A full assessment of the Covid risk of playing wind instruments

Dr Adam T Schwalje, Resident Physician , Otolaryngology – Head and Neck Surgery at University of Iowa Hospitals and Clinics, has been working on a full assessment of the risk of speading Covid-19 by playing wind and woodwind instruments.

Together with his colleague Dr Henry T Hoffman, Dr Schwalje, who is himself a wind player (pictured), has written this paper for publication in medical journals. You read it here first.

Take your time. Do not rush to the conclusions.

 

Wind Musicians’ Risk Assessment in the Time of COVID-19

 

Adam T Schwalje MD, DMA; Henry T Hoffman MD

10 June 2020

COVID-19 is a severe and dangerous disease. Its heart-wrenching infectivity and virulence hit home for many musicians, as we learned of the several choirs which were affected by superspreading events early in the pandemic. One was in Amsterdam, where 102 of 130 participants wound up with coronavirus infection; one in Washington state, where 52 of 60 participants were infected, and at least two others in Europe. Several choir members unfortunately died as a result. These were early hints that singing itself might be risky. The risks were strong enough that an alarm was raised by Dr. Lucinda Halstead and others in a National Association of Teachers of Singing webinar (NATS), leading many including the Metropolitan Opera to forego their upcoming seasons. 

Because of similarities to singing, there is concern that wind players might also be at additional risk, above the background risk, for spread of COVID-19. It is vitally important to be clear about the current uncertainties in COVID-19 risk assessment for the wind instrumentalist.

Background

Novel coronavirus continues its rapid spread throughout the world. Infections with SARS-CoV-2 are increasing and number more than 7.3 million worldwide, with over 400,000 deaths reported as of 10 June 2020 (Dong et al.). There are likely many more infections than reported due to well-publicized issues with testing and the high prevalence of asymptomatic infection.

The pandemic is serious and deadly. More than 1 in 3000 Americans have died from the disease thus far. Symptoms are gradual in onset and flu-like, however, many infected individuals are asymptomatic or presymptomatic and still infectious (Gandhi et al.). It is likely that COVID-19 is several times more deadly than influenza, which itself is a dangerous disease (Faust et al.). Most deaths from COVID-19 are in those who are elderly and / or have comorbidities including high blood pressure or diabetes (Parohan et al.). However, over 15 percent of US deaths, numbering over 17000, have been in those younger than 65 years (National Center for Health Statistics, updated 3 June 2020). Significant disease is also possible in children and teens (e.g., Licciardi et al.). 

Spread of SARS-CoV-2 is mostly by droplets or aerosol. The larger droplets can deposit on surfaces. Smaller droplets and aerosols can hang in the air and remain infectious. The smallest aerosols may lead to more serious disease, as they can be inhaled further into the lungs (Meselson). The 6-foot radius of safety is commonly mentioned as this is a distance over which larger droplets will not remain airborne. But, if an infected individual is coughing in a small room, for example, the air in the room can remain infectious for some time (Meselson). 

Musicians and SARS-CoV-2

K-12 programs, collegiate programs, and orchestras are struggling to imagine how they might survive the tremendous challenges represented by COVID-19. Despite the ongoing pandemic, a few orchestras are already back to work, and many music programs and ensembles are making plans to resume operations. 

It is understandable to wonder what the additional risks are for wind musicians, above the nonzero background risk of COVID-19 spread. How might we mitigate these risks for ourselves, our colleagues, audiences, students, and families? Some groups have put out detailed guidelines which purport to reduce risk of transmission of SARS-CoV-2 (personal communication). Others have put out blanket statements, for example that “any potential risk of infection or transmission of the virus [from wind playing] is essentially gone as long as proper social distancing and other precautions are being observed” (Nashville Music Scoring, 2020). The risks are unknown, but they are assuredly not zero.

Scientific and Ethical Underpinnings

It is more important than ever to read studies and guidelines with a critical eye and keep in mind the basics of scientific inquiry. A scientific study would cite sources, would be peer reviewed, in the case of COVID-19 would have the input of a physician or infectious disease specialist, and would be clear about who is producing the study and any conflicts of interest. The ability to replicate results is crucial, though this aspect of scientific inquiry can take time. Musicians who do rely on the conclusions of non-reproducible studies might underestimate either the risks of their activities or the uncertainty involved in assessment of these risks. Unfortunately, there are several recent, widely-circulated, pseudoscientific assessments of risk and risk mitigation strategies for wind musicians. The good news is that there are several scientific studies on these questions also, most of which are still ongoing.

