Sneezing used to be a low-key sign that someone was getting sick or had allergies, and sneezing into your elbow was a polite way to indicate to those around us that we didn’t want to give them whatever we might have. However, the novel coronavirus, which has infected more than 6 million Americans and killed at least 180,000, causes a respiratory disease called covid-19 and spreads most easily between people. In the midst of a global pandemic, sneezing into our elbows may no longer be enough.

When we sneeze, cough or talk, different sizes and amounts of respiratory droplets are released into the air, explains Maria Sundaram, a postdoctoral fellow and principal investigator on covid-19 epidemiological research at ICES Ontario. The bigger the droplets are, the quicker they fall to the ground, and the smaller they are, the more likely they are to travel greater distances. “When you cough or sneeze, these particles can travel much further than they usually would by talking at a normal volume or just exhaling in a normal way,” Sundaram says.

The Washington Post has collected thousands of reader questions about life during the coronavirus pandemic. One reader, Vicki Kapaun, wrote in to ask: “What is the etiquette now for sneezing? Sneeze into my mask AND elbow? Remove the mask to sneeze into my elbow like the good old days? I’ve Googled this and can’t find an answer. I find it disgusting to sneeze into my mask and then continue wearing it.”

Covering sneezes with our elbows is actually a relatively new phenomenon. It wasn’t until 2006, after severe acute respiratory syndrome (SARS) spread through Asia, that the Central Maine Medical Center released a video that shows how to cough into your elbow. A study done by the National Institutes of Health found that this was one of the first documented explanations about how to perform this maneuver and the rationale behind it. According to the World Health Organization, the novel coronavirus appears to transmit more easily than SARS, probably because the amount of virus, or viral load, appears to be highest in the nose and throat of infected people shortly after symptoms develop. That’s why, with the virus that causes covid-19, everyone needs to be all the more careful to cover their sneezes, because those who don’t even know they’re sick could be the most contagious.

Although wearing a mask in public settings has been introduced into the Centers for Disease Control and Prevention’s recommendations for protecting yourself and others from the novel coronavirus, it has not changed its etiquette for coughing and sneezing to include a mask. Whether sneezing into a mask is appropriate, safe or polite remains undetermined.

“It’s not a simple yes or no answer,” says Eleanor Murray, assistant professor of epidemiology at Boston University School of Public Health. “The goal is to keep your particles away from other people, and to keep other people’s particles away from you. Whether that’s through physical distancing or a barrier of some kind, either of those will work.”

That’s where a mask comes in handy.

“The reason we’re asking people to wear masks is that we want to reduce the amount of those particles that can travel really far away from you,” Sundaram says. “While the cloth, homemade masks don’t prevent every single little particle from spreading out in the air, they really interrupt the trajectory of a lot of those different particles.”

But sneezing into a mask can make it wet, which Murray says makes it less effective. She recommends carrying a backup mask with you when you are in public and happen to sneeze into your mask. That way, you can put your soiled mask into your bag and replace it with a new, clean one.

Sundaram also suggests sneezing into a tissue, because this should catch the droplets in the same way a mask would — as long as you cover your nose and mouth with the tissue.

“Be sure to dispose of the tissue in a safe way, but also immediately clean your hands very well, either with hand sanitizer or washing with soap and water for 20 seconds at least,” Sundaram says.

Sundaram also approves of the sneezing into the elbow tactic as long as you remain aware of the fact that you now may have respiratory droplets on your inner elbow. As long as these droplets remain moist, if someone else touches them and then touches their nose or mouth, they could become infected. Sundaram recommends not hugging anyone after you’ve sneezed into your elbow (something you probably shouldn’t be doing anyway, according to the CDC’s social distancing recommendations).

Lastly, perhaps the safest option is to go outside when you feel a sneeze coming on. Murray says being outside alone is safer than being inside when you sneeze, because the air circulation is better and will help those droplets disperse. If you don’t have a mask on you and are outside, try to sneeze or cough somewhere that is at least 15 to 20 feet away from others.

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