Data Table for Rate/Trend Comparison by Cancer
Death Rate/Trend Comparison by Cancer, 2019-2023
Virginia Counties versus United States
All Cancer Sites
All Races, Both Sexes
Sorted by rateratio
Counties
|
Priority Index1 1=highest 9=lowest 
|
Recent Trend2 |
County Death Rate Compared to US Rate |
Average Annual Count
|
Age-Adjusted Death Rate deaths per 100,000 (95% Confidence Interval)
|
Rate Ratio3 County to US 
|
Recent 5-Year Trend2 in Death Rates (95% Confidence Interval)
|
|---|---|---|---|---|---|---|---|
| United States | - | falling | - | 605,771 | 145.4 (145.2, 145.6) | - | -1.3 (-1.5, -1.2) |
| Virginia | - | falling | - | 15,616 | 147.9 (146.9, 149.0) | - | -1.3 (-1.5, -0.7) |
| Manassas Park City | 9 | falling | lower | 10 | 76.2 (55.4, 101.8) | 0.5 | -5.1 (-7.6, -2.7) |
| Fairfax County | 9 | falling | lower | 1,311 | 103.3 (100.7, 105.8) | 0.7 | -2.2 (-2.4, -2.1) |
| Arlington County | 9 | falling | lower | 226 | 106.5 (100.2, 113.0) | 0.7 | -2.3 (-2.7, -2.0) |
| Loudoun County | 9 | falling | lower | 406 | 110.9 (106.0, 115.9) | 0.8 | -2.5 (-3.0, -1.9) |
| Albemarle County | 9 | falling | lower | 194 | 116.0 (108.7, 123.8) | 0.8 | -1.9 (-2.4, -1.4) |
| Alexandria City | 9 | falling | lower | 176 | 116.9 (109.2, 125.1) | 0.8 | -2.5 (-3.0, -1.9) |
| Rappahannock County | 6 | stable | similar | 17 | 120.1 (94.7, 152.3) | 0.8 | -1.5 (-3.0, 0.2) |
| York County | 9 | falling | lower | 113 | 124.2 (114.1, 135.1) | 0.9 | -2.7 (-3.4, -1.9) |
| James City County | 9 | falling | lower | 186 | 124.4 (116.2, 133.1) | 0.9 | -1.2 (-2.0, -0.4) |
| Highland County | 6 | stable | similar | 7 | 126.6 (87.4, 192.3) | 0.9 | -1.1 (-3.8, 1.6) |
| Prince William County | 9 | falling | lower | 529 | 127.4 (122.4, 132.6) | 0.9 | -2.1 (-2.4, -1.8) |
| Greene County | 8 | falling | similar | 36 | 129.6 (111.0, 150.8) | 0.9 | -1.6 (-2.8, -0.2) |
| Powhatan County | 8 | falling | similar | 58 | 131.0 (115.6, 148.1) | 0.9 | -2.8 (-3.5, -2.0) |
| Goochland County | 8 | falling | similar | 56 | 132.5 (116.7, 150.2) | 0.9 | -2.2 (-3.2, -1.0) |
| Roanoke County | 8 | falling | similar | 208 | 136.9 (128.5, 145.8) | 0.9 | -1.1 (-1.6, -0.5) |
| Fluvanna County | 8 | falling | similar | 57 | 139.3 (123.2, 157.3) | 1.0 | -1.3 (-2.2, -0.3) |
| Montgomery County | 8 | falling | similar | 137 | 139.7 (129.3, 150.8) | 1.0 | -1.3 (-1.9, -0.6) |
| Harrisonburg City | 6 | stable | similar | 57 | 141.7 (125.5, 159.5) | 1.0 | -1.1 (-2.4, 0.3) |
| Charlottesville City | 8 | falling | similar | 62 | 142.2 (126.3, 159.5) | 1.0 | -1.9 (-2.6, -1.1) |
| Augusta County | 6 | stable | similar | 178 | 142.8 (133.4, 152.8) | 1.0 | 3.2 (-1.1, 6.3) |
| Rockbridge County | 8 | falling | similar | 60 | 143.7 (127.0, 162.5) | 1.0 | -1.6 (-2.5, -0.6) |
