States| 23▪

Tennessee Department of Health will promote drowning prevention recommendations fromthe American Academy of Pediatrics Drowning Prevention Toolkit through social media andpress releases and will promote resources for swimming lessons.

Ohio
Ongoing prevention activities in Ohio focused on preventing child abuse
and neglect fatalities included county and state-level efforts. The OhioChildren’s Trust Fund coordinates primary and secondary child abuse andneglect prevention services for all of Ohio’s 88 counties through aregional service-delivery model that focuses on the implementation ofevidence-based child abuse and neglect prevention programs.
Based on reviews of 152 child abuse and neglect fatalities between 2015 and 2019, Ohio’s
Childhood Fatality Review program made the following prevention recommendations in
20203:▪

Promote the use of 24-hour parenting hotlines as a safe and confidential source for parents incrisis▪

Support educational programs that assist parents and guardians in understanding age
appropriate behaviors, using alternatives methods of discipline, and choosing suitablecaregivers▪

Implement public service announcements educating lay people on signs of child abuse andneglect and how to report it▪

Change the child protective services policy of closing a case after it has been referred toanother agency; instead, ensure the agency to which the case has been referred has received
and acted on it

3

Ohio Department of Health. Ohio Child Fatality Review 20th Annual Report, 2020.
https://odh.ohio.gov/wps/portal/gov/odh/know-our-programs/child-fatality-review/media/2020-cfr-annualreport
Status of CDR in the United States| 24

Conclusion
The CDR field remained active and engaged in 2020, despite myriad challenges presented by
COVID-19. By the end of the year, there was data from over 239,000 completed child death
reviews submitted to the NFR-CRS. Most states engaged in state-level networking andtechnical assistance opportunities and built or maintained strategic partnerships with key
service agencies. Despite diverse lead agencies, protocols, case selection criteria and intraprogram coordination, in-depth, multidisciplinary fatality review continues to support
prevention efforts across the country.
The diversity of various aspects of these programs reflects the diversity among the states inwhich they operate. The information from the bi-annual state profile surveys provides anopportunity for child fatality prevention systems and CDR programs to learn from thestructure, methods, and experiences of other programs to support ongoing efforts to review
child fatality cases to inform prevention efforts, and ultimately save children’s lives.

For more information about child death review in the United States,
please contact the National Center for Fatality Review andPrevention (URL:http://www.ncfrp.org) at info@ncfrp.org.

Status of CDR in the United States| 25

Status of CDR in the United States| 26