The elbow maneuver spread globally not because of evidence but because a hospital in Maine made a funny video in 2006
We can do better
Prevent > Cover > Protect
And for repeated symptoms: wear a respirator
Share if your IPC training never included any of this
3. REPEATED symptoms = wear a respirator
Before the cough or sneeze, not instead of covering
Protects you from your own triggers
Protects others from your unknowns
2. COVER for what gets through
Shirt > tissue > cupped hands
Never bare elbow alone
Two-handed elbow (pressing arm firmly to face) is mechanistically better but still inferior to shirt
So here's what the evidence actually supports:
1. PREVENT the sneeze
Philtrum pressure + tongue to hard palate the moment you feel it coming
Takes practice
Teachable to most people
Works ~70-80% of the time once learned.
Divers: use what you already know.
"I'm not sick, it's just allergies"
Wear a respirator
1. You will inhale less pollen → fewer sneezes, less misery (36% reduction in moderate-severe nasal symptoms in mask-wearers with pollen allergy)
2. Your repeated high-velocity sneezes are dispersing your respiratory microbiome to everyone around you
Wearing a respirator during allergy season protects YOU primarily
The protection of others is a co-benefit
📄 Pollen + mask evidence: https://t.co/g4NxfOdlOF
"I might be coughing or sneezing but I'm not sick - why would I need a respirator?"
6% of apparently healthy people are actively shedding respiratory virus at any given time
57-93% of positive respiratory virus samples come from asymptomatic individuals
Human bacterial pathogens (S. aureus, H. influenzae, MRSA) have been detected in exhaled breath of healthy carriers
Your respiratory microbiome is real
Whether it's pathogenic to the person next to you depends on THEIR immune status, not yours
📄 Asymptomatic shedding: https://t.co/nBP4fFCv02
📄 Exhaled breath pathogens: https://t.co/cfnZxFNcO9
Any condition causing REPEATED coughing or sneezing (cold, flu, COVID, allergies) should be a trigger to wear a respirator in shared spaces
Before the cough happens
This should be standard in healthcare
And become a cultural norm everywhere
A 2013 University of Alberta laser-diffraction study measured droplet size during cough etiquette maneuvers
97% of cough droplets <1 micron
Particles escaped regardless of maneuver - elbow, tissue, hands, surgical mask
📄 Zayas et al. 2013: https://t.co/wlP4J3RP3X
A 2025 University of Utah study compared cough maneuvers directly using slow-motion video
Elbow - 59.6% reduction
Surgical mask - 93.2% reduction
INTO THE SHIRT - 95.4% reduction
The shirt beat the elbow by 36 points
📄 Steimle et al. 2025: https://t.co/iO48SDTAKU
A 2020 study in Physics of Fluids used Schlieren imaging to visualize cough plumes under 9 different covering conditions
Finding: a BARE elbow cannot form a seal against the face
Aerosol leaks in multiple directions
📄 Simha & Rao 2020: https://t.co/kYTMvZOXiG
🧵 "Cough into your elbow" has no peer-reviewed origin
Researchers traced it to a 2006 hospital video
And a 1994 quote from a pediatrician who said she learned it from daycare
Neither CDC nor WHO can tell you who invented it
It's just folklore that gained a following
Tip: Try to PREVENT sneezes
1. Press firmly below your nose (philtrum) when you feel a sneeze coming (stimulates trigeminal nerve, can abort the reflex)
2. Press your tongue hard against your hard palate simultaneously
Competing touch signals interrupt irritant cascade upstream of the motor program (gate control theory)
📄 Mechanism: https://t.co/y2KUFy2o3G
@stats_feed Sorry, last one I promise. Couch co-op games. I have a kid and being able to play the same game on the same system on the same TV on the same couch is such a fun experience. Also great couple-fun once the kid is asleep. (Not taking anything away from other gaming, that's fun too)