| Spotsylvania County | 8 | falling | similar | 232 | 144.5 (136.1, 153.4) | 1.0 | -1.8 (-2.4, -1.1) |
| Lexington City | 8 | falling | similar | 11 | 144.7 (108.8, 190.2) | 1.0 | -16.3 (-37.5, -4.2) |
| Chesterfield County | 8 | falling | similar | 609 | 144.8 (139.6, 150.2) | 1.0 | -1.7 (-1.9, -1.4) |
| Rockingham County | 6 | stable | similar | 181 | 144.9 (135.4, 154.9) | 1.0 | 2.9 (-1.6, 6.2) |
| Northampton County | 8 | falling | similar | 35 | 145.1 (123.0, 171.1) | 1.0 | -12.3 (-20.6, -2.8) |
| Northumberland County | 8 | falling | similar | 44 | 145.6 (125.8, 169.4) | 1.0 | -1.7 (-2.9, -0.6) |
| Stafford County | 8 | falling | similar | 203 | 146.1 (136.8, 155.8) | 1.0 | -2.0 (-2.3, -1.5) |
| Virginia Beach City | 8 | falling | similar | 771 | 146.5 (141.9, 151.3) | 1.0 | -1.5 (-1.8, -1.3) |
| Richmond City | 8 | falling | similar | 353 | 148.3 (141.2, 155.6) | 1.0 | -2.8 (-3.2, -2.5) |
| Henrico County | 8 | falling | similar | 622 | 148.6 (143.3, 154.0) | 1.0 | -1.3 (-1.7, -1.0) |
| Clarke County | 8 | falling | similar | 38 | 149.9 (129.0, 174.0) | 1.0 | -1.7 (-3.1, -0.4) |
| Williamsburg City | 8 | falling | similar | 27 | 150.6 (125.7, 179.8) | 1.0 | -23.0 (-40.1, -10.5) |
| Botetourt County | 6 | stable | similar | 86 | 150.9 (136.5, 166.7) | 1.0 | 6.4 (-1.4, 12.3) |
| Fauquier County | 8 | falling | similar | 143 | 151.0 (139.9, 162.8) | 1.0 | -1.2 (-2.0, -0.4) |
| Charles City County | 8 | falling | similar | 19 | 151.0 (120.4, 189.4) | 1.0 | -2.2 (-4.0, -0.4) |
| Franklin County | 8 | falling | similar | 135 | 151.3 (139.4, 164.1) | 1.0 | -0.6 (-1.1, -0.1) |
| Campbell County | 8 | falling | similar | 130 | 152.1 (140.3, 164.8) | 1.0 | -1.6 (-2.4, -0.8) |
| Appomattox County | 6 | stable | similar | 37 | 152.7 (130.9, 177.5) | 1.1 | -1.3 (-2.9, 0.3) |
| Hanover County | 8 | falling | similar | 237 | 153.0 (144.2, 162.2) | 1.1 | -1.4 (-2.0, -0.9) |
| Prince George County | 8 | falling | similar | 64 | 153.5 (136.8, 171.7) | 1.1 | -1.7 (-2.6, -0.6) |
| Floyd County | 6 | stable | similar | 40 | 153.7 (132.2, 178.4) | 1.1 | -0.3 (-1.5, 0.9) |
| Bland County | 6 | stable | similar | 17 | 154.6 (122.5, 194.9) | 1.1 | -1.1 (-3.0, 0.8) |
| Westmoreland County | 8 | falling | similar | 54 | 155.0 (136.3, 176.3) | 1.1 | -2.3 (-3.7, -1.0) |
| Madison County | 6 | stable | similar | 34 | 155.1 (131.3, 182.6) | 1.1 | -1.1 (-2.4, 0.2) |
| Pulaski County | 8 | falling | similar | 85 | 155.2 (140.3, 171.4) | 1.1 | -1.8 (-2.4, -1.2) |
| Carroll County | 8 | falling | similar | 84 | 155.6 (140.5, 172.3) | 1.1 | -1.1 (-2.2, -0.1) |
| Middlesex County | 8 | falling | similar | 39 | 155.8 (133.2, 182.8) | 1.1 | -1.5 (-2.5, -0.4) |
