Absolute neutrophil count (ANC)
The absolute neutrophil count is the number of neutrophils in blood. A European guideline defines neutropenia in adults as below 1,800 cells/µL and severe neutropenia as below 500. Reference intervals in people with the Duffy-null blood type start near 1,000 to 1,200. Higher counts were linked to more cardiovascular disease, and low counts to viral infections and blood cancers.
- Status
- Reported with the differential of a complete blood count, ordered by a clinician and also sold direct to consumers by some US laboratories. FDA classifies automated differential cell counters, which identify the types of white cell in blood, as class II devices [1].
- Measures
- The number of neutrophils, the most numerous type of white blood cell, in a given volume of whole blood, counted by an automated cell counter or calculated from the white cell count and the neutrophil percentage.
- Also called
- ANC, absolute neutrophils, neutrophils absolute, Neutrophils (Absolute), neutrophil count, NEUT#, NE#, segmented neutrophils absolute, absolute granulocyte count, polys absolute
- Tested for
- infection risk, low white count follow-up, chemotherapy monitoring, clozapine monitoring, benign ethnic neutropenia, Duffy-null associated neutrophil count, inflammation, immune health
Strong several reviews agree · Moderate one review or consistent trials · Limited one or a few small studies · Untested no study in people, listed with what it rests on
Linked in research2
- ModerateLinked to more heart failure, heart attack and peripheral arterial disease at higher counts within the usual range, in two large United Kingdom cohorts.
- LimitedLimited evidence: one Danish primary care cohort linked low counts to more viral infections, blood cancers and deaths, more strongly the lower the count.
Reported risks1
Reference ranges
Each range is the one its source published, in cells/µL. Also reported in ×10⁹/L. Where sources differ, each is shown.
European Hematology Association and EuNet-INNOCHRON neutropenia guideline, 2023, adults
Adults. The guideline adopts the 1,800 threshold for Caucasian adults and states that counts below 1,500 are considered normal in people of African and Middle Eastern ancestry · [2]
| Range | What the source calls it |
|---|---|
| below 200 cells/µL | "agranulocytosis" A doctor, immediately |
| 200 to 499 cells/µL | "severe" A doctor, immediately |
| 500 to 999 cells/µL | "moderate" |
| 1000 to 1799 cells/µL | "mild" |
| 1800 or above cells/µL | No name given |
The guideline prints its cut-offs in ×10⁹/L: neutropenia below 1.8 in adults, mild from 1.0 to 1.5 (or 1.8 for adults), moderate from 0.5 to 1.0 and severe below 0.5. It uses the term agranulocytosis for severe neutropenia below 0.2 and describes it as usually associated with a high risk of severe, life-threatening infections. Its text puts a count of exactly 1.0 at the edge of both mild and moderate, and this block places it in mild. The severity classes were extrapolated from the relationship between circulating counts and infections in people having chemotherapy. The guideline states that some people of African and Middle Eastern descent have normal counts from 0.5 to 1.5 and less often lower, a variation tied to the Duffy-null blood type, and that the risk of bacterial infection depends on the capacity to deliver neutrophils to tissues and not only on the blood count [2].
European Hematology Association and EuNet-INNOCHRON neutropenia guideline, 2023, children older than 1 year
Children older than 1 year, up to adulthood · [2]
| Range | What the source calls it |
|---|---|
| below 200 cells/µL | "agranulocytosis" A doctor, immediately |
| 200 to 499 cells/µL | "severe" A doctor, immediately |
| 500 to 999 cells/µL | "moderate" |
| 1000 to 1499 cells/µL | "mild" |
| 1500 or above cells/µL | No name given |
The same severity classes as for adults, with the guideline's cut-off for neutropenia from age 1 year to adulthood, 1.5 ×10⁹/L. The guideline's footnote on African and Middle Eastern ancestry applies here too [2].
European Hematology Association and EuNet-INNOCHRON neutropenia guideline, 2023, infants
Infants from 14 days to 1 year old · [2]
| Range | What the source calls it |
|---|---|
| below 200 cells/µL | "agranulocytosis" A doctor, immediately |
| 200 to 499 cells/µL | "severe" A doctor, immediately |
| 500 to 999 cells/µL | "moderate" |
| 1000 or above cells/µL | No name given |
The guideline's cut-off for neutropenia in this age group is 1.0 ×10⁹/L, so its mild class does not apply. It gives separate, higher limits for newborns in the first 14 days of life, which vary with gestational age and hours since birth and are not shown here [2].
