How Do I Calculate ANC: Step-by-Step Guide

The Absolute Neutrophil Count (ANC) is a crucial measurement, especially for patients undergoing chemotherapy treatments or those with compromised immune systems, with the National Institutes of Health (NIH) providing extensive guidelines on its clinical significance. This number, vital for assessing the body's ability to fight infection, is derived from a standard complete blood count (CBC) test, typically processed in hematology labs. Understanding how do I calculate ANC involves basic math skills combined with the values reported in the CBC, where the total white blood cell (WBC) count is used to determine percentages of neutrophils and bands. Several online calculators are available, though understanding the manual calculation ensures accuracy and a deeper comprehension of what the oncologist needs to know about the immune status of the patient.

The Absolute Neutrophil Count (ANC) is a critical metric in assessing the health and functionality of the immune system. It provides valuable insights into the body's ability to defend itself against infections. This section serves as an introduction to the concept of ANC and its significance in various medical contexts.

What is Absolute Neutrophil Count (ANC)?

The Absolute Neutrophil Count (ANC) is a calculation that represents the number of neutrophils present in the blood. Neutrophils are a type of white blood cell, crucial for fighting off infections, particularly bacterial and fungal infections.

The ANC is expressed as the number of neutrophils per microliter (µL) or cubic millimeter (mm3) of blood. It's not simply the total number of white blood cells. Instead, it's a specific count of the neutrophils, offering a focused view of this key immune component.

Why is the ANC so important? Because it's a direct indicator of the body's capacity to mount an effective immune response. A healthy ANC signifies that the body has a sufficient number of neutrophils ready to combat invading pathogens.

A low ANC, on the other hand, suggests a compromised immune system. This makes the individual more vulnerable to infections.

The Role of Neutrophils in Immunity

Neutrophils are a vital part of the innate immune system. They act as the first line of defense against invading microorganisms. They are a type of White Blood Cell (WBC) and belong to a broader category called Granulocytes (due to the granules in their cytoplasm).

Their primary function is to identify, engulf, and destroy pathogens through a process called phagocytosis. When an infection occurs, neutrophils are rapidly recruited to the site of infection.

Upon reaching the infected area, neutrophils engulf the bacteria or fungi. They then use enzymes and other toxic substances within their granules to kill and digest the pathogens. This process effectively eliminates the threat and prevents the infection from spreading.

Think of neutrophils as the body's frontline soldiers, constantly patrolling for invaders and ready to neutralize them. Without sufficient neutrophils, the body's ability to fight off infection is severely compromised.

How ANC is Measured: An Overview

Measuring the ANC involves a laboratory test performed on a blood sample. The process begins with a Complete Blood Count (CBC), a comprehensive analysis of different blood components. The CBC provides information on red blood cells, white blood cells, platelets, and other parameters.

The ANC is not directly measured. Rather, it's calculated from the CBC results, specifically using the total white blood cell count and the percentage of neutrophils present. This calculation requires a "differential count," which identifies and quantifies the different types of white blood cells.

The subsequent sections will delve deeper into the specifics of the ANC calculation. This includes explaining how the CBC and differential count contribute to determining the ANC value.

The Absolute Neutrophil Count (ANC) is a critical metric in assessing the health and functionality of the immune system. It provides valuable insights into the body's ability to defend itself against infections. This section delves into the specifics of how ANC is calculated, focusing on the Complete Blood Count (CBC) and differential count, the key components for determining ANC values.

Decoding the ANC Calculation: CBC and Differential Count

Calculating the Absolute Neutrophil Count (ANC) requires understanding two essential laboratory tests: the Complete Blood Count (CBC) and the differential count. These tests provide the necessary data to determine the number of neutrophils in your blood.

This section breaks down the process, explaining how these tests work together to give a clear picture of your neutrophil levels.

The Complete Blood Count (CBC) as the Foundation

The Complete Blood Count (CBC) is a comprehensive blood test that evaluates various components of your blood.

While often associated with white blood cells, the CBC provides a broader overview, including red blood cells (responsible for oxygen transport), platelets (essential for blood clotting), hemoglobin, hematocrit, and other crucial parameters.

This comprehensive analysis helps healthcare professionals assess overall health and detect a wide range of conditions.