| Manassas City | 6 | stable | similar | 52 | 156.3 (136.6, 178.0) | 1.1 | 1.4 (-2.1, 10.0) |
| Bedford City and County | 8 | falling | similar | 200 | 156.5 (146.6, 167.0) | 1.1 | -0.9 (-1.5, -0.3) |
| Culpeper County | 8 | falling | similar | 101 | 156.8 (143.1, 171.4) | 1.1 | -1.4 (-2.1, -0.7) |
| Alleghany County and Clifton Forge City | 8 | falling | similar | 44 | 156.8 (135.8, 180.9) | 1.1 | -1.5 (-2.8, -0.3) |
| Winchester City | 8 | falling | similar | 55 | 157.0 (138.7, 177.1) | 1.1 | -1.9 (-2.8, -1.0) |
| Louisa County | 8 | falling | similar | 90 | 157.2 (142.3, 173.4) | 1.1 | -1.9 (-2.9, -1.0) |
| Caroline County | 8 | falling | similar | 64 | 159.4 (141.9, 178.5) | 1.1 | -2.0 (-2.7, -1.4) |
| Poquoson City | 6 | stable | similar | 29 | 160.2 (134.9, 189.5) | 1.1 | -0.9 (-2.4, 0.8) |
| Frederick County | 5 | falling | higher | 200 | 160.7 (150.7, 171.3) | 1.1 | -1.4 (-1.9, -0.8) |
| Southampton County | 8 | falling | similar | 47 | 161.1 (140.7, 184.2) | 1.1 | -1.5 (-2.4, -0.6) |
| Chesapeake City | 5 | falling | higher | 430 | 161.3 (154.4, 168.5) | 1.1 | -1.8 (-2.2, -1.5) |
| Suffolk City | 5 | falling | higher | 181 | 161.4 (150.8, 172.5) | 1.1 | -2.1 (-2.6, -1.6) |
| King George County | 8 | falling | similar | 48 | 161.7 (141.3, 184.2) | 1.1 | -1.7 (-2.8, -0.4) |
| Amherst County | 5 | falling | higher | 81 | 162.6 (146.8, 179.9) | 1.1 | -1.6 (-2.4, -0.9) |
| Pittsylvania County | 5 | falling | higher | 165 | 163.8 (152.2, 176.1) | 1.1 | -1.1 (-1.7, -0.5) |
| Buena Vista City | 8 | falling | similar | 15 | 164.2 (128.3, 207.9) | 1.1 | -1.6 (-3.3, -0.1) |
| Surry County | 6 | stable | similar | 18 | 164.2 (129.6, 206.9) | 1.1 | -1.6 (-3.9, 0.7) |
| Mathews County | 6 | stable | similar | 29 | 165.0 (135.7, 200.4) | 1.1 | -1.1 (-3.0, 0.7) |
| Nelson County | 6 | stable | similar | 47 | 166.3 (144.1, 191.6) | 1.1 | -0.8 (-1.9, 0.2) |
| Hampton City | 5 | falling | higher | 276 | 168.1 (159.1, 177.5) | 1.2 | -1.4 (-1.9, -0.8) |
| Isle of Wight County | 5 | falling | higher | 95 | 168.6 (153.3, 185.2) | 1.2 | -1.7 (-2.6, -0.7) |
| Fredericksburg City | 5 | falling | higher | 42 | 169.5 (146.9, 194.6) | 1.2 | -2.4 (-3.5, -1.3) |
| Falls Church City | 6 | stable | similar | 28 | 169.6 (142.2, 201.0) | 1.2 | 11.8 (-2.6, 31.1) |
| Henry County | 4 | stable | higher | 147 | 170.4 (157.6, 184.1) | 1.2 | -0.6 (-1.4, 0.2) |
| Washington County | 4 | stable | higher | 152 | 170.6 (158.1, 183.9) | 1.2 | 1.7 (-1.2, 7.1) |
| King William County | 5 | falling | higher | 39 | 170.6 (146.7, 197.4) | 1.2 | -2.0 (-3.1, -0.8) |
| Accomack County | 5 | falling | higher | 100 | 171.3 (155.9, 188.0) | 1.2 | -1.6 (-2.1, -1.0) |
| Richmond County | 6 | stable | similar | 25 | 171.7 (142.1, 206.5) | 1.2 | -0.6 (-1.8, 0.6) |
