effectiveness of cough etiquette

… Despite the inconsistencies among global health authorities and their cough etiquette recommendations, the indication of “cover your cough with your elbow/arm/sleeve” has reached a phenomenal, close to universal acceptance, including elementary school children who are being successfully trained to practice it. Furthermore, this remarkable compliance around the globe has occurred in a very short period of time. Society has adopted this maneuver without asking for or demanding scientific evidence.

The prompt acceptance, implementation, societal/individual behavior modification, and global dissemination of the maneuver present the scientific community with a dilemma: why was this maneuver so popular in light of the lack of evidence to support it? Involved are several facts and actions: a) no peer review publication documenting this maneuver, b) no scientific evidence supporting the effectiveness of such a maneuver, and c) no scientist author, developer or designer fathering such a maneuver.

…The lack of scientific evidence supporting this particular maneuver is a valid argument for most global health agencies to avoid including it in their set of written recommendations, however it is still conditionally included in pictorial recommendations, as seen in CDC campaigns [18].

Whether or not this particular maneuver is based on scientific evidence, the general public accepted it and voluntarily adopted a change in behavior. This can serve as an example for the scientific community to understand how knowledge should be structured, translated, and communicated to get the message across and subtly induce positive behavioral change in the population.

In summary, assessed public health maneuvers, including facemasks, do not fully protect against the millions of smaller cough droplets, as micron size droplets dehydrate rapidly, form nuclei, remain airborne, and penetrate deep in the lung when inhaled, augmenting the risk of infection, of developing disease, and even increasing mortality due to transmitted infection.

Conclusions

…The results acquired in this study indicate that all CE maneuvers assessed do not block droplets expelled as aerosol when coughing. This aerosol can penetrate profound levels of the respiratory system. Practicing these assessed primary respiratory hygiene/cough etiquette maneuvers would still permit direct, indirect, and/or airborne transmission and spread of IRD, such as influenza and Tuberculosis.

Acquired data suggests that in the case of an individual infected with a highly pathogenic microorganism, infectious cough droplets would still be released to the surrounding environment when covering the mouth/nose with any of the assessed respiratory maneuvers, allowing the probability of infecting susceptible individuals.

lucky rabbit’s foot

In some cultures, the foot of a rabbit is carried as an amulet believed to bring good luck. This belief is held by individuals in a great number of places around the world, including Europe, China, Africa, and North and South America. In variations of this superstition, the donor rabbit must possess certain attributes, such as having been killed in a particular place, using a particular method, or by a person possessing particular attributes (e.g., by a cross-eyed man).

It has been suggested by Benjamin Radford that the rabbit’s foot could be connected to a European good luck charm called the Hand of Glory, a hand cut from a hanged man and then pickled.

Humorist R. E. Shay is credited with the witticism, "Depend on the rabbit's foot if you will, but remember it didn't work for the rabbit."

cloth masks compared with medical masks

… This study is the first RCT of cloth masks, and the results caution against the use of cloth masks. This is an important finding to inform occupational health and safety. Moisture retention, reuse of cloth masks and poor filtration may result in increased risk of infection. Further research is needed to inform the widespread use of cloth masks globally. However, as a precautionary measure, cloth masks should not be recommended for HCWs, particularly in high-risk situations, and guidelines need to be updated.

…Cloth masks resulted in significantly higher rates of infection than medical masks, and also performed worse than the control arm.

…The control arm was ‘standard practice’, which comprised mask use in a high proportion of participants. As such (without a no-mask control), the finding of a much higher rate of infection in the cloth mask arm could be interpreted as harm caused by cloth masks, efficacy of medical masks, or most likely a combination of both.

handkerchief

…The 1918–1919 influenza pandemic taught public health experts a complex and contradictory set of lessons. On the positive side, the pandemic seems to have diminished the appeal of atmospheric theories of infection. Although some commentators continued to mention weather conditions as a variable in the disease's spread, the Spanish influenza confirmed the importance of droplet and contact infection. As William Osler was credited with observing, the flu never traveled faster than modern transportation, confirming that it was human bodies and not some ethereal atmospheric force that spread it.45 Natural experiments, such as the flu's introduction into San Quentin prison, enabled a clearer understanding of the contingent nature of infection; at the prison, the peaks of the illness followed nights that the inmates had gathered to watch a movie (and likely without benefit of handkerchiefs).19

