I got curious about the old fashion handkerchief. (Perhaps because disposable tissues just seem too small and thin for me, but mostly because they were commonly used decades ago, and that got me thinking.) There seems to be little scientific data on the fair comparison between use of cloth handkerchiefs, disposable tissues, and cloth/surgical masks as it relates to influenza. And there seems to be no clear scientific study that points to why handkerchiefs fell out of favor. (At least none that I could find.) Not to long ago:
Influenza is in a highly contagious disease which may be caused by one of a whole family of viruses. A flu virus is spread through coughs and sneezes, and by contact with surfaces where the droplets thrown out by coughs and sneezes have settled. A flu vaccine grants temporary immunity from one particular variety of flu, but does not provide protection from the others. Washing your hands will reduce the chance of infection, and using a handkerchief will reduce the chance of spreading the virus to others.
There only seems to be anecdotal evaluation of cloth handkerchiefs where it is assumed that one uses it multiple times, that it is kept in a pocket with other items, is touched by hands and objects throughout the day, and is shared with others. (It is not difficult to discard an unclean handkerchief for later wash/reuse and to rotate in a clean replacement.) Contrast that to discussions of disposable tissues where usage assumes that the used tissue is disposed of promptly and the person washes their hands immediately. This is an unfair and misleading comparison. It would be interesting to see a fair comparison of the single use of a cloth handkerchief to a disposable tissue for both ambient airborne particulate dispersal and amounts of particulates on hands.
There is, however, some scientific evidence that there is little difference in small particulate and aerosol dispersal between coughing/sneezing into one’s hands, tissue, or elbow/sleeve. I was surprised by that. It would be interesting to see a scientific comparison of a single use cloth handkerchief against coughing into hands, tissue, and elbow/sleeve. It seems a resonable hypothesis that the cloth handkerchief would perform better than all three. It seems prudent to identify and practice the best manner in which to contain potential pathogens from a cough or sneeze.
As it relates to cloth and surgical masks, it seems interesting that handkerchiefs are considered unsafe because it is presumed that they are used throughout the day with multiple coughs and sneezes and touches by hands, and yet that approximates the results of mandated long term/continual mask usage as prescribed/observed.
If influenza transmission from an infected person is believed to correlate with the density of infectious virus material in a particle and/or surrounding airspace, size of particle (droplet or aerosol), depth of inhalation, and duration of exposure, it also seems reasonable to consider a comparison of properly coughing/sneezing into a single use cloth handkerchief to that of a coughing/sneezing into a cloth/surgical mask. Again, if a primary concern is reduction of infected droplets from a cough or sneeze, then determining the most effective way to reduce that quantity, should be of scientific and personal interest.
Furthermore, if airborne and fomite transmission are areas of concern, it would be interesting to see comparisons of on-person quantity of pathogens/contaminants and aerosol dispersants between a subject that had been coughing/sneezing into single use handkerchiefs over a prescribed amount of time away from an area and time of testing, to a that of person in the same scenario solely wearing a cloth/surgical mask for same duration and testing. As pathogens that were contained by a handkerchief that is discarded are thereby no longer on person, it could be interesting to know how that differs from residual pathogens that may be retained in the mask and thereby potentially be released during continued wearing. (i.e. The pathogens collected into a handkerchief can be disposed of after use, whereas pathogens collected into the mask are on/in the mask for the duration. Presumably at a later time the handkerchief user would have less total contaminants on their person than the mask wearer all things being equal.)
The lack of scientific evaluation of proper handkerchief use, may be the result of the extremely effective marketing, popularity, ease of use, and presumed advantages of disposable tissues. However, in light of guidelines promoting long term continual wearing of cloth masks, and actual results from using disposable tissues, actual scientific analysis of effectiveness of cloth handkerchiefs for coughing/sneezing may be warranted. In the absence of a previous scientific study, it seems reasonable to revisit and revaluate the handkerchief. Perhaps someone will find it fit to study and compare effectiveness of a simple handkerchief compared to the other alternatives.
The above is not intended to be a statement against the best practices of appropriate wearing of N95 masks (which are a completely different class of protective measures and equipment) where the situation warrants, but rather an exploration of basic practices and consideration of options how they might compare in effectiveness and risk reduction to each other in ordinary real world scenarios as practiced in the long run, with consideration of difficulty, discomfort, and disruption to individuals and society as a whole. The larger conversation and practices of disease and COVID-19 prevention involves many factors of which masks are only a part (and generally considered the last line of defense) including:
avoidance/isolation (stay away from sick people/avoid people if ill)
proximity (social distancing)
duration (limiting time in uncontrolled/unknown areas)
ventilation (avoiding confined spaces with poor ventilation that are risky)
disinfecting/cleaning/washing
reduction/protection (tissues/handkerchiefs/masks/face-shields/goggles)
maintaining over-all health (sleep/diet/etc)
sunlight/Vitamin-D
environmental factors (fresh air/heat/humidity)
monitoring key indicators (temperature/cough/fatigue, etc)
and more that thought or science may reveal or make possible.
It could be argued that educated, responsible choices that focus on using several of the above to accomplish a cumulative risk reduction appropriate for the situation is more important and effective than any one method prescribed generically by mandate. In the meantime, I have added using good old fashion handkerchiefs to my ensemble and practices (many of those of which I plan on continuing well after COVID-19 subsides), and am still looking forward to the day we can refer to this time period as the “old abnormal”. -rws