| Radford City | 8 | falling | similar | 20 | 171.9 (139.2, 209.8) | 1.2 | -1.4 (-2.7, -0.1) |
| Grayson County | 5 | falling | higher | 47 | 172.4 (150.3, 197.6) | 1.2 | -1.2 (-2.3, -0.2) |
| Amelia County | 5 | falling | higher | 36 | 172.7 (147.5, 201.7) | 1.2 | -1.6 (-2.7, -0.4) |
| Newport News City | 5 | falling | higher | 340 | 174.4 (166.0, 183.1) | 1.2 | -1.1 (-1.6, -0.7) |
| Mecklenburg County | 5 | falling | higher | 98 | 174.6 (158.8, 191.9) | 1.2 | -0.9 (-1.6, -0.2) |
| Gloucester County | 5 | falling | higher | 101 | 174.6 (159.2, 191.3) | 1.2 | -1.2 (-2.2, -0.3) |
| Essex County | 6 | stable | similar | 29 | 174.9 (146.2, 208.4) | 1.2 | -1.1 (-2.6, 0.3) |
| Lunenburg County | 5 | falling | higher | 35 | 175.5 (149.4, 205.5) | 1.2 | -1.3 (-2.5, 0.0) |
| Page County | 4 | stable | higher | 68 | 176.5 (157.8, 197.3) | 1.2 | -0.3 (-1.3, 0.8) |
| Shenandoah County | 4 | stable | higher | 122 | 177.1 (162.8, 192.3) | 1.2 | -0.5 (-1.2, 0.1) |
| Emporia City | 8 | falling | similar | 14 | 177.1 (136.0, 227.5) | 1.2 | -2.0 (-3.9, -0.3) |
| Dinwiddie County | 5 | falling | higher | 70 | 178.5 (159.7, 199.2) | 1.2 | -1.8 (-2.6, -1.0) |
| Wythe County | 4 | stable | higher | 78 | 178.9 (161.0, 198.4) | 1.2 | -0.7 (-1.6, 0.1) |
| Warren County | 4 | stable | higher | 96 | 179.3 (163.1, 196.8) | 1.2 | -0.7 (-1.4, 0.0) |
| Norfolk City | 5 | falling | higher | 408 | 179.8 (171.8, 188.1) | 1.2 | -1.4 (-1.8, -1.0) |
| Buckingham County | 5 | falling | higher | 46 | 180.6 (157.5, 206.6) | 1.2 | -1.6 (-2.8, -0.4) |
| Lancaster County | 5 | falling | higher | 48 | 180.8 (154.1, 212.3) | 1.2 | -1.2 (-2.4, 0.0) |
| Staunton City | 4 | stable | higher | 70 | 182.4 (163.4, 203.3) | 1.3 | -0.3 (-1.3, 0.8) |
| Bath County | 6 | stable | similar | 15 | 182.7 (141.6, 235.8) | 1.3 | -0.8 (-3.1, 1.5) |
| Salem City | 4 | stable | higher | 66 | 183.2 (163.4, 204.9) | 1.3 | -0.6 (-1.7, 0.4) |
| Scott County | 4 | stable | higher | 69 | 183.4 (163.8, 205.2) | 1.3 | -0.7 (-1.9, 0.4) |
| New Kent County | 4 | stable | higher | 56 | 183.7 (161.3, 208.5) | 1.3 | -0.9 (-2.1, 0.6) |
| Bristol City | 4 | stable | higher | 50 | 183.7 (161.0, 209.2) | 1.3 | -0.8 (-2.4, 0.6) |
| Orange County | 5 | falling | higher | 100 | 184.1 (167.9, 201.6) | 1.3 | -1.1 (-1.8, -0.3) |
| Cumberland County | 4 | stable | higher | 28 | 184.7 (153.7, 220.9) | 1.3 | -1.1 (-2.3, 0.1) |
| Lynchburg City | 4 | stable | higher | 157 | 184.9 (171.9, 198.7) | 1.3 | 0.0 (-0.8, 3.1) |
| Brunswick County | 4 | stable | higher | 47 | 185.7 (161.9, 212.6) | 1.3 | 0.6 (-2.0, 9.5) |
| Charlotte County | 4 | stable | higher | 34 | 186.2 (158.0, 218.7) | 1.3 | 0.1 (-1.1, 4.6) |
| Giles County | 4 | stable | higher | 50 | 186.5 (163.5, 212.4) | 1.3 | -1.0 (-2.0, 0.0) |