How ANC is Derived from the CBC

The ANC isn't directly measured in the CBC. Instead, it's calculated using data obtained from the CBC, specifically the total white blood cell (WBC) count.

The CBC indicates the total number of WBCs present in a microliter (µL) or cubic millimeter (mm3) of blood. This value is a crucial starting point for the ANC calculation.

To determine the absolute number of neutrophils, we need to know what proportion of those WBCs are actually neutrophils.

This is where the differential count comes into play, providing a detailed breakdown of the different types of white blood cells.

Differential Count: Breaking Down the White Blood Cells

The differential count is a critical component of the CBC that identifies and quantifies the different types of white blood cells present in the blood sample.

WBCs are not a homogenous group; they consist of several types, each with a specific role in the immune system, including neutrophils, lymphocytes, monocytes, eosinophils, and basophils.

The differential count determines the percentage of each type of WBC, providing valuable information about the body's immune response and potential underlying conditions.

For the ANC calculation, we're primarily interested in the percentage of neutrophils.

Segs and Bands: The Neutrophil Breakdown

Within the neutrophil category, there are two main types to consider: segmented neutrophils (Segs) and band neutrophils (Bands).

Segs, also known as segmented neutrophils or polymorphonuclear neutrophils (PMNs), are mature neutrophils with a multi-lobed nucleus. They are the most abundant type of neutrophil in healthy individuals.

Bands, or band neutrophils, are immature neutrophils with a horseshoe-shaped nucleus. An elevated number of bands can indicate that the bone marrow is releasing neutrophils prematurely, often in response to an infection.

The ANC calculation typically considers the sum of Segs and Bands to represent the total neutrophil count.

Therefore, the differential count provides the percentages of Segs and Bands, which are essential for calculating the ANC.

Units of Measurement: Understanding the Numbers

Understanding the units of measurement is crucial for interpreting ANC values accurately.

The ANC is typically expressed in two common units: Cells/µL (cells per microliter) and Cells/mm3 (cells per cubic millimeter). Since 1 µL is equal to 1 mm3, these units are interchangeable and represent the same concentration.

For instance, an ANC of 2,500 Cells/µL is equivalent to an ANC of 2,500 Cells/mm3.

These units indicate the number of neutrophils present in a specific volume of blood.

The Role of Percentage (%) in ANC Calculation

While the final ANC value is expressed as an absolute number (e.g., 2,500 Cells/µL), the percentage (%) plays a crucial role in its calculation.

The differential count reports the proportion of each type of white blood cell as a percentage of the total WBC count.

For example, if the differential count shows that neutrophils (Segs + Bands) make up 60% of the total WBCs, this percentage is used in conjunction with the total WBC count to calculate the ANC.

The formula will be discussed in the next section to show you how to calculate your ANC.

Once the Absolute Neutrophil Count (ANC) is calculated, the next crucial step is understanding what those numbers actually mean. Interpreting your ANC values involves comparing them to established normal ranges and understanding the potential implications of results that fall outside of those ranges.

Interpreting Your ANC Values: Normal Ranges, Neutropenia, and Neutrophilia

This section serves as a guide to interpreting ANC results, defining what constitutes a normal ANC, and discussing conditions associated with abnormal values, namely neutropenia (low ANC) and neutrophilia (high ANC).

Normal ANC Ranges: What's Considered Healthy?

A normal ANC indicates that you have a sufficient number of neutrophils to effectively fight off infections.

The typical ANC range for adults is generally between 2,500 and 6,000 neutrophils per microliter (Cells/µL), or per cubic millimeter (Cells/mm3), as the units are interchangeable.

However, it's important to acknowledge that "normal" can vary slightly depending on the laboratory and the specific population being tested.

It’s important to note that ANC values for children differ and vary based on age, therefore always consult a pediatrician to interpret children's ANC values.

The ranges are wider and depend on the child's developmental stage.

Factors Influencing Normal Ranges

While the typical range provides a general guideline, several factors can influence what's considered "normal" for an individual.

These factors include:

• Age: As mentioned, normal ANC ranges vary significantly in children depending on their age and developmental stage.
• Ethnicity: Some studies suggest that individuals of African descent may have lower normal ANC ranges compared to other populations. This is often attributed to benign ethnic neutropenia, a non-pathological condition.
• Geographical Location: Certain environmental factors or regional variations may influence ANC levels.
• Laboratory Method: Different laboratories may use slightly different methods for performing CBC and differential counts, potentially leading to minor variations in reported ANC values.