US National Cancer Institute, Common Terminology Criteria for Adverse Events version 6.0, 2025
People in cancer clinical trials, as grades for reporting a decreased neutrophil count as an adverse event · [3]
| Range | What the source calls it |
|---|---|
| below 100 cells/µL | "Grade 4" A doctor, immediately |
| 100 to 499 cells/µL | "Grade 3" A doctor, immediately |
| 500 to 999 cells/µL | "Grade 2" |
| 1000 to 1499 cells/µL | "Grade 1" |
| 1500 or above cells/µL | No name given |
A scale for grading side effects of treatment, not a definition of a normal count. The criteria define Grade 3 in general as severe or medically significant but not immediately life-threatening, and Grade 4 as life-threatening consequences with urgent intervention indicated. Version 5.0, published in 2017 and still used by trials that began under it, drew each grade one step higher: Grade 1 from the laboratory's lower limit down to 1,500, Grade 2 from 1,000 to under 1,500, Grade 3 from 500 to under 1,000 and Grade 4 below 500 [4]. A count of 700 is therefore Grade 3 under version 5.0 and Grade 2 under version 6.0. Both versions define febrile neutropenia as a count below 1,000 with a single temperature above 38.3 °C or a sustained temperature of 38 °C or more for over one hour [3][4].
Duffy-null reference range from one US hospital, Merz and colleagues, 2023
Adults with the Duffy-null blood type, Fy(a-b-), which is common in people of African and Middle Eastern ancestry · [5]
| Range | What the source calls it |
|---|---|
| below 1210 cells/µL | No name given |
| 1210 to 5390 cells/µL | "reference range" |
| above 5390 cells/µL | No name given |
The central 95% interval, calculated without assuming a distribution, in 120 Duffy-null adults who reported Black or African American race and were attending nonurgent primary care visits at one Boston hospital. The hospital's standard range at the time was 1,920 to 7,600 [5]. The range is tied to a blood type, not to race: in a related study at the same clinic, 66.7% of 120 Black adults were Duffy-null, and the counts of those who were not did not differ from the standard range [6]. Duffy status is found by a red cell antigen test or a genetic test and is not part of a routine blood count.
Duffy-null reference intervals from 23 sites, Merz and colleagues, 2026, adults
Adults aged 18 and older with the Duffy-null blood type, which is common in people of African and Middle Eastern ancestry · [7]
| Range | What the source calls it |
|---|---|
| below 1030 cells/µL | No name given |
| 1030 to 7300 cells/µL | "reference interval" |
| above 7300 cells/µL | No name given |
Calculated to Clinical and Laboratory Standards Institute guidelines from 662 Duffy-null adults at 23 sites, with collection methods that varied by site. A quarter of these adults had a count below 2,000. The interval is wider at both ends than the single-hospital range of 1,210 to 5,390 published in 2023 [5][7]. Numbers are converted from the paper's ×10⁹/L and were read from its abstract.
Duffy-null reference intervals from 23 sites, Merz and colleagues, 2026, ages 13 to 17
Adolescents aged 13 to 17 with the Duffy-null blood type · [7]
| Range | What the source calls it |
|---|---|
| below 900 cells/µL | No name given |
| 900 to 4890 cells/µL | "reference interval" |
| above 4890 cells/µL | No name given |
From 216 Duffy-null adolescents. Across the four pediatric age groups in this study, 24% to 53% of children had a count below 1,500 [7].
Duffy-null reference intervals from 23 sites, Merz and colleagues, 2026, ages 7 to 12
Children aged 7 to 12 with the Duffy-null blood type · [7]
| Range | What the source calls it |
|---|---|
| below 870 cells/µL | No name given |
| 870 to 5340 cells/µL | "reference interval" |
| above 5340 cells/µL | No name given |
From 190 Duffy-null children, derived the same way [7].
Duffy-null reference intervals from 23 sites, Merz and colleagues, 2026, ages 3 to 6
Children aged 3 to 6 with the Duffy-null blood type · [7]
| Range | What the source calls it |
|---|---|
| below 780 cells/µL | No name given |
| 780 to 4670 cells/µL | "reference interval" |
| above 4670 cells/µL | No name given |
From 160 Duffy-null children, derived the same way [7].