If we assume there’s no risk, or if we assert that unstudied risk mitigation procedures work, then people can’t make an informed decision about whether to put themselves in those potentially risky situations. Also, if there is at least an acknowledgement of risk, then those who are at greater personal risk from COVID-19 (the elderly, those with comorbidities, etc.) may be able to seek accommodations for risk mitigation from their local governments. In the US, for example, this might be accomplished through the Americans with Disabilities Act (EEOC).

Specific Risks of Wind Playing

 

  • The Issue of Aerosols

 

Much attention has been given to the risks of singing, largely because of early superspreading events. The mechanism of singing requires deep breathing, vibration of the vocal folds, active manipulation of the larynx, pharynx, tongue, and lips, and produces aerosols which can hang in the air for at least hours. Some individuals produce significantly more aerosol than others, for unknown reasons (Asadi). 

Risks of playing a wind instrument are probably different than those involved in singing, though there are similarities. The flute, for example, creates a strong airflow, though other instruments do not. But airflow does not tell the whole story. Playing a wind instrument involves deep breathing, sometimes forceful exhalation, and possible aerosolization of the mucus in the mouth and nose, along with secretions from deeper airway structures. The only peer-reviewed, published study on a wind “instrument” and aerosolization investigated the vuvuzela and found significant aerosol production (Lai et al.). There is, therefore, at least a theoretical risk of droplet or aerosol transmission during wind performance, but more study needs to be done. 

Two oft-referenced recent studies, one from Vienna Philharmonic and one from Freiburg University, investigated airflow and wind instrument playing (Vienna Philharmonic; Spahn et al.). Neither of these were peer-reviewed or published in a journal. Neither of these addressed aerosol generation, which is the main issue, as aerosols can hang in the air for extended periods of time and can be infectious. Dispersion of aerosols was hinted at in both studies, but dispersion is dependent on external factors like room airflow and mixing dynamics, which were not examined in either paper. A lack of evidence about aerosol generation and elements of aerosol dispersion is explicitly noted in the Freiburg review. Even if there is minimal airflow from playing, if aerosols are produced especially in the context of deep breathing, there is a risk of spreading the aerosols around the environment. This risk is not quantifiable at the moment. Several centers in the US are investigating aerosol production from wind instrumentalists; these include University of Colorado at Boulder, Colorado State University, Rice University, and University of Maryland. 

Other behaviors associated with wind playing might also be risky: Wind players buzz on their mouthpieces, blow out tone holes, blow out spit valves, clean their instruments with swabs and feathers, and might have leaking embouchures or nasal emissions during playing. How to mitigate these risks is not yet known, though many approaches have been suggested and are even being put into use. One example is the use of disposable rags to blow out spit valves for brass musicians. This is intuitively cleaner and less likely to spread infection than, for example, emptying them onto the bare floor for everyone to track around – but the potential for aerosolization if any force is used to expel the contents, for example, is not known. Another strategy is use of shields of plexiglass surrounding wind players. This strategy has not been studied for wind musicians, but is reminiscent of (though not entirely similar to) the idea of using polycarbonate face shields to protect healthcare workers from aerosol spread – effective in the short term to protect from an infected patient coughing in one’s face, but after 30 minutes during which aerosols mixed with surrounding air the face shield was found to be ineffective (Lindsley et al.).

The risk of aerosol production posed by wind instrument performance is not known, though there are several indications that it might exceed background risk of COVID-19 transmission. Studies on this risk, and the effectiveness of risk mitigation strategies, have not yet been completed. 

 

  • Reeds

 

Reedmaking is a large part of many people’s livelihoods. But, it is very important to recognize that there are no guidelines, no US Centers for Disease Control (CDC) recommendations, no EPA or FDA recommendations, and very little science, which specifically supports or instructs on how to make a reed safe from coronavirus. There is no validated method that will eliminate the risk of viral transmission from reeds. The safest approach would be to treat all reeds as if they are infectious; to not work on others’ reeds and not share reeds with others. This can be difficult, especially for double reed players. 

CDC guidelines which have been referenced by some reedmakers, like the suggestion for a soak in 70% alcohol, are designed for disinfecting already clean surfaces (CDC). Unfortunately, reeds are not like other typically-studied surfaces. Played-upon reeds include proteins, respiratory secretions, and dead skin, in addition to the structure of the reed itself – all of which would probably tend to stabilize the virus (based on studies of SARS-CoV1, Geller et al.). The CDC has no recommendations on how long, or with what, to soak or process a reed to render it safe from coronavirus. 