Because of these variables, it's crucial to discuss your specific ANC results with your healthcare provider, who can interpret them in the context of your overall health and medical history.

Neutropenia: Understanding Low ANC and Its Risks

Neutropenia is a condition characterized by an abnormally low number of neutrophils in the blood. This deficiency impairs the body's ability to fight off infections, making individuals more susceptible to bacterial, fungal, and viral infections.

The severity of neutropenia is classified based on the ANC value:

• Mild Neutropenia: ANC between 1,000 and 1,500 Cells/µL
• Moderate Neutropenia: ANC between 500 and 1,000 Cells/µL
• Severe Neutropenia: ANC less than 500 Cells/µL

The lower the ANC, the greater the risk of infection. Severe neutropenia carries the highest risk of life-threatening infections.

Increased Risk of Infections

With a reduced number of neutrophils, the body's first line of defense against invading pathogens is compromised.

This can lead to:

• Bacterial Infections: Increased susceptibility to common bacterial infections, such as pneumonia, cellulitis, and bloodstream infections (sepsis).
• Fungal Infections: Higher risk of opportunistic fungal infections, particularly in individuals with severe neutropenia or those undergoing chemotherapy.
• Viral Infections: While neutrophils primarily target bacteria and fungi, neutropenia can also increase the risk of certain viral infections.

Individuals with neutropenia often require prompt medical attention and may need antibiotics or antifungal medications to prevent or treat infections.

Neutrophilia: Exploring High ANC and Potential Causes

Neutrophilia refers to an abnormally high number of neutrophils in the blood. While it can sometimes be a normal response to certain stressors, it can also indicate an underlying medical condition.

Neutrophilia is generally defined as an ANC above 7,700 Cells/µL. (However, lab values may vary.)

Potential Causes of Neutrophilia

Several factors can contribute to elevated neutrophil levels, including:

• Infection: Bacterial infections are the most common cause of neutrophilia. The body releases more neutrophils to fight off the invading bacteria.
• Inflammation: Inflammatory conditions, such as rheumatoid arthritis and inflammatory bowel disease, can trigger neutrophilia.
• Stress: Physical or emotional stress can temporarily increase neutrophil counts.
• Medications: Certain medications, such as corticosteroids, can cause neutrophilia as a side effect.
• Smoking: Chronic smoking can lead to persistently elevated neutrophil levels.
• Underlying Medical Conditions: In some cases, neutrophilia may be a sign of a more serious underlying condition, such as leukemia or other blood disorders.

When is Neutrophilia a Normal Response?

Neutrophilia is not always a cause for concern. It can be a normal physiological response in certain situations.

For example:

• Acute Infection: A temporary increase in neutrophils is expected during an acute infection as the body mobilizes its immune defenses.
• Post-Surgery: Neutrophilia can occur after surgery due to the inflammatory response associated with tissue healing.
• Exercise: Strenuous exercise can temporarily elevate neutrophil counts.

However, persistent or significantly elevated neutrophilia should always be evaluated by a healthcare professional to rule out any underlying medical conditions.

A healthcare provider will be able to assess your symptoms, medical history, and other lab results to determine the cause of the neutrophilia and recommend appropriate treatment or monitoring.

Factors Influencing ANC: Medications, Conditions, and Treatments

The Absolute Neutrophil Count (ANC) is not a static value; it's a dynamic reflection of the body's internal environment and can be influenced by a variety of factors. Understanding these influences is crucial for accurately interpreting ANC results and making informed clinical decisions. This section explores the key factors that can affect ANC, including medical treatments like chemotherapy, underlying medical conditions, and specific medications.

Chemotherapy and its Impact on Neutrophil Production

Chemotherapy, a cornerstone in cancer treatment, often has a significant impact on neutrophil production. Chemotherapeutic drugs are designed to target rapidly dividing cells, a characteristic of cancer cells. However, they also affect other rapidly dividing cells in the body, including those in the bone marrow responsible for producing blood cells, including neutrophils.

The Effect on Bone Marrow

Chemotherapy can suppress bone marrow function, leading to a decrease in the production of neutrophils. This condition is known as chemotherapy-induced neutropenia and is a common side effect of many chemotherapy regimens. The severity of neutropenia depends on the type and dosage of chemotherapy drugs used, as well as individual patient factors.

