The Winter Sneeze – Hand, Tissue or Dracula Style? (Gesundheit!)

When I was a kid from the wrong side of the tracks, wiping your nose on your clothes was a marker of our social class. Lots of us girls were very keen on our hankies, though. I used to embroider initials on them and crochet lace around their edges.

Now it’s hankies that should make people go ewww! and the upper sleeve should be respectable for catching coughs and sneezes.

Before they became controversial as germ-catchers, the European handkerchief had an interesting history [PDF] – and rather a long association with class. Erasmus apparently said the cap or the sleeve “might be alright for pastry-cooks,” but hands were a bit better and handkerchiefs were what social betters should use. Marie Antoinette has been credited with insisting – ultimately supported by royal edict – that hankies be square. Perhaps that one’s an apocryphal tale. Wikipedia says the material hankies are made of still “can be symbolic of the socio-economic class of the user.”

Back in the Spanish flu era early last century, covering your mouth with a handkerchief when you coughed or sneezed was recommended in the US. And face masks made of gauze were used in sickrooms and hospitals.

According to the CDC, tissues are the first line – to be tossed in the waste afterwards, with the upper sleeve as back-up if you don’t have a tissue handy. In 2009, this picked up the nickname, “the Dracula Sneeze,” after the full Dracula pose. “Dracula sneeze” made it onto a best new words list in 2010.

The CDC also recommends washing your hands with soap and warm water for 20 seconds often, or using an alcohol-based hand rub (at least 60% alcohol).

Has all this taken off? The Dracula sneeze might have, although there’s not much data to go on. An observational study in New Zealand during a 2009 flu epidemic found that less than 4% of people used a hanky or tissue and less than 2% used their elbow or arm to cover their coughing and sneezing. They were more likely to cover up when they were close to other people.

But then a 2014 study saw a whopping 42% rate of sneezing Dracula style. They watched students’ behavior in 22 classrooms at a U.S. university. Tissues only made it to the nose 3% of the time, and 45% used their hands. People were less likely to cover up their coughing, though.

There was no gender difference in using Dracula style, but overall for coughing and sneezing, men were much more likely to not cover up at all: 37% compared to only 17% of women.

Some people don’t shake hands, kiss others or share glasses when they’ve got a cold, but when the flu’s going around, you don’t see all that big a change in social life.

There certainly seem to be some people using hand-sanitizers in some countries, but that doesn’t seem to be all that common either. Not many use those dispensers provided in institutions.

That people don’t really do these things is one of the barriers to them working, but not the only one. We can spray those droplets up to 6 feet away, and they last on surfaces for 2 to 8 hours. The virus gets into our respiratory system either directly by droplets reaching our eyes, nose or mouth, or from our hands when we touch our faces. There are just so many ways for the flu virus to spread.

Logically, if there’s no one around, since it’s hard to keep our hands away from our faces, sneezing or coughing directly into your hands would be worse than not covering up – hence the recent advice.

[Note: the following section was updated on 5 March 2020 based on more recent evidence.]

In 2014, authors of a study of US college students saw less than a quarter of them using their sleeves, arm, or a tissue when they sneezed or coughed – and they were more likely to do so when they sneezed than coughed. Masks have become popular and recommended in some countries, but not others.

You would think we would have a lot of strong evidence to guide us on all this, wouldn’t you? But we don’t really. There’s a systematic review of personal anti-infection etiquette by Patrick Saunders-Hastings and colleagues with a cut-off date for evidence in June 2016. We still don’t have trials comparing coughing/sneezing practices. The evidence for frequent hand washing has grown, though, and there have been some more trials since that review (for example in 2016, another in 2016, and in 2018). The higher the exposure to infected people or surfaces, the more frequent hand washing needs to be.

There haven’t been enough controlled studies of face masks for personal use for that to be a reliable basis for decision-making. There’s more evidence on masks for healthcare workers in epidemics, though, but not as much as you would think. And we still need more evidence on effective interventions in communities in lower and middle-income countries.

So there’s still no word specifically on the tissues vs hand vs elbow question – but nothing at all is clearly pretty anti-social at this point. Ever since I wrote this post, I found myself “doing the Dracula” more and more. It’s faster than scrambling for a tissue, for me at least. It makes sense. Kinda feels like being back in the old neighborhood.

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Want to know more about sneezing? Here’s a great post by SciCurious.

The Statistically Funny cartoon is my own (CC BY-NC-ND license). (More cartoons at Statistically Funny and on Tumblr.)

The public health poster is from around 1925, in Wikimedia Commons.

[This post was updated with the 2014 study in university classrooms on 10 December 2016, as well as the 2010 best new words citation. It was updated again on 5 March 2020, in the early days of the spread of COVID-19. The version at 20 December 2016 is in the Internet Archive. The original review was based on a systematic review on the whole array of ways to physically interrupt the spread of respiratory viruses with an updated search in 2010, but it is very out of date now. At that time, found the evidence about what works and doesn’t work had grown a little. There are more trials now (like these: 2012, 2012, 2013, 2014, 2014, 2015, 2016, 2016, and 2018). I updated again on 28 March 2020 on the issue of face masks for general use.]

* The thoughts Hilda Bastian expresses here at Absolutely Maybe are personal, and do not necessarily reflect the views of the National Institutes of Health or the U.S. Department of Health and Human Services.