American Journal of Infection Control 42 (2014) 1317-8

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American Journal of Infection Control

American Journal of Infection Control

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Examining university students’ sneezing and coughing etiquette Thomas D. Berry PhD a, *, Angela K. Fournier PhD, LP b a b

Department of Psychology, College of Natural and Behavioral Sciences, Christopher Newport University, Newport News, VA Department of Psychology, College of Health Sciences and Human Ecology, Bemidji State University, Bemidji, MN

Key Words: Cough etiquette Respiratory event Coughing and sneezing Sex differences

University students’ cough etiquette (CE) was observed and compared with the standards of the Centers for Disease Control and Prevention (CDC). Contrary to the CDC’s recommendations, most students covered their mouth with their hands (53.3%) or did not cover at all (23.5%). Less than one-quarter of students used a sleeve arm, elbow, or tissue as advised by the CDC. Sex analysis revealed women were more likely to use a hand cover than men, whereas men were twice as likely to sneeze or cough into the air. Future research to study and improve student CE is encouraged. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Each year, on average, respiratory tract infections (RTIs) produced by influenza are responsible for 114,000 hospitalizations, 36,000 deaths, and a 1 in 10 mortality rate for at-risk patients.1,2 In the United States, it is estimated that 69% of RTIs are viral based, with 80% of these RTIs resulting from rhinovirus.3 Overall, the medical and economic costs of RTIs in the United States amount to $10 billion and $87 billion each year, respectively.4 Nonhospital populations (eg, college students) may incur the greater RTI risk because of their proximal living and increased socializing.5 Typically, researchers have targeted student hand hygiene to explain and control pathogen transmission.6-9 In addition to hand hygiene, the CDC has developed cough etiquette (CE) recommendations to mitigate the spread of respiratory-borne pathogens.10,11 Specifically, the Centers for Disease Control and Prevention (CDC) recommend 2 covering responses for coughing or sneezing. First, the preferred response requires a tissue to cover the mouth and nose. Second, when a tissue is unavailable, a person should cough or sneeze into one’s upper sleeve or elbow. The CDC does not recommend coughing or sneezing into the hands. An estimated 50% of RTIs are linked to handborne transmission1; therefore, using the hand to cover a respiratory event is not advised. Although CE is recommended, far little is known about how college students cover up their own respiratory events.

* Address correspondence to Thomas D. Berry, PhD, Department of Psychology, College of Natural and Behavioral Sciences, 1 Avenue of the Arts, Christopher Newport University, Newport News, VA 23606-3072. E-mail address: [email protected] (T.D. Berry). Conflicts of interest: None to report.

The objectives of this observational study of college students are to record the frequency and association of respiratory events and subsequent cover-up responses, identify sex differences across types of cover-up responses, compare the cover-up responses to the given CDC’s recommendations, and review the results for possible university health interventions. METHOD Participants and procedures Data collection took place in 22 different classrooms of a midsize Southeastern university; the university’s institutional review board approved all measures and procedures. Seven research assistants were used as data collectors, and each was given detailed instruction and practice concerning the procedures and ethics of this study. Data collectors used a standardized form to record each respiratory event and cover response emitted in a classroom. Each of the 7 research assistants selected classrooms while students were in class. Classroom selections and data collections were made independent of each other to ensure no overlap in observation. For each respiratory event, data collectors recorded the type of respiratory event (cough or sneeze), cover response, and sex of the observed person. The covering-up responses were recorded as using one’s hands, tissues or handkerchiefs, arm sleeve or elbow, or no covering response. Additionally, we operationally defined a respiratory event as beginning with a single cough or sneeze and continuing until coughing or sneezing ceased for at least 4 seconds. Data were analyzed using c2 tests (SPSS version 22, SPSS Inc, Chicago, IL) along with corrected Bonferroni tests.

0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.


T.D. Berry, A.K. Fournier / American Journal of Infection Control 42 (2014) 1317-8


Table 1 Cover response percentages for coughing and sneezing Respiratory event Cover response Tissue Arm or elbow Hand No cover Combined

Cough 0.0 17.9 55.4 26.7 80.2

(0) (55)* (170) (82)* (307)

Sneeze 2.6 42.1 44.7 10.5 19.8

(2) (32)* (34) (8)* (76)

Combined 0.5 22.7 53.3 23.5 100.0

(2) (87) (204) (90) (383)

NOTE. Values are % (n). *Statistically significant differences (P < .05) with Bonferroni correction.

Table 2 Percentages of 4 cover responses by women and men Sex Cover response Tissue Armor elbow Hand No cover Combined

Women 0.8 23.1 58.7 17.4 69.3

(2) (61) (155)* (46)* (264)

Men 0.0 21.4 41.9 36.8 30.7

(0) (25) (49)* (43)* (117)

Combined 0.5 22.6 53.5 23.5 100.0

(2) (86) (204) (90) (381)

NOTE. Values are % (n). *Statistically significant differences (P < .05) with Bonferroni correction.