The reduced neutrophil count increases the risk of infection, as the body's ability to fight off pathogens is compromised.

Managing Chemotherapy-Induced Neutropenia

Managing chemotherapy-induced neutropenia is critical for preventing serious infections and ensuring that patients can continue their cancer treatment safely. Several strategies are employed to mitigate this risk.

• Growth Factors: These are medications that stimulate the bone marrow to produce more neutrophils. Granulocyte colony-stimulating factor (G-CSF) is a commonly used growth factor to help increase ANC.
• Antibiotics: Prophylactic antibiotics may be prescribed to prevent bacterial infections, especially in patients at high risk of severe neutropenia.
• Dose Adjustments: Adjusting the dosage or schedule of chemotherapy may be necessary to reduce the severity of neutropenia.
• Protective Isolation: In some cases, patients with severe neutropenia may need to be placed in protective isolation to minimize exposure to potential pathogens.

Other Medical Conditions and Their Effect on ANC

Beyond chemotherapy, various medical conditions can influence ANC, either by directly affecting neutrophil production or by altering their distribution and function.

Infections: A Double-Edged Sword

Infections, whether bacterial, viral, or fungal, can have complex effects on ANC. Initially, the body may respond to an infection with neutrophilia, an increase in neutrophil count, as the bone marrow releases more neutrophils to combat the invading pathogens.

However, in severe or prolonged infections, the bone marrow's capacity to produce neutrophils may become exhausted, leading to neutropenia. Some infections, particularly viral infections, can also directly suppress bone marrow function, contributing to neutropenia.

Autoimmune and Inflammatory Disorders

Autoimmune diseases, such as systemic lupus erythematosus (SLE) and rheumatoid arthritis, can affect ANC through various mechanisms.

In some autoimmune disorders, antibodies may target and destroy neutrophils, leading to neutropenia.

Inflammatory disorders, such as inflammatory bowel disease (IBD), can cause neutrophilia as part of the systemic inflammatory response.

The chronic inflammation associated with these conditions can stimulate the bone marrow to produce more neutrophils.

Hematologic Disorders

Conditions affecting the bone marrow, such as myelodysplastic syndromes (MDS) and aplastic anemia, can disrupt normal neutrophil production, often resulting in persistent neutropenia. Leukemia, a cancer of the blood, can also affect ANC, with some types causing neutrophilia and others causing neutropenia.

Medications That Influence ANC

A wide range of medications can influence ANC, either by decreasing or increasing neutrophil levels. It's essential to consider medication history when interpreting ANC results, as drug-induced neutropenia or neutrophilia can occur.

Medications That Decrease ANC

Several medications are known to cause neutropenia as a side effect. These include:

• Antibiotics: Certain antibiotics, such as some sulfonamides and cephalosporins, can suppress bone marrow function.
• Antipsychotics: Clozapine, an atypical antipsychotic, is a well-known cause of severe neutropenia (agranulocytosis) and requires careful monitoring.
• Anticonvulsants: Some anticonvulsants, such as carbamazepine and valproic acid, can occasionally cause neutropenia.
• Immunosuppressants: Medications like azathioprine and methotrexate, used to suppress the immune system in autoimmune diseases, can also affect neutrophil production.

Medications That Increase ANC

Certain medications can cause neutrophilia, including:

• Corticosteroids: These medications, used for their anti-inflammatory effects, can increase neutrophil counts by mobilizing neutrophils from the bone marrow and reducing their migration out of the bloodstream.
• Lithium: This mood stabilizer can stimulate neutrophil production and is sometimes used to treat neutropenia.
• Epinephrine: Often administered during allergic reactions, epinephrine promotes a transient increase in neutrophil counts by causing the release of neutrophils from the marginated pool into the circulating pool.

Understanding the factors that influence ANC is crucial for healthcare providers to accurately interpret lab results, diagnose underlying conditions, and manage patient care effectively. By considering the impact of chemotherapy, other medical conditions, and medications, clinicians can provide the best possible care for patients with abnormal ANC values.