Duffy-null reference intervals from 23 sites, Merz and colleagues, 2026, ages 6 months to 2 years
Children aged 6 months to 2 years with the Duffy-null blood type · [7]
| Range | What the source calls it |
|---|---|
| below 530 cells/µL | No name given |
| 530 to 4500 cells/µL | "reference interval" |
| above 4500 cells/µL | No name given |
From 184 Duffy-null children, derived the same way. The lower limit sits close to the 500 line that the European guideline uses for severe neutropenia [2][7].
Race-specific reference intervals from a US national survey, Lim and colleagues, 2010, Black men
Non-Hispanic Black men older than 18, grouped by self-reported race and not by Duffy status · [8]
| Range | What the source calls it |
|---|---|
| below 1300 cells/µL | No name given |
| 1300 to 6600 cells/µL | "reference interval" |
| above 6600 cells/µL | No name given |
The 2.5th to 97.5th percentiles in a US national survey from 2000 to 2003, after excluding people by ferritin, blood pressure, creatinine and glucose criteria. The authors report that these limits are significantly lower than those for non-Hispanic white and Mexican American adults, whose limits are not printed in the abstract read here [8]. In the 1999 to 2004 rounds of the same survey, a count below 1,500 was found in 4.5% of Black, 0.79% of white and 0.38% of Mexican American participants [9]. The lower counts are tied to the Duffy-null variant, a change in one gene that predicted white cell and neutrophil counts in 6,005 African Americans [10]. A range set by race groups Duffy-null people together with those who are not [6].
Race-specific reference intervals from a US national survey, Lim and colleagues, 2010, Black women
Non-Hispanic Black women older than 18, grouped by self-reported race and not by Duffy status · [8]
| Range | What the source calls it |
|---|---|
| below 1400 cells/µL | No name given |
| 1400 to 7500 cells/µL | "reference interval" |
| above 7500 cells/µL | No name given |
Derived the same way, with the same exclusions [8].
Race-specific reference intervals from a US national survey, Lim and colleagues, 2010, Black boys aged 12 to 18
Non-Hispanic Black boys aged 12 to 18, grouped by self-reported race and not by Duffy status · [8]
| Range | What the source calls it |
|---|---|
| below 1000 cells/µL | No name given |
| 1000 to 6200 cells/µL | "reference interval" |
| above 6200 cells/µL | No name given |
Derived the same way, with the same exclusions [8].
Race-specific reference intervals from a US national survey, Lim and colleagues, 2010, Black girls aged 12 to 18
Non-Hispanic Black girls aged 12 to 18, grouped by self-reported race and not by Duffy status · [8]
| Range | What the source calls it |
|---|---|
| below 1200 cells/µL | No name given |
| 1200 to 6600 cells/µL | "reference interval" |
| above 6600 cells/µL | No name given |
Derived the same way, with the same exclusions [8].
Pregnancy reference interval from an Oxford cohort, Dockree and colleagues, 2021
Pregnant women from 8 to 40 weeks of pregnancy · [11]
| Range | What the source calls it |
|---|---|
| below 3700 cells/µL | No name given |
| 3700 to 11600 cells/µL | "reference interval" |
| above 11600 cells/µL | No name given |
The 95% interval from 80,637 blood counts in 24,318 women who delivered single live babies in Oxford, United Kingdom. The interval was stable from 8 to 40 weeks, so one range is given for the whole of pregnancy. The authors set it beside a non-pregnant interval of 2,000 to 7,500 taken from a clinical handbook and report an upper limit 55% higher in pregnancy. The white cell count rose further from the first day after birth and returned to the pre-delivery level by an average of seven days [11].
What has been shown to move it
Shown to lower it1
Very low white blood cell count
The label reports agranulocytosis in 2 of 2,796 people in premarketing trials, and severe neutropenia in a third. All three recovered after stopping.
The numbers and sources
- How common
- Rare: fewer than 1 in 1,000 people.
- Effect
- In premarketing trials, 2 of 2,796 people treated with mirtazapine developed agranulocytosis with signs such as fever or infection, one of whom had Sjögren's syndrome, and a third developed severe neutropenia without symptoms. Onset was on days 61, 9 and 14 of treatment, and all three recovered after the drug was stopped [7].