RESULTS A total of 383 respiratory events were observed over 23 days. Observations according to sex showed 264 women and 117 men; sex could not be recorded for 2 of the observations. The length of observation sessions ranged from 4-75 minutes (mean  SD, 36.1  24.1 minutes). The number of people in a classroom during observation ranged from 6-100 (mean  SD, 42.4  18.4). On average, there were more women present during observation (mean  SD, 31.6  13.7) than men (mean  SD, 10.2  7.2). Overall, a c2 test indicated that cover response percentages showed significant dependency (c23 ¼ 215, P < .001), including the following: hand use (53.3%), no cover response (23.5%), arm sleeve or elbow (22.7%), and tissue use (0.5%). Table 1 shows the percentage of each cover response by respiratory event. A c2 test of independence indicated cover response was dependent on the respiratory event (c23 ¼ 31.9, P < .001; Cramer V ¼ .29, P < .001). Of the total respiratory events observed, 80.2% (n ¼ 307) were coughing events, whereas 19.8% (n ¼ 76) were sneezing events. Specifically, the arm sleeve or elbow response was used to cover a greater proportion of sneezes (42.1%) than coughs (17.9%), whereas a no cover response was more common for coughs (26.7%) than sneezes (10.5%). There was no difference in the proportion of respiratory events covered with a hand or tissue. Table 2 gives the percentage differences between women and men emitting cover responses. An overall dependent association was observed between sex and cover responses (c23 ¼ 18.25, P < .001; Cramer V ¼ .22, P < .001). Sex comparisons indicate that arm sleeve or elbow and tissue covering responses were not dependent on sex. In contrast, both hand and no cover responses showed significant dependent associations. Specifically, women were more likely to cover with their hands than men (58.7% vs 41.9%, respectively). However, the no cover response was more likely emitted by men than women (36.8% vs 17.4%, respectively). Additionally, respiratory events were not dependent on sex (c21 ¼ 1.3, P ¼ .30).

By combining hand cover and no cover responses, our study found that 77% of students did not comply with the CDC’s CE standards, whereas 23% showed proper CE by using arm sleeve or elbow or tissue cover. Also, university student cover-up responses showed a dependency associated with the type of respiratory event and sex. Differences found between respiratory events showed proper CE (arm sleeve or elbow) was twice as likely to occur after a sneeze than a cough. In contrast, coughing compared with sneezing was twice as likely associated with a no cover response. With regard to sex, significant sex differences occurred only in hand cover and no cover response percentages. Specifically, women used a hand cover response more frequently than men, whereas men were twice as likely as women to cough or sneeze into the air. These sex and respiratory-event differences demonstrate the varied ways pathogens are possibly spread. CE is often discussed as a prudent recommendation, but actual research appears scarce.12 Because the CDC10 recommends coughing and sneezing into tissues or into arm sleeves or elbows, our results warrant further CE study and public health attention. Investigation appears needed to identify how varying cover-up responses become elicited, habitual, and socially influenced; and how to educate proper cover-up responses. The assumption is that by increasing proper CE among students, the incidence of RTIs will be mitigated. However, continued research to determine a best practice for covering is necessary, especially assessments on how to better contain aerosol droplets expelled during a respiratory event.13

References 1. Bloomfield SF, Aiello AE, Cookson B, O’Boyle C, Larson EL. The effectiveness of hand hygiene procedures, including handwashing and alcohol-based hand sanitizers, in reducing the risks of infections in home and community settings. Am J Infect Control 2007;35(Suppl 1):S27-64. 2. Bridges CB, Kuehnert MJ, Hall CB. Transmission of influenza: implications for control in health care settings. Clin Infect Dis 2003;37:1094-101. 3. Monto AS, Sullivan KM. Acute respiratory illness in the community: frequency of illness and the agents involved. Epidemiol Infect 1993;110:145-60. 4. Molinari NA, Ortega-Sanchez IR, Messonnier ML, Thompson WW, Wortley PM, Weintraub E, et al. The annual impact of seasonal influenza in the US: measuring disease burden and costs. Vaccine 2007;25:5086-96. 5. Nichol KL, Heilly SD, Ehlinger E. Colds and influenza-like illnesses in university students: impact on health, academic and work performance, and health care use. Clin Infect Dis 2005;40:1263-70. 6. Aiello AE, Perez V, Coulborn RM, Davis BM, Uddin M, Monto AS. Facemasks, hand hygiene, and influenza among young adults: a randomized intervention Trial. PLoS One 2012;7:e29744. 7. Anderson JL, Warren CA, Perez E, Louis RI, Phillips S, Wheeler J, et al. Gender and ethnic differences in hand hygiene practices among college students. Am J Infect Control 2008;36:361-8. 8. Berry TD, Mitteer DR, Fournier AK. Examining hand-washing rates and durations in public restrooms: a study of gender differences via personal, environmental, and behavioral determinants. Environ Behav; 2014. http:// 9. Fournier AK, Berry TD. Effects of response cost and socially-assisted interventions on hand-hygiene behavior of university students. Behav Soc Iss 2012;21:152-64. 10. Centers for Disease Control and Prevention. Respiratory hygiene/cough etiquette in healthcare settings. Available from: professionals/infectioncontrol/resphygiene.htm. Accessed May 9, 2014. 11. Centers for Disease Control and Prevention. Cover your cough. Available from: Accessed May 9, 2014. 12. Barry T, Manning S, Lee MS, Eggleton R, Hampton S, Kaur J, et al. Respiratory hygiene practices by the public during the 2009 influenza pandemic: an observational study. Influenza Other Respir Viruses 2011;5:317-20. 13. Zayas G, Chiang MC, Wong E, MacDonald F, Lange CF, Senthilselvan A, et al. Effectiveness of cough etiquette maneuvers in disrupting the chain of transmission of infectious respiratory diseases. BMC Public Health 2013;13:811.

Examining university students' sneezing and coughing etiquette.

University students' cough etiquette (CE) was observed and compared with the standards of the Centers for Disease Control and Prevention (CDC). Contra...
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