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Wednesday, October 27, 2004 - Page updated at 03:44 P.M.

Flu fears spur new "respiratory etiquette"

By Carol M. Ostrom and Marsha King
Seattle Times staff reporters

People in Hong Kong wear masks for protection against the Severe Acute Respiratory Syndrome (SARS) in 2003. The mystery virus that killed hundreds worldwide brought the rise of "respiratory etiquette."
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With a century of stunning medical advances under our collective belt, we've now been given this latest flu-prevention advice: Wash your hands long enough to sing "Happy Birthday" twice.

Facing a nationwide flu-vaccine shortage, that's what some nursing-home residents are being taught. You can't blame them if this advice makes them a bit dizzy: Isn't this the same thing their mothers said when they were children, back in the 1920s and 1930s?

Thorough and frequent hand-washing is part of a new "respiratory etiquette" public-health officials believe is taking hold as we try to protect ourselves without the flu shot we've come to count on.

No longer will people be insulted if a proffered handshake is rebuffed; instead, they will thank the germy person refusing to shake for being so thoughtful. Paper masks will contain the droplets of the walking coughing. People who are sick will be encouraged by their employers to stay home, and thanked warmly by their colleagues for doing so.

Offering someone a squirt or two of alcohol-gel hand cleaner will be considered a polite gesture, much as offering the now-scorned cigarette was once the mannerly thing to do.

People like Gloria Rhodes of Auburn, a 72-year-old with a chronic lung condition, won't have to be embarrassed about avoiding crowds because she couldn't get a flu shot.

So you're sick, now what?

The expert advice sounds a lot like what your mother told you:

• Get some rest.

• Drink plenty of liquids.

• Avoid using alcohol and tobacco.

• Take medication to relieve symptoms (but never give aspirin to children or teenagers who have flulike symptoms — and particularly fever — without first speaking to your doctor).

• Antiviral drugs taken within the first two days of illness can reduce the duration of the disease but won't cure it. Influenza is caused by a virus, so antibiotics don't help.

Sources: National Institute of Allergy and Infectious Diseases, Centers for Disease Control and Prevention

Rhodes shopped at odd hours and steered clear of her local post office for three weeks as she hunted for vaccine. "I was avoiding anything that would put me in a closed area where there were other people who might be sick."

Although flu season is not yet upon us, already there are scattered reports of people in meetings "masking up." State Department of Health Secretary Mary Selecky, recovering from a cold, donned a mask when she visited a health-care institution recently.

In a telephone conference last week, Selecky and state health officer Dr. Maxine Hayes referred repeatedly to "good respiratory etiquette." Clearly, covering a cough and forgoing the automatic handshake when ill will be part of that.

But how far will it go this season, if the loss to contamination of nearly half the nation's vaccine turns many a workplace, social event or church function into a breeding ground for the flu virus?

Will the socially conscious begin carrying a stack of masks in their briefcases, thoughtfully offering them to hacking strangers? And what's the respectful yet assertive way to suggest to people in close quarters that they cough into their sleeve if nothing else is available? Will the "SaniPhone," a "doctor-recommended" surgical scrub suit for a public telephone receiver, become a hot flu-season item?

"I definitely think our etiquette is changing," says Chris Martin, administrative director of Harborview Medical Center's emergency department. "There's much more emphasis put on not sharing your bugs with each other."

SARS' silver lining

Credit SARS, a pneumonialike illness that killed hundreds around the world last year, for jump-starting our consciousness.

"You realize that there are diseases out there that can kill people, and that makes people much more vigilant," Martin says. "It should make us all more vigilant about our health and hygiene."

Dr. Jeff Duchin, chief of communicable disease control for Public Health — Seattle & King County, says this year's respiratory etiquette has its roots in the SARS outbreak.

"The one good thing about SARS was it made people much more aware of respiratory diseases, how they're transmitted, and how to protect yourself using simple measures," Duchin says.

Early last year, when SARS struck, it didn't take health officials long to realize that hand-washing, masks and other infection-control techniques hastily adopted by health providers and the general public would not only help stem SARS, but also control other respiratory infections, Duchin says.

Dr. Jeff Duchin's tips for a safer flu season

The chief of communicable disease control for Public Health — Seattle & King County says taking a bit more care this season may help to keep the flu at bay.

Wash your hands — a lot: It may sound obvious, but frequent hand washing is one of the best ways to keep germs from getting a grip. Wet hands, apply soap, rub hands together for at least 15 seconds, cover all surfaces of hands and fingers, rinse with water and dry thoroughly — and then use the paper towel to turn off the water faucet (and maybe to open the door to the restroom, too).

Learn to love alcohol-gel hand cleaner: Carry little bottles of alcohol-based cleaner with you when you can't wash your hands. Amazingly handy stuff, it should be used only if your hands aren't grimy. Stash them everywhere.