There is some timeframe, of unknown duration, during which virus particles deposited on and in a reed will lose their ability to infect a new host. Unfortunately, it is unclear how long coronavirus particles remain infectious on or in items like reeds. The closest available comparison is with cardboard, on which virus particles seem to have a relatively short time of remaining infectious (24h compared to 72h + for solid surfaces, van Doremalen et al.). But, one review concluded “the most common coronaviruses may well survive or persist on surfaces for up to one month.” (Ren et al.). In any case, the materials tested to draw these conclusions are not soaked in someone’s mouth for hours on end, and these types of tests generally exclude presence of other substances like proteins. Therefore, applicability to reeds in a real-world situation is unknown. 

Another theoretical option for reed disinfection is a high-temperature soak (e.g., at 77 degrees C or 170 degrees F, for 30 min), which is more conservative than the 30 minutes at 65 degrees C used for heat inactivation of commercially available SARS-CoV2 (provided in a protein-rich serum, https://www.beiresources.org/Catalog/antigen/NR-52286.aspx). This might be a way to ensure that the entire reed is disinfected – though this method has yet to be validated.

For cleaning and disinfecting reedmaking equipment, a reedmaker might be able to use resources like: https://www.cdc.gov/coronavirus/2019-ncov/prepare/cleaning-disinfection.html or https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars- cov-2. Knives and other reed tools should be treated like food preparation equipment; potentially dangerous chemicals should be removed from their surfaces before use. 

Putting one’s mouth on a reed which has been sucked on by another person is not without risk in the COVID-19 era. It is impossible to quantify this risk. It is likely that some procedure like heating in water or waiting for a specified time decreases this risk, but it is impossible to say how much the risk is reduced with this or any other method. To support those who choose to wait for some length of time before using a reed which has been played by others, reeds should be marked with their date of last play-testing. Using a “sanitizing procedure” could give a false sense of security but is probably better than doing nothing, if there is no alternative to sharing.

 

  • Music Education

 

Those players who are less experienced are more likely to have leakage of air around the embouchure, more likely to have stress velopharyngeal incompetence or nasal emissions, and are likely to work harder to produce sound – all of which may create more risk of aerosol production and subsequent COVID-19 spread.

Practice rooms are small spaces which might easily be filled with aerosol. These particles may take hours to settle and could still remain infectious on surfaces even when settled from the air. Appropriate ventilation and cleaning precautions should be used, with some minimum time required before cleaning and re-use.

In K-12 school music and collegiate methods courses, sharing and storage of instruments present another set of challenges. While brass instruments can probably be effectively cleaned using the CDC guidelines for surfaces, using an instrument brush / hot soapy water for cleaning followed by a disinfectant wash, it is unclear how other instruments, made of delicate woods, felts, and corks, can be cleaned or disinfected. Careful management of a full class of school-age recorder players, in this context, would be difficult. The instrument storage room presents additional possibilities for spread of potentially infectious droplets. 

Unknown risks

The risks of wind playing in the COVID-19 era are unknown. There is a possibility, currently being studied, that the risks of wind playing and associated behaviors are greater than baseline risk of spread of COVID-19. This has wide ramifications as programs are attempting to re-open. Acknowledging the risks and attempting to mitigate them is important – but should not lull musicians into a false sense of security. Unfortunately, the available scientific evidence is too scant to reliably inform decisions about risk mitigation strategies for wind musicians. Musicians should be empowered to make their own decisions based on their individual risk tolerance. Leaders should be cautious in their representations of risk and clear about uncertainty regarding the efficacy of risk mitigation strategies.

About the Authors

Dr. Adam Schwalje is a resident physician and National Institutes of Health (NIH) T32 research fellow in the Department of Otolaryngology at the University of Iowa Hospitals and Clinics (UIHC). In addition to his work as a physician, he holds the DMA in bassoon performance from the University of Cincinnati College – Conservatory of Music, where he studied with the late William Winstead. Adam has played in professional orchestras including full time in the Macau Symphony. He has also been a band teacher and music educator, and is currently the medical liaison for the International Double Reed Society. 

Dr. Henry Hoffman is Professor of Otolaryngology at the University of Iowa Hospitals and Clinics (UIHC). He graduated from the University of California, San Diego School of Medicine and completed his otolaryngology residency at the University of Iowa with subsequent fellowships in head and neck surgery and facial plastic surgery. He is Director of the Voice Clinic and is extensively involved in research addressing laryngeal pathophysiology. He is creator and editor of the Iowa Protocols (https://medicine.uiowa.edu/iowaprotocols/) and has published over 200 scientific works. His bands, occasionally including bassoon, can be heard throughout southeast Iowa.