| Tazewell County | 4 | stable | higher | 120 | 186.8 (171.5, 203.2) | 1.3 | -0.2 (-1.0, 0.6) |
| King and Queen County | 4 | stable | higher | 21 | 187.0 (151.3, 230.3) | 1.3 | -1.2 (-2.6, 0.1) |
| Halifax County with South Boston City | 4 | stable | higher | 111 | 187.6 (171.5, 205.0) | 1.3 | -0.5 (-1.3, 0.4) |
| Russell County | 4 | stable | higher | 78 | 188.5 (169.4, 209.4) | 1.3 | -0.6 (-1.5, 0.2) |
| Roanoke City | 5 | falling | higher | 242 | 188.6 (177.8, 199.9) | 1.3 | -0.7 (-1.1, -0.3) |
| Portsmouth City | 5 | falling | higher | 210 | 188.7 (177.1, 200.8) | 1.3 | -1.3 (-1.8, -0.8) |
| Craig County | 4 | stable | higher | 16 | 189.8 (148.3, 241.9) | 1.3 | -0.2 (-2.3, 2.0) |
| Patrick County | 4 | stable | higher | 62 | 190.5 (168.7, 215.0) | 1.3 | -0.3 (-1.3, 0.8) |
| Dickenson County | 4 | stable | higher | 44 | 192.4 (166.8, 221.6) | 1.3 | -0.6 (-2.0, 0.8) |
| Covington City | 5 | falling | higher | 16 | 195.3 (153.7, 246.0) | 1.3 | -11.1 (-25.4, -5.1) |
| Prince Edward County | 4 | stable | higher | 50 | 196.4 (171.9, 223.5) | 1.4 | 0.4 (-0.5, 3.9) |
| Waynesboro City | 4 | stable | higher | 60 | 197.0 (174.9, 221.2) | 1.4 | -0.4 (-1.4, 0.6) |
| Buchanan County | 4 | stable | higher | 66 | 197.2 (175.8, 221.0) | 1.4 | 0.7 (-1.0, 6.7) |
| Nottoway County | 4 | stable | higher | 44 | 201.1 (175.1, 230.2) | 1.4 | -0.8 (-1.7, 0.1) |
| Colonial Heights City | 4 | stable | higher | 53 | 205.0 (180.5, 232.3) | 1.4 | 2.5 (-0.1, 11.0) |
| Smyth County | 4 | stable | higher | 99 | 205.9 (187.6, 225.7) | 1.4 | -0.3 (-0.9, 0.2) |
| Lee County | 4 | stable | higher | 73 | 206.1 (184.9, 229.5) | 1.4 | -0.6 (-1.6, 0.4) |
| Sussex County | 4 | stable | higher | 31 | 207.1 (174.5, 244.7) | 1.4 | -0.7 (-1.7, 0.3) |
| Hopewell City | 5 | falling | higher | 58 | 219.3 (194.3, 246.8) | 1.5 | -0.9 (-1.7, 0.0) |
| Danville City | 1 | rising | higher | 138 | 221.3 (204.5, 239.3) | 1.5 | 7.5 (5.5, 10.3) |
| Wise County | 4 | stable | higher | 110 | 226.4 (207.4, 246.9) | 1.6 | -0.5 (-1.1, 0.1) |
| Greensville County | 4 | stable | higher | 30 | 229.1 (193.0, 270.5) | 1.6 | 0.2 (-1.7, 2.1) |
| Petersburg City | 4 | stable | higher | 99 | 238.7 (217.4, 261.7) | 1.6 | 1.1 (-0.3, 6.6) |
| Norton City | 4 | stable | higher | 12 | 241.6 (183.1, 314.5) | 1.7 | -0.4 (-2.5, 1.8) |
| Martinsville City | 1 | rising | higher | 42 | 244.3 (211.2, 281.3) | 1.7 | 1.4 (0.1, 2.8) |
| Fairfax City | 1 | rising | higher | 65 | 249.9 (223.0, 279.3) | 1.7 | 5.1 (1.3, 13.5) |
| Franklin City | 1 | rising | higher | 29 | 251.3 (210.7, 298.2) | 1.7 | 14.1 (3.5, 20.6) |
| Galax City | 5 | falling | higher | 24 | 273.1 (224.8, 329.2) | 1.9 | -8.9 (-19.0, -3.4) |
Notes:
Created by statecancerprofiles.cancer.gov on 03/13/2026 11:12 pm.