- Population
- 2,796 people in premarketing clinical trials [7].
- Sources
- [7]
- Caveats
- Three cases with no placebo comparison. The band above is for the two cases of agranulocytosis.
Shown to raise it2
Inflammation and white blood cells
Limited evidence: small company-funded trials found white blood cell counts shifted after damaging exercise with grounding. No study measured C-reactive protein or an inflammatory disease.
Compared with sham grounding [4][5]
The numbers and sources
- Effect
- On day 3 after exercise, neutrophils were higher in grounded than sham-grounded men (P = 0.05), and platelets rose significantly in the grounded group on days 2 to 4 [4]. White blood cell counts were among the measures that differed by 10% or more in the 8-person pilot [5]. A review by researchers holding shares in the sponsoring company states that grounding alters circulating neutrophils, lymphocytes and inflammatory factors [6].
- Population
- 32 healthy young men [4]. 8 healthy adults [5]. Studies summarized in a review [6].
- Sources
- [4], [5], [6]
- Caveats
- A higher neutrophil count is not a lower level of inflammation, and the trials did not say whether these shifts help or harm. The review's authors disclose contracts with and shares in the company sponsoring grounding research [6].
Raised white blood cell count
One study of 80 patients found prednisone raised the white blood cell count, in some above 20,000 per cubic millimeter, mainly through neutrophils.
The rise was mainly in neutrophils, with fewer eosinophils and a variable fall in lymphocytes.
The numbers and sources
- How common
- How often is not known: the sources give no rate.
- Effect
- In 80 patients, the white blood cell count rose on prednisone, passing 20,000 per cubic millimeter as early as the first day in some, peaking within 2 weeks in most and then falling without returning to pretreatment levels. The rise was mainly in neutrophils, with fewer eosinophils and a variable fall in lymphocytes. More than 6% band forms was rare, which the authors offer as a way to tell the change from infection [30].
- Population
- 80 patients treated with prednisone [30].
- Sources
- [30]
- Caveats
- One uncontrolled study from 1981. The abstract gives no mean change.
How it compares with the reference method
Mixed results1
Variation from one draw to the next in one person
Shown to vary about 15% from one draw to the next within the same person, in a pooled estimate from a European laboratory federation.
The numbers and sources
- Compared with
- The same person's results on repeated venous draws
- Effect
- The European Federation of Clinical Chemistry and Laboratory Medicine database gives a pooled within-person variation of 14.6% for the neutrophil count, with lower and upper limits of 6.3% and 26.0%, from 9 estimates in 7 studies. Variation between people is 24.8% [16]. At a count of 3,000 cells/µL, 14.6% is about 440 cells/µL.
- Population
- Adults without known illness in the studies the database pools [16].
- Sources
- [16]
- Caveats
- A summary across studies of volunteers. The database states no threshold for agreement, so the result is given as numbers only [16]. A result near the edge of a range may fall on the other side of it at the next draw.
What studies tie it to
Linked in research2
Cardiovascular disease
Linked to more heart failure, heart attack and peripheral arterial disease at higher counts within the usual range, in two large United Kingdom cohorts.
The numbers and sources
- Effect
- In linked English health records, a count of 6,000 to 7,000 cells/µL against 2,000 to 3,000 had adjusted hazard ratios of 2.04 (95% CI 1.82 to 2.29) for heart failure, 1.95 (1.72 to 2.21) for peripheral arterial disease, 1.78 (1.51 to 2.10) for unheralded coronary death, 1.58 (1.42 to 1.76) for nonfatal heart attack and 1.36 (1.17 to 1.57) for ischemic stroke. There was no association with stable angina or bleeding in the brain. The associations were linear, with higher risk already at 3,000 to 4,000 [12]. In UK Biobank, the highest tenth of neutrophil count against the fifth had hazard ratios for cardiovascular death of 1.59 (1.22 to 2.08) in men and 2.15 (1.38 to 3.35) in women. In an analysis that left out people with existing illness and the first two years, each 1,000 cells/µL higher count had a hazard ratio of 1.07 (1.04 to 1.11) in both sexes combined [13].
