The kids in Jon Nessan's fourth-grade classroom know what you're supposed to do when you feel a tickle in your throat: Cough in your elbow.
"They've been doing it since kindergarten; it's an automatic reflex for them," says Nessan, a teacher at Meridian Park public elementary school in the Shoreline section of Seattle.
Over the past decade or so, schools and day-care centers around the country have gradually adopted the technique as a way to ward off colds, flu, whooping cough and other easily transmitted bugs. It's been replacing the traditional cover-your-mouth-with-your-hands-or-a-tissue approach that has long been considered the polite and most sanitary technique.
The reasons are fairly obvious -- when you use your hands to block a cough or sneeze, the germs stay here. And your hands can then spread the germs to doorknobs, desks, chairs and anything else you touch.
So one solution is to cough and sneeze in your elbow or on your sleeve, instead.
"As long as you don't wipe your face with your elbow you basically decrease your chances of transmission," says Dr. Craig Rubens, an expert on pediatric infectious diseases at the University of Washington.
The technique is now recommended by the U.S. Centers for Disease Control and Prevention and the American Academy of Pediatrics, which both pass out health information to schools and public health officials around the country. The CDC distributes posters showing ways to prevent the spread of germs -- including an illustration of a child with his elbow tucked beneath his nose.
Over the past 20 or so years, researchers have confirmed that viruses can remain viable for several hours once they land on a surface like a doorknob or chair. A sneeze or cough may send viral material or bacteria out into the air, but gravity quickly sends it to the ground. Germs on the hands can be easily transferred to other surfaces, and are then passed on to other people when their hands touch those surfaces.
"I think people still don't understand how important hands are," says Rubens, referring to the transmission of germs.
Along with government agencies, there are also freelance proselytizers of elbow coughing, elbow sneezing and other germ-fighting techniques.
Dr. William Sawyer, a family practice physician in Cincinnati, has created "Henry the Hand," a sort of good-hygiene crusader. Henry, in the form of a cartoon or costumed character, has met more than 150,000 health-care providers and more than 110,000 students around the country, by Sawyer's count.
Hand hygiene has the potential to change the world, Sawyer proclaims. "It's the latest breakthrough in biotech and it didn't cost anything."
Sawyer advocates the "four principles" of hand awareness. Two of them are familiar to nearly everyone -- wash your hands before eating, and don't put your fingers in your eyes, nose or mouth. But the other two tell kids to sneeze and cough into their elbows, instead of their hands.
"It absolutely has a huge impact," Sawyer says. He notes that "Henry the Hand" materials have been ordered and downloaded by health care professionals in Europe, Africa and India, among other places.
"I wouldn't say we'd have no flu," Sawyer says, "But it would certainly be decreased dramatically."
Grade schools in Oregon, public health officials in Georgia and nursery schools in Tennessee now teach kids to cough and sneeze in their elbows. The Lake County, Ill., Health Department recommends elbow coughing to help prevent the spread of whooping cough, or pertussis. The Montgomery County Health Department in Maryland endorses it; so does the Colorado Children's Immunization Coalition.
Cindy Ertle, a public health nurse in Benton County, Ore., says officials there have been recommending elbow coughing for at least three years, as part of an effort to teach "respiratory etiquette" -- wash your hands, don't share drinks and so on.
"It's just darling to see them in the cafeteria or wherever they're at -- when they cough or sneeze up comes their elbow," she says.
Even a University of Wisconsin Law School graduate student center has picked up the habit, after one of the directors saw a CDC poster suggesting elbow sneezing.
"That's something personally I had never heard of and I thought, that's a neat little trick," says Susan Katcher, the associate director at the law school's East Asian Legal Studies Center.
Katcher says she's taken up the habit herself, but admits it's "a little weird."
The California Childcare Health Program has recommended it at least since 1995, says Bobbie Rose, a nurse with the organization. The program provides health care advice for childcare providers throughout the state.
"I think it's pretty standard," she says. "I would say they would learn [coughing in your elbow] right along with washing their hands."
Marion Ator, a teacher at the Twin Hills Public Schools in Okmulgee, Okla., even wrote a song about it:
When you sneeze, do what I do:
(Sneeze to the left -- into a tissue or crook of elbow.)
Wait, I think there might be two.
(Sneeze to the right -into tissue or crook of elbow.)
Kids are generally easy to train, says Rose. But adults -- who have to overcome lifelong habits and maybe a little embarrassment -- are a different story.
"It's tough to change that intuitive, innate reaction," says Sawyer, the doctor who created Henry the Hand. "It's very funny -- the kids are now teaching the parents."
While the technique continues to spread, there is no consensus on who first thought it up. Some public health officials recall it first being taught in the mid-1990s, but no one appears certain where it came from.
And while elbow sneezing and elbow coughing may be relatively new hygienic innovations, health experts wouldn't consider them as important as old-fashioned hand washing. "Henry the Hand," for instance, stresses the "fourth principle of hand awareness" the most: "Above all, don't put your fingers in your eyes nose or mouth," Henry says. And some experts say stick with tissues when you feel a sneeze coming on.
But slowly and surely, elbow coughing and elbow sneezing are joining hand washing as an everyday routine to keep germs from spreading.
"I just had a kindergartner in my office and I asked him where he sneezed," says Elizabeth Anderson, the school nurse at Mercer Elementary in Shaker Heights, Ohio. "He said, lots of times in his hands, but sometimes in his elbow, so he doesn't get germs on his hands -- so they do know."
After a rough flu season this past year, Anderson isn't sure if elbow coughing and sneezing makes a difference. But still, she's adopted the technique herself, putting her right hand on her left shoulder when she feels a sneeze coming on.
"It works pretty well," she says.