How not to spread the flu

Cough and sneeze etiquette
At some point during a pandemic, you will need to cough or sneeze. Do so in such a way that if you are carrying influenza virus, you reduce the chance of spreading it. Cough and sneeze etiquette is sometimes referred to as respiratory hygiene. Not every cough that you have during a pandemic will be influenza. You may be sneezing or coughing because of a cold or your allergies, but remember that you could at the same time be in the incubation period of influenza and be shedding virus anyway. Cough and sneeze etiquette is a worthwhile courtesy at all times, and even more relevant during an influenza pandemic.

Turn away from the people around you. Don't cough or sneeze on people, and especially not in their faces. Ideally, cough or sneeze into a disposable paper tissue, holding it with your non-dominant hand (if you are right-handed, sneeze into a tissue in your left hand, and vice versa). Immediately throw the tissue away in a garbage can. Regard both hands as potentially contaminated, and wash them both thoroughly as soon as possible. Do not unnecessarily touch or handle any objects with either hand until you have done so.

Simple? Sounds like it. Easier said than done? Yes. Try it. Doing all these things in real life may be challenging. For instance, you may need to sneeze on the subway at rush hour. If you are in a crowded place and can't turn away from everyone, try to cover your nose and mouth as well as possible when you cough or sneeze. Or you may have run out of tissues. If so, cough or sneeze into your bare non-dominant hand, or into your upper shirt sleeve. This piece of clothing, or your bare hand, is now certainly contaminated if you have influenza. After sneezing into your upper sleeve, don't push doors open with your shoulder. If you've coughed into your left hand, use your right hand to open doors.

There is no scientific literature to support using your non-dominant hand to address your sneeze, and then preferring your dominant hand if you need to handle objects before you're able to wash both hands. We just think it makes sense, because you're going to need to use one of your hands. Interestingly, in many cultures, such as in India, the left hand is seen as a contaminated hand and performs "dirty" daily activities; consequently, one never greets another person with that hand. Ideally, after sneezing you shouldn't handle anything but should immediately throw away the tissue and wash both hands fastidiously. In a perfect world, bathrooms would be everywhere, they wouldn't have doors, and all sinks would be motion-activated. Since this isn't the case, and the ideal of not touching anything after you sneeze until you thoroughly wash your hands isn't always going to be possible, we recommend using your dominant and non-dominant hands, as well as your shirt sleeve in the fashion we describe above. Keeping a hand sanitizer in your pocket or purse will also help mitigate the unavailability of bathrooms.

Being coughed on or sneezed on
At some point during an influenza pandemic, someone may cough or sneeze near you, or perhaps on you. During Phase 6, this is the pandemic influenza equivalent of having unprotected sex. Avoid it. It would be better if it hadn't happened, but once it has, it's good to know how you might mitigate your risk of contracting influenza and your potential for spreading it further. There is no formal scientific literature in this area, so what follows is our carefully considered opinion based on the best knowledge that exists.

Don't flip out. Don't panic, and don't become hostile toward the person who just coughed or sneezed on you. There's no point. Once it's happened, it's happened. Perhaps the sneezer just has allergies. But you may also have been exposed to influenza. If you have just been exposed but no virus has entered your mucous membranes, you may not yet have contracted influenza.

You could ask the person if he is ill, but this is optional. The answer shouldn't change what you do. Our opinion is that during Phase 6 of a pandemic, you should treat any situation in which someone directly coughs or sneezes on you the same way. If the cough or sneeze reached your hands or belongings, wash them carefully. Be especially sure to give your hands a thorough washing before you touch your own eyes, nose, or mouth. What if someone has coughed or sneezed in your face? First, wash your hands. Then wash your face thoroughly. You may choose to rinse your eyes and mouth. Be sure to wash your hands carefully before touching your face, because if your hands are contaminated, there's no point introducing contamination to your face in your attempt to clean it.

You may consider, in a civilized and non-confrontational manner, advising the cougher or sneezer to employ cough and sneeze etiquette in the future. Finally, if you have been coughed or sneezed upon, be additionally careful in your own subsequent habits. In this way, if you have been infected, you can hopefully reduce the risk of transmitting the infection to others. Remember, even if you contract influenza, you have a high chance of surviving.

Page 2 of 3