This article has not been peer reviewed. There is no external funding source. It represents the general opinions of Drs. Schwalje and Hoffman and is not intended to offer or replace specific medical advice. If you have questions about your medical situation or your specific risks regarding COVID-19, please contact your physician.

 

References

Dong, E., Du, H., & Gardner, L. (2020). An interactive web-based dashboard to track COVID-19 in real time. The Lancet. Infectious diseases, 20(5), 533–534. https://doi.org/10.1016/S1473-3099(20)30120-1. https://coronavirus.jhu.edu/map.html accessed 10 June 2020.

NATS National Association of Teachers of Singing (5 May 2020). https://www.youtube.com/watch?v=DFl3GsVzj6Q accessed 8 June 2020.

Gandhi, M., Yokoe, D., & Havlir, D. (2020). Asymptomatic Transmission, the Achilles’ Heel of Current Strategies to Control Covid-19. The New England Journal of Medicine, 382(22), 2158-2160.

Faust JS, del Rio C. Assessment of Deaths From COVID-19 and From Seasonal Influenza. JAMA Intern Med. Published online May 14, 2020. doi:10.1001/jamainternmed.2020.2306.

Parohan M, Yaghoubi S, Seraji A, Javanbakht MH, Sarraf P, Djalali M. Risk factors for mortality in patients with Coronavirus disease 2019 (COVID-19) infection: a systematic review and meta-analysis of observational studies [published online ahead of print, 2020 Jun 8]. Aging Male. 2020;19. doi:10.1080/13685538.2020.1774748. 

National Center for Health Statistics (updated 3 June 2020). https://data.cdc.gov/NCHS/Provisional-COVID-19-Death-Counts-by-Sex-Age-and-S/9bhg-hcku accessed 7 June 2020.

Licciardi, F., Pruccoli, G., Denina, M., Parodi, E., Taglietto, M., Rosati, S., & Montin, D. (2020). SARS-CoV-2-Induced Kawasaki-Like Hyperinflammatory Syndrome: A Novel COVID Phenotype in Children. Pediatrics, Pediatrics, May 21, 2020.

Meselson, M. (2020). Droplets and Aerosols in the Transmission of SARS-CoV-2. The New England Journal of Medicine, 382(21), 2063-2063.

Nashville Music Scoring (2020). Brass & Woodwinds Air projection. youtube.com/watch?v=K5Yu4ll8JGg&t=6s, accessed 7 June 2020.

EEOC US Equal Employment Opportunity Commission (updated May 7 2020). What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws. https://www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-ada-rehabilitation-act-and-other-eeo-laws accessed 8 June 2020.

Asadi S, Wexler AS, Cappa CD, Barreda S, Bouvier NM, Ristenpart WD. Aerosol emission and superemission during human speech increase with voice loudness. Sci Rep. 2019;9(1):2348. Published 2019 Feb 20. doi:10.1038/s41598-019-38808-z.

Lai KM, Bottomley C, McNerney R. Propagation of respiratory aerosols by the vuvuzela. PLoS One. 2011;6(5):e20086. doi:10.1371/journal.pone.0020086.

Vienna Philharmonic (2020). Aerosolausstoßtest: Geringes Infektionsrisiko durch die Verbreitung von Atemluft von Musikern [Aerosol Emissions Test: Low Risk of Infection through Musicians’ Breath]. https://www.wienerphilharmoniker.at/orchester/philharmonisches-tagebuch/year/2020/month/4/blogitemid/1423/page/1/pagesize/20?fbclid=IwAR2wCggWqcd-Q_8Ewzr3E8rwX3_RxWKOpQXo3hMkDpag04O-YY9BDfPE8qQ, accessed 8 June 2020.

Spahn C, Richter B, Leitung des Freiburger Institut für Musikermedizin (FIM), Universitätsklinikum und Hochschule für Musik Freiburg (updated 19 May 2020). Risikoeinschätzung einer Coronavirus-Infektion im Bereich Musik [Risk assessment of a coronavirus infection in the field of music – second update of 19 May 2020]. https://www.mh-freiburg.de/en/university/covid-19-corona/risk-assessment, accessed 8 June 2020.

Lindsley WG, Noti JD, Blachere FM, Szalajda JV, Beezhold DH. Efficacy of face shields against cough aerosol droplets from a cough simulator. J Occup Environ Hyg. 2014;11(8):509518. doi:10.1080/15459624.2013.877591.

CDC Center for Disease Control and Infection (2020). Cleaning and Disinfecting Your Facility. https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html, accessed 8 June 2020.