Clinical Significance of ANC: Monitoring, Assessing Immunity, and Diagnosis

The Absolute Neutrophil Count (ANC) is far more than just a number on a lab report. It's a vital sign that provides critical insights into a patient's immune status and overall health. Its clinical significance spans across numerous medical contexts, from closely monitoring treatment efficacy to acting as a key indicator in the diagnosis of underlying conditions. Understanding how ANC informs clinical decisions is essential for both healthcare professionals and patients alike.

Monitoring ANC During Treatment: A Crucial Safety Net

Many medical treatments, particularly those targeting rapidly dividing cells, can significantly impact bone marrow function and, consequently, neutrophil production. Chemotherapy, radiation therapy, and certain immunosuppressants can all lead to neutropenia, a potentially life-threatening reduction in ANC.

Regular Complete Blood Count (CBC) tests, including ANC, become indispensable during these treatments.

• Frequency of Monitoring: The frequency of CBC tests varies depending on the specific treatment regimen and individual patient factors.

  • Some protocols may require daily monitoring, while others may suffice with weekly or bi-weekly checks.
• Early Detection is Key: Serial ANC measurements enable clinicians to detect neutropenia early, allowing for timely interventions to prevent serious infections.
• Personalized Treatment Plans: Monitoring ANC helps tailor treatment plans to minimize myelosuppression while maintaining therapeutic efficacy. Dosage adjustments, treatment delays, or the use of growth factors (G-CSF) may be necessary to manage neutropenia and ensure patient safety.

Assessing Immune System Function with ANC: A Window into Immune Competence

ANC serves as a reliable indicator of immune competence, reflecting the body's capacity to mount an effective defense against invading pathogens. Neutrophils are the first responders to infection, engulfing and destroying bacteria, fungi, and other harmful microorganisms.

A sufficient number of neutrophils is essential for preventing and controlling infections.

• ANC as a Predictor of Infection Risk: Low ANC (neutropenia) significantly increases the risk of infection, particularly bacterial and fungal infections. The severity of neutropenia correlates with the likelihood and seriousness of infectious complications.
• Interpreting ANC in Immunocompromised Patients: In individuals with underlying immune deficiencies, such as those with HIV/AIDS or undergoing immunosuppressive therapy, ANC monitoring is critical for assessing their susceptibility to opportunistic infections and guiding prophylactic strategies.
• Impact on Treatment Decisions: The ANC level often dictates treatment decisions for infections. Profound neutropenia may necessitate the use of broad-spectrum antibiotics or antifungal agents, as well as supportive measures like protective isolation.

Role of ANC in Diagnosing Underlying Conditions: Unveiling Hidden Clues

Abnormal ANC values, whether neutropenia or neutrophilia, can provide valuable clues to the presence of underlying diseases. While not diagnostic on its own, ANC acts as an important signal that prompts further investigation.

• Neutropenia as a Diagnostic Clue: Neutropenia can be a sign of various conditions, including:

  • Hematologic Disorders: Leukemia, myelodysplastic syndromes (MDS), and aplastic anemia.
  • Autoimmune Diseases: Systemic lupus erythematosus (SLE) and rheumatoid arthritis.
  • Infections: Viral infections like HIV and parvovirus B19.
  • Nutritional Deficiencies: Vitamin B12 and folate deficiency.

• Neutrophilia as a Diagnostic Clue: Neutrophilia can be associated with:

  • Infections: Bacterial infections, especially those causing tissue damage.
  • Inflammation: Inflammatory disorders like rheumatoid arthritis and inflammatory bowel disease (IBD).
  • Stress: Physiological stress such as trauma, surgery, or burns.
  • Certain Medications: Corticosteroids and lithium.

• The Diagnostic Process: When an abnormal ANC is detected, a thorough evaluation is necessary to determine the underlying cause. This may involve:

  • Detailed Medical History and Physical Examination: Assessing risk factors, symptoms, and signs of underlying conditions.
  • Review of Medications: Identifying potential drug-induced neutropenia or neutrophilia.
  • Bone Marrow Examination: Evaluating bone marrow cellularity and morphology to rule out hematologic disorders.
  • Infectious Disease Testing: Screening for viral, bacterial, and fungal infections.
  • Autoimmune Workup: Testing for autoimmune antibodies and inflammatory markers.