Cover your cough or sneeze: Use a disposable tissue, and throw it away. If you don't have one, sneeze or cough into your upper sleeve — not your hand. If you're around vulnerable people, consider wearing a disposable paper mask.

Assume your hands aren't clean: And don't touch your eyes, nose or mouth with them. Think about where the bugs are: People cough into their hands, then they shake yours, then you touch your mouth with your hand ... bingo.

Avoid close contact with people who are sick: And if you're sick, don't shake hands, kiss, etc. "Consider a smile, nod or other friendly gesture as an alternative way to greet people," says Duchin.

Keep things clean: Wipe common surfaces, such as telephones, doorknobs and keyboards, with disinfectant.

Stay home if you're sick: Help prevent others — who may not be as tough as you are — from getting sick.

Still, a street scene in Seattle, unlike cities in Asia, rarely includes people wearing disposable masks. Perhaps the last time there was widespread mask use here was during the deadly flu epidemic of 1918, when some places, including streetcars, required masks for entry.

In a normal flu year, he says, he wouldn't recommend routinely wearing masks. But this year, with the vaccine shortage, is different. If you're sick, a mask can prevent you from coughing or sneezing virus-laden droplets into the air, where they could infect people within arm's length.

Recently, hospitals have begun requesting that coughing patients in waiting rooms wear masks. And if you have to be at work while you're coughing or sneezing, Duchin says, "your colleagues would appreciate it if you put on a mask."

For a healthy person, he says, wearing a mask doesn't make much sense. "Stay away from sick people" is his recommendation. Duchin stashes little bottles of waterless hand cleaner everywhere, and he has been known to abandon an elevator shared with a hacking, sneezing virus producer.

A virus, he notes, isn't truly airborne, and it travels only about 3 feet during a sneeze or cough, so close contact is necessary to spread infection. Typically, the flu virus is passed when a sick person wipes his nose or covers a cough, and then touches something — a telephone you're about to use? Food you're about to eat? Your outstretched hand?

"This season, I may shake fewer hands than I normally do," says Duchin, who, as an infectious disease specialist, is picky about the bugs he associates with.

People might want to practice their lines for use in elevators or other close spaces. "Would you mind using a Kleenex?" he suggests. "I think offering someone a Kleenex is a nice thing to do."

We're in this together

For many institutions, fears about smallpox during bioterror scares ramped up infection-control measures that were reinforced by the threat of SARS and, now, by the possibility of a flu season without adequate vaccines, Martin says.

"We're definitely in a different mode than we were even three or four years ago," she says.

Health providers relentlessly educate patients to use tissue, wash hands, use alcohol-gel hand cleaner, she says, and even urge hospital patients to ask doctors and nurses who come into their rooms if they've washed their hands.

Martin believes other workplaces are changing, too.

"Ten years ago, when you were sick, you'd come to work whether you believed you were contagious or not," she says. "Now, with the issues we have, people are much more concerned — and co-workers are much more concerned — about being exposed to contagious diseases."

Employers who require people to work when they're sick may look at it differently if many in the community become sick and some even die, she says.

In an average year, the virus kills 36,000 people, mostly the elderly.

"People would say you're negligent coming to work sick," she says. "I think practices will have to change because people will get scared."

Whether it's SARS or flu, containing a contagious respiratory disease depends on shared responsibility.

"I will count on you to have your hands washed, and you will count on me," Martin says. "If I have a fever and respiratory disease, you will count on me to stay home," and vice versa. "It's a matter of keeping each other honest."

Do others a favor, she advises, and err on the side of caution: The Centers for Disease Control and Prevention (CDC) says you can spread the virus a day before any symptoms hit and as long as seven days after becoming ill.

For many years, Martin says, we have coasted along, believing that the medical profession had a magic bullet for everything. Not anymore: "We're back in the realm of 'Oh my gosh, we could die of these things.' "

And that, despite all the advances in science, takes us back to what those 80- and 90-year-old nursing-home residents learned before the invention of the electron microscope, the device that gave scientists the first glimpse of a flu virus.

"We're back to those things our moms told us to do: Wash your hands, cover your mouth, and if you're sick, go to bed," Martin says.

"It's basic, common sense."

Carol M. Ostrom: 206-464-2249


Is it the flu?
It's sometimes hard to tell the difference between the flu and a bad cold.
FeverRareCharacteristic, lasts 3-4 days
Aches and painsSlightUsual, often severe
Fatigue, weaknessMildCan last up to 2-3 weeks
Stuffy noseCommonSometimes
Sore throatCommonSometimes
CoughHacking coughCan be severe

Copyright © 2004 The Seattle Times Company

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