- Population
- 775,231 adults aged 30 or older with no history of cardiovascular disease, 55,004 cases over a median 3.8 years [12]. 478,259 UK Biobank participants followed a median 7.0 years [13].
- Sources
- [12], [13]
- Caveats
- Observational. Smoking, infection and long-term illness raise the count and also raise cardiovascular risk, and adjustment may not remove this. The UK Biobank authors call for trials of treatments that lower neutrophils to investigate causality [13].
Viral infections, blood cancers and death after a low count on a routine test
Limited evidence: one Danish primary care cohort linked low counts to more viral infections, blood cancers and deaths, more strongly the lower the count.
The numbers and sources
- Effect
- Neutropenia, defined as below 1,500 cells/µL, was seen in about 1% of people. Odds ratios for viral infections were 2.32 (95% CI 1.84 to 2.91) at 1,500 to 1,800, 2.80 (2.20 to 3.57) at 1,000 to 1,500 and 4.77 (3.22 to 7.07) below 1,000. For blood cancers they were 3.23 (2.35 to 4.45), 8.69 (6.58 to 11.47) and 46.03 (33.98 to 62.35). Neutropenia was particularly associated with HIV, acute leukemias and myelodysplastic syndromes, and not with autoimmune disorders or solid cancers. For severe neutropenia the authors report absolute risks of 40% for blood cancers and above 50% for death from any cause over 4 years [14].
- Population
- More than 370,000 people with a routine blood count in Danish primary care, linked to national health registers and followed for 4 years [14].
- Sources
- [14]
- Caveats
- Observational, in people whose doctor had ordered a blood count. A low count can be the first sign of an illness already present, so the count marks the risk and need not cause it [14].
Checked, no link found1
Infections in people with the Duffy-null genotype
Limited evidence: one study of two population samples found the Duffy-null genotype lowered neutrophil counts and was not linked to more infections.
The numbers and sources
- Effect
- In UK Biobank participants of Black African or Caribbean ethnicity, the mean count was 2,820 cells/µL with the Duffy-null genotype and 4,430 without it. About 21% of people with the genotype had a count below 2,000, against 1.1% of the others. The genotype was not associated with a higher risk of viral or bacterial infection in UK Biobank or in a Danish sample. Among people with the genotype, 17.4% of those with a count of 1,500 to 2,000 had an infection against 18.8% of those with a count of 2,000 to 7,500 (RR 0.94, 95% CI 0.81 to 1.10) [15].
- Population
- UK Biobank, including 7,450 people with the Duffy-null genotype, and the Danish iPSYCH case-cohort sample [15].
- Sources
- [15]
- Caveats
- Observational. Only 323 people with the genotype had a count of 1,000 to 1,500, and the authors state that the small numbers below 1,500 preclude firm conclusions about infection risk at those counts [15].
Risks
Reported risks1
Bone marrow biopsies after a low count in people with the Duffy-null genotype
Linked to bone marrow biopsies that found nothing: 97% of biopsies done for an isolated low white count in Duffy-null African American patients were normal.
The numbers and sources
- How common
- How often is not known: the sources give no rate.
- Effect
- Among 399 African American patients who had a bone marrow biopsy at three US medical centers, 35 had it for an isolated low white cell count. Of those 35, 34 (97%) had the Duffy-null genotype, against 243 of 364 (67%) biopsied for other reasons. Among the 34, 33 biopsies (97%) were normal, compared with 134 of 243 (55%) done for other reasons [17]. In a separate US hospital biobank, the 2.5th percentile of first measured counts in adults was 1,239 cells/µL with the Duffy-null genotype and 2,107 without it, and 4.8% against 0.5% of adults had a first count below 1,500 [18].
- Population
- 399 African American patients younger than 90 biopsied from 1998 to 2020 [17]. 3,739 biobank participants with a blood count from a health maintenance examination, 65% of them with the Duffy-null genotype [18].
- Sources
- [17], [18]
- Caveats
- A retrospective study of people who had a biopsy. It gives no count of how many people with a low result went on to have one, so no rate can be stated [17].