The Healthcare Team: Roles in ANC Testing and Monitoring

The Absolute Neutrophil Count (ANC) isn't just a solitary data point; it's a critical piece of information that requires a coordinated effort from various members of the healthcare team to ensure accurate testing, vigilant monitoring, and informed clinical decision-making. Effective patient care hinges on the collaboration of medical technologists, nurses, and physicians, each bringing their unique expertise to the table. Understanding their distinct roles is essential to appreciate the comprehensive approach required for optimal ANC management.

Medical Technologists/Laboratory Technicians: Ensuring Accuracy

Medical technologists, also known as clinical laboratory scientists, are the unsung heroes behind the scenes. They are responsible for performing the Complete Blood Count (CBC) and differential count, the cornerstones of ANC determination.

Their expertise is crucial for ensuring the accuracy and precision of these tests.

Precision in Testing

The process begins with meticulous sample collection and preparation. Medical technologists utilize sophisticated automated analyzers to count and classify blood cells. Their proficiency in operating and maintaining these instruments is paramount.

They must be able to troubleshoot any technical issues that may arise and ensure that the instruments are properly calibrated and functioning optimally.

Quality Control Measures

Laboratories adhere to stringent quality control protocols to guarantee the reliability of ANC results. These measures include:

• Regular Calibration: Ensuring instruments are accurately calibrated using known standards.
• Internal Controls: Running control samples with known values to monitor assay performance.
• External Quality Assurance Programs: Participating in proficiency testing programs to compare results with other laboratories and identify any discrepancies.
• Rigorous Documentation: Maintaining detailed records of all testing procedures, quality control data, and instrument maintenance.

These comprehensive quality control measures are essential for minimizing errors and ensuring that clinicians can rely on the accuracy of ANC values when making critical treatment decisions.

Nurses: Monitoring Trends and Reporting Changes

Nurses play a vital role in the ongoing monitoring of ANC trends and the early detection of any significant changes. As the primary point of contact for patients, they are uniquely positioned to observe subtle signs and symptoms that may indicate fluctuations in ANC levels.

Vigilant Monitoring

Nurses carefully track ANC values over time, noting any upward or downward trends. They are trained to recognize patterns that may signal the onset of neutropenia or neutrophilia.

They are also skilled at assessing patients for signs and symptoms of infection, such as fever, chills, and localized inflammation, which can be early indicators of neutropenia-related complications.

Patient Education and Communication

Nurses educate patients about the importance of ANC monitoring, particularly during treatments that can affect bone marrow function.

They explain the potential risks associated with low ANC levels, such as increased susceptibility to infection. They also instruct patients on how to minimize their risk of infection by practicing good hygiene and avoiding exposure to sick individuals.

Effective communication between nurses and physicians is crucial for ensuring timely intervention when ANC levels deviate from the normal range. Nurses promptly report any significant changes or concerning symptoms to the physician, facilitating prompt diagnosis and treatment.

Physicians: Interpreting Results and Making Decisions

Physicians are responsible for interpreting ANC results in the context of a patient's overall health status and medical history. They integrate ANC values with other clinical findings, such as physical examination findings, imaging results, and other laboratory data, to arrive at an accurate diagnosis.

Comprehensive Interpretation

Physicians must consider various factors that can influence ANC, including medications, underlying medical conditions, and recent infections. They use their clinical judgment to determine whether an abnormal ANC value warrants further investigation or treatment.

Physicians tailor treatment plans to the individual needs of each patient, taking into account the severity of neutropenia or neutrophilia, the underlying cause, and the patient's overall health.

Treatment Strategies

Depending on the clinical scenario, physicians may recommend a range of interventions, including:

• Antibiotics or Antifungal Medications: To treat or prevent infections in patients with neutropenia.
• Growth Factors (G-CSF): To stimulate neutrophil production in the bone marrow.
• Immunosuppressant Adjustments: Dosage adjustments of immunosuppressive medications to minimize myelosuppression.
• Further Diagnostic Testing: Bone marrow examination, infectious disease testing, or autoimmune workup to identify the underlying cause of abnormal ANC values.

The physician's expertise is critical for guiding patient care and optimizing outcomes in individuals with ANC abnormalities. They rely on the collaborative efforts of medical technologists and nurses to provide comprehensive and coordinated care.

So, there you have it! Calculating your ANC might seem a little intimidating at first, but hopefully, this step-by-step guide makes understanding how do I calculate ANC much easier. Remember to double-check your numbers and consult with your healthcare provider if you have any concerns. Stay healthy!