…During the pandemic, another, more common alternative, namely the cloth handkerchief, came to fill a similar function. Although the gauze mask received the greater degree of publicity, the handkerchief got an equally big boost from public health authorities. Starting in September 1918, public health officials urged the public to use their hankies as cloth shields when coughing or sneezing. This message appeared in the first influenza precautions issued by Surgeon General Rupert Blue and was repeated by local health departments throughout the remainder of the epidemic.45The City of Chicago even passed a law making people who coughed or sneezed without using a handkerchief liable to arrest.46 Likely one big reason for the emphasis on handkerchief use was its ease of practice. Compared with gauze masks, which were expensive to buy and uncomfortable to wear, the cheap, easily washed handkerchief was a good substitute. But for very poor Americans, even a handkerchief, much less a frequently washed one, represented a luxury.

…With even greater zeal, interwar advertisers carried on the work of promoting personal hygiene by invoking the fear of influenza. Timed to run during cold and flu season, advertising promotions of mouthwash, cough drops, and tonics reminded their readers that “a cold may be something far more dangerous.”58 For example, the 1929 ads for Listerine® alerted readers to the dangers of “street car colds,” using illustrations of men sneezing while using public transportation.59 When in the late 1920s, consumers began to use paper tissues—originally marketed to remove cold cream—as disposable handkerchiefs, advertisers quickly began to promote this usage of the product. Ads for disposable tissues in the 1940s and 1950s featured mothers training their sons to manage their “man sized sneezes.”60

immune system facts and myths

Your immune system is your friend. It protects your body from infection. Give it your full support and, as with any friend, there will be perks.

Here’s how it works: Your immune system creates, stores, and distributes the white blood cells that fight bacteria and viruses that enter your body, especially during cold and flu season. 

For such a simple-sounding process, there's a lot of bad information out there. Here are some myths and facts about the immune system and how it works.

Eating fruits and veggies keeps your immune system strong.

Fact. Mom and dad were right when they told you to eat your fruits and vegetables. Studies show that people who eat a lot of them get sick less. The nutrients in them can help your immune system fight viruses and bacteria. 

Not getting enough sleep has no effect on your immune system.

Myth. There's a strong link between sleep and a healthy immune system. But not just any sleepwill do. Restorative sleep, which means enough sleep to get the body back into fighting shape, is key. Sleep needs vary by person, but most adults need 7-8 hours a night. Teens need 9-10 hours, school-aged kids need at least 10 hours, preschoolers need 11-12 hours, and newborns need 16-18 hours.

Over the past few decades, though, the average time asleep has dropped to less than 7 hours a night for adults. If you sleep less than your body needs, you’ll build up a sleep debt. And you can't make that up with naps or by sleeping in on weekends. Bottom line: Get to bed at a time when you know you can sleep at least 7 hours. 

A positive attitude can be healthy.

Fact. A good outlook may be good for your health. One study of law students showed that their immune systems kept pace with their thoughts about how tough school would be. When they felt better about school, they had a better immune system. When they were worried, their immune system slowed. The upshot: Looking on the bright side might better equip your body to fight illnesses.

Covering your mouth when you cough can keep germs at bay.

Fact. Coughing, sneezing, or even talking near someone who has the flu can make you sick when droplets of the virus get into the air. And you can inhale these droplets even if you are 2-3 feet away. If you’re the person who’s sick, stay home. If you must be around others, cover your mouth and nose when you cough or sneeze into your shoulder or the inside of your elbow. If you’re healthy and suspect others around you are sick, stand at least 4 feet away. Also, since germs can live on hard surfaces like doorknobs for hours, wash hands frequently, and keep them away from your face.

Supplements can help you feel better faster.

Myth. Taking a daily multivitamin is probably a good idea to stay healthy if you eat poorly. But taking megadoses of a single vitamin or supplement has not been proven to help the immune system.

Kids need supplements to build a healthy immune system.

