How Should You Sneeze or Cough When You’re Wearing a Face Mask?

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The COVID-19 pandemic has dramatically shifted the way you approach several things, but one thing that the U.S. Centers for Disease Control (CDC) hasn’t changed its guidance on quite yet is how you should sneeze or cough — despite the fact that you’re wearing a face mask in public.

A single cough produces approximately 3,000 respiratory droplets, while a sneeze releases approximately 40,000, per a September 2020 review published in the American Journal of Respiratory and Critical Care Medicine.

The most common method of spread for respiratory viruses like the one that causes COVID-19 is through respiratory droplet transmission, in which virus-laden droplets are propelled from an infected person directly onto the mucosal surfaces (found in the nose, mouth, and eyes) of a host. These droplets can also linger in the air and on surfaces.

Cloth face masks help prevent the spread of COVID-19 from sick or asymptomatically infected persons. They also protect the mask wearer from being exposed to as many viral particles, which can reduce the odds of someone getting sick if they’re near a person with COVID-19.

It’s critically important to wear a face mask to prevent the spread of germs. An October 2020 study published in the journal Nature Medicine suggests that widespread use of masks could prevent nearly 130,000 of 500,000 COVID-related death experts estimate will occur by March 2021 in the United States.

However, it’s not guaranteed that a mask will capture every respiratory droplet when someone coughs or sneezes.

The CDC’s general guidance for stopping the spread of germs through sneezes or coughs has not changed:

• Use a tissue to cover your mouth and nose when you cough or sneeze
• Throw used tissues in the trash
• If you don’t have a tissue, cough or sneeze into your elbow, not your hands
• Remember to immediately wash your hands after blowing your nose, coughing, or sneezing

In addition to this general guidance, here are five additional strategies doctors recommend. Of course, if you’re sneezing or coughing because you are sick, you should stay home. Contact your health care provider and follow CDC guidelines if you believe you might have COVID-19.

1. Still use a tissue, even if you’re wearing a mask

Masks aren’t fail-proof, and respiratory droplets can still escape — especially if you’re not wearing a properly-fitted cloth mask.

“In general, the best thing is really to go outside if you know you’re going to cough or sneeze, where there’s plenty of ventilation,” says Magdalena Cadet, MD, a clinical rheumatologist in New York City and Associate Attending Physician at NYU Langone Health in New York City.

But of course, you can’t always control when a sneeze or cough occurs, so keeping a tissue on hand may be a good way to protect those around you when you only have a second’s notice.

“You can use a tissue as an extra protective layer outside of the mask to help prevent transmission,” says Dr. Cadet. “You just have to make sure you wash your hands afterward in case the particles get on your hands, and have several tissues available to use frequently.”

Dr. Cadet says that she also inserts a tissue into her mask (as a barrier between her mouth and the mask’s fabric) to regularly replace. However, it’s important to make sure you’re able to change that tissue in an isolated area away from others and hygienically — without infecting yourself with infectious particles that may be on your mask.

2. Use your elbow as a backup, but don’t count on it

Coughing or sneezing into the elbow was an idea introduced in 2006 in response to severe acute respiratory syndrome (SARS) that was spreading through Asia, per the Washington Post. However, this maneuver is meant to replace coughing or sneezing into your hands — and doesn’t replace wearing a mask.

When you are wearing a mask, it’s ideal to use a tissue as additional protection because you can dispose of it. If you don’t have a tissue available, using your elbow is another option, but be aware of how germs on your elbow could then be spread to others.

“The problem with using your elbow is that someone else can come and touch your elbow and it can still be infected,” says Dr. Cadet.

You’re probably already avoiding physical contact like hugs right now, but this underscores the importance of staying conscious of the little ways you might infect loved ones — especially if you’ve been sneezing or coughing Dracula-style.

3. Carry extra masks with you

It’s best to change into a new mask when the one you’re wearing gets soiled after you cough or sneeze into it. Not only is it more comfortable and may help you avoid adjusting your mask (and consequently touching your face more often), but it may affect your mask’s efficacy. Masks may not work as well when wet, per the CDC.

“It’s good to carry extra masks with you in case something happens to that mask you’re wearing, like if you really sneeze heavily into it,” says Peter Gulick, DO, infectious disease expert and Professor of Medicine at Michigan State University in East Lansing. “Then you have something you can change into.”

If sneeze or cough into a disposable mask, toss it in the trash and replace it. If you sneeze or cough into a reusable cloth mask, put the mask in its own resealable bag to wash later and replace it.

Because virus-laden particles can adhere to the outside of your mask, it’s important to separate it from your other belongings. An April 2020 report published in The Lancet found that the infectious SARS-CoV-2 virus can live on a surgical mask for seven days.

Make sure to thoroughly wash or sanitize your hands after removing your mask (more on this below).

4. Carefully remove your mask without spreading germs

If you need to replace your mask or wipe your nose with a tissue, be sure to go to an isolated area where you’re at least six feet (and ideally more) from others.

“I’ve had this problem myself,” says Dr. Gulick. “If you’re in a store or another public space, try to go to an area where nobody is there. Look for an isolated area where you’re by yourself and beyond six feet from anyone else, and clean your nose off or replace your mask with a new one.”

The Mayo Clinic recommends replacing your mask whenever it is wet or dirty, and doing so by untying it or lifting off the ear loops without touching the front of the mask or your face. After removing your mask, wash or sanitize your hands immediately.

You should also regularly wash your mask with soap and water by hand or by tossing it in the washing machine (it’s okay to wash it with other laundry).

“I tell my patients to wash their mask every day and to make sure it’s adequately dried before wearing it again,” says Dr. Cadet. “A lot of times I’ll also advise patients, especially those who have chronic diseases or are immunocompromised, to replace their mask during the day as well — and to bring extras with them so they can do so.”

5. Talk to your kids about sneezing and coughing hygiene

The same etiquette rules apply to kids ages 2 and older who wear masks, but you may need to be more mindful about bringing extra masks for them.

“It may be a little tougher for a child to have a tissue with them, so I think that may be the only difference,” says Dr. Cadet. “But if they do sneeze into their mask, I recommend changing it.”

Send extra masks with your child when they head off to school, and help them practice handling masks by the straps and immediately washing their hands afterward.

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