1 Priority indices were created by ordering from rates that are rising and above the comparison rate to rates that are falling and below the comparison rate.
2 Recent trend in death rates is usually an Average Annual Percent Change (AAPC) based on the APCs calculated by Joinpoint. Due to data availability issues, the time period and/or calculation method used in the calculation of the trends may differ for selected geographic areas.
3 Rate ratio is the county rate divided by the US rate. Previous versions of this table used one-year rates for states and five-year rates for counties. As of June 2018, only five-year rates are used.
Source: Death data provided by the National Vital Statistics System public use data file. Death rates calculated by the National Cancer Institute using SEER*Stat. Death rates are age-adjusted to the 2000 US standard population (20 age groups: <1, 1-4, 5-9, ... , 80-84, 85-89, 90+). The Healthy People 2030 goals are based on rates adjusted using different methods but the differences should be minimal. Population counts for denominators are based on Census populations as modified by NCI. The US Population Data File is used with mortality data.
Note: When the population size for a denominator is small, the rates may be unstable. A rate is unstable when a small change in the numerator (e.g., only one or two additional cases) has a dramatic effect on the calculated rate. Suppression is used to avoid misinterpretation when rates are unstable.
State Cancer Registries may provide more current or more local data. Data presented on the State Cancer Profiles Web Site may differ from statistics reported by the State Cancer Registries (for more information).
Interpret Rankings provides insight into interpreting cancer statistics. When the population size for a denominator is small, the rates may be unstable. A rate is unstable when a small change in the numerator (e.g., only one or two additional cases) has a dramatic effect on the calculated rate.
Data for United States do not include Puerto Rico.
Created by statecancerprofiles.cancer.gov on 03/13/2026 11:12 pm.
Trend2
Rising
when 95% confidence interval of average annual percent change is above 0.
Stable
when 95% confidence interval of average annual percent change includes 0.
Falling
when 95% confidence interval of average annual percent change is below 0.
Rate Comparison
Above when 95% confident the rate is above and Rate Ratio3 > 1.10
Similar
when unable to conclude above or below with confidence.
Below when 95% confident the rate is below and Rate Ratio3 < 0.90
Rising
when 95% confidence interval of average annual percent change is above 0.Stable
when 95% confidence interval of average annual percent change includes 0.Falling
when 95% confidence interval of average annual percent change is below 0.Rate Comparison
Above
when 95% confident the rate is above and Rate Ratio3 > 1.10Similar
when unable to conclude above or below with confidence.Below
when 95% confident the rate is below and Rate Ratio3 < 0.901 Priority indices were created by ordering from rates that are rising and above the comparison rate to rates that are falling and below the comparison rate.
2 Recent trend in death rates is usually an Average Annual Percent Change (AAPC) based on the APCs calculated by Joinpoint. Due to data availability issues, the time period and/or calculation method used in the calculation of the trends may differ for selected geographic areas.
3 Rate ratio is the county rate divided by the US rate. Previous versions of this table used one-year rates for states and five-year rates for counties. As of June 2018, only five-year rates are used.
Source: Death data provided by the National Vital Statistics System public use data file. Death rates calculated by the National Cancer Institute using SEER*Stat. Death rates are age-adjusted to the 2000 US standard population (20 age groups: <1, 1-4, 5-9, ... , 80-84, 85-89, 90+). The Healthy People 2030 goals are based on rates adjusted using different methods but the differences should be minimal. Population counts for denominators are based on Census populations as modified by NCI. The US Population Data File is used with mortality data.
Note: When the population size for a denominator is small, the rates may be unstable. A rate is unstable when a small change in the numerator (e.g., only one or two additional cases) has a dramatic effect on the calculated rate. Suppression is used to avoid misinterpretation when rates are unstable.
State Cancer Registries may provide more current or more local data. Data presented on the State Cancer Profiles Web Site may differ from statistics reported by the State Cancer Registries (for more information).
Interpret Rankings provides insight into interpreting cancer statistics. When the population size for a denominator is small, the rates may be unstable. A rate is unstable when a small change in the numerator (e.g., only one or two additional cases) has a dramatic effect on the calculated rate.
Data for United States do not include Puerto Rico.