Myth. Vitamins and minerals matter for kids too, but they should get them from eating nutritious foods. If your child is a picky eater, a vegetarian, or a vegan, your doctor may recommend a supplement. Remember: Though you can buy children’s vitamins over-the-counter, they are still drugs. Taken excessively, they can be toxic.

Sucking your baby’s pacifier can make him less likely to develop allergies.

Fact. Do you cringe when you see a parent pick up a baby’s pacifier and suck it before returning it to the baby’s mouth? Don't. A recent study found that parents who suck their infant’s pacifier may lower the baby’s risk of having allergies. The thought is that germs transferred to the infant from the parent’s saliva will kick-start the baby's immune system.

Exercise has no effect on the immune system.

Myth. While there’s no direct link between moderate exercise and keeping the average person’s immune system humming, there are lots of benefits to working out. Among other things, it lowers blood pressure, keeps body weight under control, and can protect you from certain diseases. So get moving.

Influenza Virus Aerosols in the Air and Their Infectiousness

…Influenza is one of the most contagious and rapidly spreading infectious diseases and an important global cause of hospital admissions and mortality [1]. Influenza virus concentration [2, 3], air circulation time, air temperature, and humidity [4] play an important role in overcoming the epidemic threshold.Influenza virus particles are constantly circulating in the air (airborne) in different forms (within dust particles or aerosol droplets) [5, 6]. There are some amounts of the virus in the air constantly. These amounts are insufficient to cause disease in people (the immune system of healthy humans prevents infection). However, at a higher concentration of the airborne virus, the risk of human infection increases dramatically.

… Infectious viruses and viral RNA can be detected in both larger particles of >5 μm and smaller particles of <5 μm [9, 14, 32]. Experimental studies have demonstrated that the influenza virus can remain infectious in small particle aerosols and can transit across rooms [24, 33]. Cowling et al. [33] found that aerosol transmission (particles <5 μm) accounted for approximately half of all transmission events. Infectious influenza was recovered in all aerosol fractions (5.0% in >4 μm aerodynamic diameter, 75.5% in 1–4 μm, and 19.5% in <1 μm; n = 5) [24].

The aerosol fraction that is <4 μm (the “respirable fraction”) is of particular concern because it can remain airborne for an extended time and disperse throughout a room occupied by a patient with influenza. Also, particles containing influenza RNA are small enough to be drawn down into the alveolar region of the lungs. The infectious dose required for inoculation by the aerosol route relative to contact or droplet transmission is unclear, but two reviews of previous studies concluded that the infectious dose by the aerosol route is likely to be considerably lower than the infectious dose by intranasal inoculation [21, 34] and that aerosol inoculation results in more severe symptoms [21], presumably because aerosol particles are able to deposit deeper in the respiratory tract. However, the viability of influenza viruses in particles of different sizes and the persistence of viable airborne viruses in the environment are not yet known.

…Among the temperatures tested, transmission was highly efficient at (5°C/41°F) but was blocked or inefficient at (30°C/86°F). Dry conditions (20% and 35% RH) were also found to be more favourable for spread than either intermediate (50% RH) or humid (80% RH) conditions.

… tested two influenza B viruses transmission at low (5°C/41°F) versus intermediate (20°C/68°F) temperatures. The transmission was more efficient under colder conditions. Thus, transmission of human influenza viruses by a respiratory droplet or aerosol route in the guinea pig model proceeds most readily under cold, dry conditions. These findings suggested two means by which environmental factors could drive the wintertime seasonality of influenza.

… Clear correlation and dependence of the number of diseased subjects on the concentration of the influenza virus in the air were shown in various models. For example, a relationship between the number of infected pigs and the influenza detection in the air was identified in a study on a single H1N1 viral strain [47]. The chance of detection of an influenza positive air sample increased 2.2 times per each additional nasal secretion by a sick pig. This suggests that the risk of aerosolization and perhaps aerosol transmission increases as the number of infected pigs increase.

…Atkinson and Wein [8] created a mathematical model that describes aerosol (i.e. droplet-nuclei) and contact transmission of influenza A virus subtype H5N1 within a household containing one infected. It was demonstrated that in addition to the concentration of particles in the air that a person inhales, time plays a determining role in the influenza virus infection.