Mask or tissues? SARS ushers in an age of respiratory etiquette’

Some see universal masking as unworkable

Favoring old-school etiquette over universal masking, some clinicians are urging a common-sense appeal to patients to use tissues and block coughs and sneezes in case severe acute respiratory syndrome (SARS) makes an unwelcome return. "It’s the same thing your mother told you 50 years ago," says William Scheckler, MD, a hospital epidemiologist at St. Mary’s Hospital in Madison WI.

The approach is seen as a more workable alternative to a draft recommendation by the Centers for Disease Control and Prevention (CDC) to offer surgical masks to all incoming patients with respiratory symptoms. (See Hospital Infection Control, October 2003, under archives at

"We get so high tech we forget about the common-sense, home-remedy kind of things we can do to prevent the spread of infection," says Susan Kraska, RN, CIC, an ICP at Memorial Hospital of South Bend, IN. "Washing your hands, tissues are basic. Use your arm to block a sneeze or cough because it prevents contamination of the hands. We seem to moving away from those common-sense things."

Either option is allowable in the Oct. 20, 2003 draft guidelines posted on the CDC SARS web site at While placing a stronger emphasis on the mask approach, the CDC draft stated: "Consider initiating a universal respiratory etiquette strategy for the facility. Provide surgical masks or tissues to all patients presenting with respiratory symptoms, place patients with respiratory symptoms in a private room or cubicle as soon as possible, and implement use of surgical masks by health care personnel during evaluation of patients with respiratory symptoms."

Respiratory etiquette makes common sense, but it hasn’t necessarily been a common practice in waiting rooms, emergency departments (EDs), and other health care settings where symptomatic patients may gather.

"Respiratory etiquette is really not a new concept," explained Linda Chiarello, RN, MS, epidemiologist in the CDC division of health care quality promotion. "How-ever, actively implementing it for persons with symptoms of a respiratory infection in health care settings is new. It will involve instructing all patients, and I should include all visitors and health care workers, to cover their nose and mouth with a tissue if they are coughing or sneezing."

In comments during a recent CDC health care training broadcast, Chiarello emphasized the importance of having hand hygiene materials and tissues available. "What we are talking about here really is source control, simply getting people to cover their nose and mouth when they are coughing or sneezing, and to wash their hands," she added. "This strategy is one that will be recommended as part of the new CDC TB prevention guidelines so it is really does have implications well beyond SARS." 

To assist in planning for incoming SARS, the CDC is encouraging ICPs and other clinicians to consider scenarios and run through a series of questions that include, "What would happen today if a patient with suspect or probable SARS is admitted to your hospital?"

"Now is the time to begin planning the way patients with symptoms of respiratory infection are currently handled in your setting," Chiarello said. "Are patients asked about symptoms of a respiratory infection? Are your personnel trained to look for symptoms in patients as well as visitors? What instructions do they provide if they see someone who is symptomatic?"

It’s not going to work’

The controversy regarding masking patients who have respiratory symptoms began with the initial reaction of clinicians in workshop discussions of the CDC draft plans. In particular, primary care physicians and clinicians in outpatient clinics have said in CDC consultants’ meetings that "the notion of putting everybody with the sniffles in a mask is ridiculous; it’s not going to work," Scheckler tells HIC.

"People who come in coughing and sneezing should cover their mouth and nose," he says. "Otherwise, you spread disease. I think the biggest challenge is [EDs] where people sit around for a long time. [But] the respiratory hygiene approach of putting masks on everybody is not cost-effective and not practical."

The biggest SARS threat, based on the nosocomial outbreaks in Toronto and other areas, is unprotected exposure to the undiagnosed patient, Chiarello said. "Prevention begins when a patient or visitor walks through the door of an ED."

In that light, it is understandable that the CDC has pursued a universal masking policy. "But there has got to be a practical way to do this," Kraska tells HIC. "We run a busy emergency department. On any given day — particularly in the peak flu season — we can’t tell how many folks are going to be presenting in the triage area. A patient [with respiratory symptoms] may be coming in for something entirely different."

Kraska is working with her hospital purchasing department to get cost figures for small "purse-size" tissue packages that could be distributed to symptomatic patients. "I contacted my ED director and [suggested] implementing a respiratory etiquette program," she says. "We are going to put up respiratory etiquette signs and hand out little pamphlets and little packages of kleenex."

If the idea catches on nationally, perhaps SARS will do for respiratory infection control what HIV did for infection control of bloodborne pathogens. Prior to the emergence of HIV, far fewer health care workers wore gloves and received hepatitis B immunizations.

"If hospitals set the example in the community, you can spread respiratory etiquette to schools and get the health department on board," Kraska says. "Everybody is concerned about SARS, but we should be concerned about any respiratory infection. I think this is a good place to start. As folks become accustomed, they will not treat respiratory illnesses so frivolously. I think it is just raising the level of awareness and being cognizant. If we can stop people from coughing and sneezing in the ED, we can actually cut down [on infections overall]."

Return to sender?

Then again, such precautions may fail to resonate should SARS remain dormant. However, leading epidemiologists say SARS resurgence at some point is almost inevitable. The overriding concern is that SARS will resurface as a seasonal illness along with influenza and other respiratory infections. Indeed, it would be a surprising development if the emerging coronavirus did not return, said Julie Gerberding, MD, MPH, CDC director.

"As an infectious disease expert, I can say in my experience, I’ve never seen a pathogen emerge and go away on its own," she said at a recent press briefing. "I think we have to expect that somewhere, some time, this coronavirus is going to rear its ugly head again; and that’s the whole purpose of all this preparedness effort. We can’t say where, but given that it showed up once in Asia, it’s a good bet that would be the most likely place for it to emerge again. But there’s absolutely no proof of that, and I think we have to be prepared for the unexpected."

Preparing for the unexpected means, in effect, that hospitals will be dealing with SARS whether it returns or not. During the last outbreak, the World Health Organization reported 8,422 cases of SARS with 916 deaths. In the United States, there were 74 probable cases and 344 suspect cases. The virus could return via an animal reservoir, humans with persistent infection, unrecognized transmission in humans, or even — as almost happened recently in Singapore — escape from a research lab. 

"What is the source of the virus?" Gerberding asked. "The short answer is, we don’t know. We are continuing to work with our collaborators in Asia and characterize as many of the strains of coronavirus that can be collected, but we have no proof of the specific animal reservoir source of this outbreak. That obviously leads us to be concerned about a potential reemergence."

Meanwhile, both private sector entities as well as government agencies are working hard to improve SARS diagnostics. "We know that we have a very sensitive test for finding the virus genome when it’s present, but the difficulty is that people did not seem to have virus present in the relevant samples early in the course of illness," Gerberding said. "So we’re still looking for a test that would both be sensitive but also [effective] early enough in the course of illness before the patient became contagious."

In the interim, shoe-leather epidemiology — some of it by workers who may never have been trained to think that way — is going to be necessary to detect the first cases. Clinicians who dealt with the virus during outbreaks became adept at that, but the prospect is daunting, considering the potential panoply of SARS presentations.

"For SARS, all bets are off," Scheckler states. "We don’t know how to identify it. The fever, cough, infiltrate on chest X-ray, and travel history is about all we have. Some people have diarrhea without having the respiratory infections, and apparently there are very few people — but not zero — who can have asymptomatic infections. Whether they can spread the disease . . . isn’t clear. It appears the major [viral] shedders have pneumonia, at least."

And hopefully, if they are sitting in your ED, tissues or masks.