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.