Because of COVID-19 we agreed that we should no longer shake hands. However should we be “shaking” or “bumping” elbows?

With more than 23 millions of individuals infected with the severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) and more than 800 thousands deaths across the world as of August 24^th 2020 [1], the coronavirus disease 2019 (COVID-19) has established itself as the most frightening public health threats in over a century. It has been and remains a major issue for human kind. COVID-19 was first reported in Wuhan, China, in December 2019 [2]. The disease is transmitted from human to human by multiple means, namely, by droplets, aerosols and fomites [3]

At the beginning of the pandemic, many people were comparing it with the flu and were not taking it seriously. It is obvious now that this is completely different from the flu. There is no possible comparison in regards to the effect of the virus, its virulence, its mortality rate and its ability to make members of several communities mourn their loved ones.

A lot of emphasis have been rightly put on prevention, encouraging community members to always wash their hands, avoid touching their faces, avoid shaking hands, cover their coughs with the inside part of their elbows, practice social distancing and to always wear a face mask particularly when social distancing is difficult to do or is compromised.

Since people are encouraged not to shake hands, we have observed many individuals “shaking elbows” as a way to interact with and greet other people. People are keen to continue showing courtesy and fairness to others despite the fact that the coronavirus pandemic has been ravaging communities everywhere in the world.

Looking at people touching or bumping their elbows or “shaking elbows” as a way to greet others makes us think of infection prevention, and disease control. Health experts and epidemiologists have been encouraging people to cough or sneeze in their elbows. Since March 2020 I have seen an increasing number of individuals greeting others by “shaking their elbows” whereas their elbows are where they cough and sneeze. I am quite interested in finding out what is the risk of transmission via “elbow shaking” overall. I suspect that it might be a minimal risk but I believe this is an aspect of the pandemic that is worth exploring and investigating.  I believe that the risk would depend on whether the elbow is exposed or covered with clothes. People cough or sneeze in the internal part of their elbows and bump or “shake” the external part of the elbows. Nevertheless, there might be some level of risks in bumping or shaking elbows. Since many people are coughing and sneezing into their elbows and they usually use their elbows to greet others, I would not be surprised to see that there is some transmission of infection via the elbows.

In general, infected people spread viral particles whenever they talk, breathe, cough or sneeze [4]. Such viral particles are known to be encapsulated in globs of mucus, saliva, and water, and the fate or behavior of globs in the environment depends on the size of the globs. Bigger globs fall faster than they evaporate so that they splash down nearby in the form of droplets. Smaller globs evaporate faster in the form of aerosols, and linger in the air and drift farther away than the droplets do [5 – 6].

There has been no discernible evidence on the minimum infectious viral load for COVID_19 pandemic but many researchers speculate that a few hundred or one thousand of SARS-CoV2 would be enough to cause infection and then disease among susceptible hosts. A single cough releases about 3,000 droplets and droplets travel at approximately 50 miles per hour. A sneeze releases about 30,000 droplets with droplets traveling at up to 200 miles per hour. If a person is infected, the droplets in a single cough or sneeze may contain as many as 200,000,000 (two hundred millions) virus particles, which can be all dispersed into the environment around them [7].

When we cough or sneeze in our elbows, millions to billions of viral particles might find themselves in our elbows. What is the risk of transmitting those viral particles to others when we “shake elbows” with them? Obviously, that is an important point that deserves to be understood. Before we can fully understand the risk of infection associated with “elbow shaking” I think that it would be wise to encourage the public not to shake elbow, particularly when they use their elbows to cover their coughs and sneezes. It is important to emphasize that everyone should take the necessary steps to limit physical interactions with others while we are in the midst of this serious pandemic and the health experts are still looking into figuring out the SARS CoV-2.

References:

1. World Health Organization (WHO), 2020. Coronavirus Disease 2019 (COVID-19) Dashboard. https://covid19.who.int , Accessed date: August 23, 2020.
2. Chen, C.; Zhao, B. 2020. Makeshift hospitals for COVID-19 patients: where healthcare workers and patients need sufficient ventilation for more protection. J. Hosp. Infect. https://doi.org/10.1016/j.jhin.2020.03.008
3. Wang, J.; Du, G. 2020. COVID-19 may transmit through aerosol. Ir. J. Med. Sci. 1-2. https://doi.org/10.1007/s11845-020-02218-2.
4. Jayaweera, M.; Perera, H.; Gunawardana, B.; Manatunge, J. 2020. Transmission of COVID-19 virus by droplets and aerosols: A critical review on the unresolved dichotomy. Environmental Research 188 (2020) 109819. https://doi.org/10.1016/j.envres.2020.109819
5. Grayson, S.A; Griffiths, P.S; Perez, M.K; Piedimonte, G. 2016. Detection of airborne respiratory syncytial virus in a pediatric acute care clinic. Pediatr. Pulmonol. 52, 684-688. https://doi.org/10.1016/j.jinf.2010.11.010
6. Liu, L.; Wei, J.; Li, Y.; Ooi, A. 2016. Evaporation and dispersion of respiratory droplets from coughing. Indoor Air 27, 179-190. https://doi.org/10.1111/jebm.12381
7. Bromage, E.S. 2020. Coronavirus: The Risks – Know Them Avoid Them. https://www.erinbromage.com/post/the-risks-know-them-avoid-them , Accessed date: August 17, 2020