Related
Sources
- US Food and Drug Administration. 21 CFR 864.5220, Automated differential cell counter. Electronic Code of Federal Regulations. https://www.ecfr.gov/current/title-21/section-864.5220
- Fioredda F, Skokowa J, Tamary H, et al. The European Guidelines on Diagnosis and Management of Neutropenia in Adults and Children: A Consensus Between the European Hematology Association and the EuNet-INNOCHRON COST Action. HemaSphere. 2023. https://doi.org/10.1097/HS9.0000000000000872
- US National Cancer Institute, Cancer Therapy Evaluation Program. Common Terminology Criteria for Adverse Events (CTCAE) version 6.0, published July 22, 2025. https://dctd.cancer.gov/research/ctep-trials/for-sites/adverse-events/ctcae-v6.pdf
- US National Cancer Institute, Cancer Therapy Evaluation Program. Common Terminology Criteria for Adverse Events (CTCAE) version 5.0, published November 27, 2017. https://dctd.cancer.gov/research/ctep-trials/for-sites/adverse-events/ctcae-v5-8x11.pdf
- Merz LE, Osei MA, Story CM, et al. Development of Duffy Null-Specific Absolute Neutrophil Count Reference Ranges. JAMA. 2023. https://doi.org/10.1001/jama.2023.7467
- Merz LE, Story CM, Osei MA, et al. Absolute neutrophil count by Duffy status among healthy Black and African American adults. Blood Advances. 2023. https://doi.org/10.1182/bloodadvances.2022007679
- Merz LE, Fink A, Han H, et al. Establishing Absolute Neutrophil Count and White Blood Cell Count Reference Intervals for the Duffy Null Population. Blood Advances. 2026. https://doi.org/10.1182/bloodadvances.2026020900
- Lim EM, Cembrowski G, Cembrowski M, Clarke G. Race-specific WBC and neutrophil count reference intervals. International Journal of Laboratory Hematology. 2010. https://doi.org/10.1111/j.1751-553X.2010.01223.x
- Hsieh MM, Everhart JE, Byrd-Holt DD, Tisdale JF, Rodgers GP. Prevalence of Neutropenia in the U.S. Population: Age, Sex, Smoking Status, and Ethnic Differences. Annals of Internal Medicine. 2007. https://doi.org/10.7326/0003-4819-146-7-200704030-00004
- Reich D, Nalls MA, Kao WH, et al. Reduced Neutrophil Count in People of African Descent Is Due To a Regulatory Variant in the Duffy Antigen Receptor for Chemokines Gene. PLoS Genetics. 2009. https://doi.org/10.1371/journal.pgen.1000360
- Dockree S, Shine B, Pavord S, Impey L, Vatish M. White blood cells in pregnancy: reference intervals for before and after delivery. EBioMedicine. 2021. https://doi.org/10.1016/j.ebiom.2021.103715
- Shah AD, Denaxas S, Nicholas O, Hingorani AD, Hemingway H. Neutrophil Counts and Initial Presentation of 12 Cardiovascular Diseases: A CALIBER Cohort Study. Journal of the American College of Cardiology. 2017. https://doi.org/10.1016/j.jacc.2016.12.022
- Welsh C, Welsh P, Mark PB, et al. Association of Total and Differential Leukocyte Counts With Cardiovascular Disease and Mortality in the UK Biobank. Arteriosclerosis, Thrombosis, and Vascular Biology. 2018. https://doi.org/10.1161/ATVBAHA.118.310945
- Andersen CL, Tesfa D, Siersma VD, et al. Prevalence and clinical significance of neutropenia discovered in routine complete blood cell counts: a longitudinal study. Journal of Internal Medicine. 2016. https://doi.org/10.1111/joim.12467
- Legge SE, Christensen RH, Petersen L, et al. The Duffy-null genotype and risk of infection. Human Molecular Genetics. 2020. https://doi.org/10.1093/hmg/ddaa208
- European Federation of Clinical Chemistry and Laboratory Medicine. EFLM Biological Variation Database, meta-analysis estimates, read 2026-11-13. https://biologicalvariation.eu/
- Van Driest SL, Abul-Husn NS, Glessner JT, et al. Association Between a Common, Benign Genotype and Unnecessary Bone Marrow Biopsies Among African American Patients. JAMA Internal Medicine. 2021. https://doi.org/10.1001/jamainternmed.2021.3108
- Bagheri M, Chung CP, Dickson AL, et al. White blood cell ranges and frequency of neutropenia by Duffy genotype status. Blood Advances. 2023. https://doi.org/10.1182/bloodadvances.2022007680