Higher level of neutrophil-to-lymphocyte is associated with severe COVID-19

Epidemiol Infect. 2020 Jul 9;148:e139. doi: 10.1017/S0950268820001557.


In December 2019, cases of severe coronavirus 2019 (COVID-19) infection rapidly progressed to acute respiratory failure. This study aims to assess the association between the neutrophil-to-lymphocyte ratio (NLR) and the incidence of severe COVID-19 infection. A retrospective cohort study was conducted on 210 patients with COVID-19 infection who were admitted to the Central Hospital of Wuhan from 27 January 2020 to 9 March 2020. Peripheral blood samples were collected and examined for lymphocyte subsets by flow cytometry. Associations between tertiles of NLR and the incidence of severe illness were analysed by logistic regression.Of the 210 patients with COVID-19, 87 were diagnosed as severe cases. The mean NLR of the severe group was higher than that of the mild group (6.6 vs. 3.3, P < 0.001). The highest tertile of NLR (5.1-19.7) exhibited a 5.9-fold (95% CI 1.3-28.5) increased incidence of severity relative to that of the lowest tertile (0.6-2.5) after adjustments for age, diabetes, hypertension and other confounders. The number of T cells significantly decreased in the severe group (0.5 vs. 0.9, P < 0.001). COVID-19 might mainly act on lymphocytes, particularly T lymphocytes. NLR was identified as an early risk factor for severe COVID-19 illness. Patients with increased NLR should be admitted to an isolation ward with respiratory monitoring and supportive care.

Keywords: COVID-19; NLR; immune response; severe illness.

MeSH terms

  • Adult
  • Aged
  • COVID-19
  • China / epidemiology
  • Coronavirus Infections / blood
  • Coronavirus Infections / epidemiology
  • Coronavirus Infections / immunology*
  • Coronavirus Infections / pathology*
  • Cytokines / blood
  • Female
  • Humans
  • Inflammation / pathology
  • Lymphocyte Count
  • Lymphocytes / pathology*
  • Male
  • Middle Aged
  • Neutrophils / pathology*
  • Pandemics
  • Pneumonia, Viral / blood
  • Pneumonia, Viral / epidemiology
  • Pneumonia, Viral / immunology*
  • Pneumonia, Viral / pathology*
  • Risk Factors
  • Severity of Illness Index
  • Young Adult


  • Cytokines