Geller, C., Varbanov, M., & Duval, R. E. (2012). Human coronaviruses: insights into environmental resistance and its influence on the development of new antiseptic strategies. Viruses, 4(11), 3044–3068. https://doi.org/10.3390/v4113044.

van Doremalen, N., Bushmaker, T., Morris, D. H., Holbrook, M. G., Gamble, A., Williamson, B. N., Tamin, A., Harcourt, J. L., Thornburg, N. J., Gerber, S. I., Lloyd-Smith, J. O., de Wit, E., & Munster, V. J. (2020). Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. The New England journal of medicine, 382(16), 1564–1567. https://doi.org/10.1056/NEJMc2004973.

Ren, S. Y., Wang, W. B., Hao, Y. G., Zhang, H. R., Wang, Z. C., Chen, Y. L., & Gao, R. D. (2020). Stability and infectivity of coronaviruses in inanimate environments. World journal of clinical cases, 8(8), 1391–1399. https://doi.org/10.12998/wjcc.v8.i8.1391.

Many thanks to James Massol DMA and Sasha Garver DMA for their thoughtful comments

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  • So, until this paper is peer reviewed nothing should change in our precautionary actions. It’s actually a bit irresponsible to post this… the review process exists for a reason…

      • One needs to understand the publication process in science and medicine. Peer review is not intended to conceal information or delay its issue, but rather to improve a study; it’s expert assistance in detecting and resolving potential doubts, ambiguities, and/or errors before publication. In addition, prior or pre-publication can invalidate the possibility of submission to a peer-reviewed journal (the authors know this; if they authorized its reproduction here, there’s no problem).

        • You should talk to Alan Sokal, James Lindsay, Helen Pluckrose, and Peter Boghossian about how reliable and expert the assistance of “peer review” is.

          • Sokal’s bogus submission pre-dated the journals use of peer review. Thanks for making our point! Try that crap at Nature, Science, PNAS, JEM or JI.

          • Perhaps it should have been clarified that the reference was to the biological/medical, physical, mathematical sciences rather than to social sciences (the area of the hoaxers you mention).
            Of course, any system can be gamed. Nonetheless, most scientists take their own work (and the job of peer review when they’re called upon to do it) quite seriously.

          • Even peer reviewed studies are not reliable anymore. The Lancet and The New England Journal of Medicine recently retracted two high-profile papers.

        • I think you are conflating 2 issues but the gist of your comments are still accurate. A scientist can only submit a paper to one journal at a time. The peer review process can take 2 forms. First, prior to submitting a paper to a journal the first or last author may opt to circulate the paper to a small group for their comments. In competitive research areas this is rarely done for fear of being scooped. Once a paper is submitted to a peer-reviewed journal the norm is for the editor to send the paper to up to 3 journal reviewers with the expertise to determine if the results were generated by “good scientific method(s)”, if the conclusions are supported by the data and if the findings meaningfully add to the existing published results on the subject in question. It is quite common for 1 or more reviewers to have a series of questions which must be addressed before a journal will accept a paper for publication.

      • Irresponsible is to publish “opinions” about a public health crisis which are based on politics or social science. The article under discussion is neither of those but an attempt to rationally address a concern that anyone interested in the performance of music should read and reflect on before spreading nonsense.

      • Irresponsible is making decisions based on unproven « opinions » of Drs. Schwalje and Hoffman. I’m amazed that given how clear the situation regarding the still upward trend in infections in the US is, that you would recommend this instead of prudence.

    • On the other hand, this is not a pseudoscientific study, performed or commissioned by someone with a financial interest in getting musicians back to work.

      Mostly they are saying “We still don’t know all the risks, but here are some factors that must be considered,” e.g. aerosols and ventilation. Nothing irresponsible about that, IMHO.

    • There is nothing irresponsible with regards to reading a manuscript that is under peer review as long as the authors have nothing against it. Have you ever done research in science and have published anything in a scientific journal? This is the modus operandi of research publication.

      I disagree ever so slightly with Amos re the description of the peer review process.

      It has been a standard practice for decades that when a manuscript has been submitted for peer review, and possible subsequent publication, but before acceptance for publication, a pre-print can be deposited on a website from which a wider circle of colleagues and even public can download or read. There is still value to read such manuscripts in full cognizance that the content may be modified during the peer review process because flaws (major or minor) may be detected. Because the manuscript is available to such a large reader group in addition to the 2-3 official reviewers assigned by the journal, the pre-print is also subjected to critical reading and comments from other researchers in the field.

      • Perhaps I’m showing my age but back in the day, the norm wasn’t to circulate widely pre-prints until the paper was accepted. At national meetings, pre-publication results were routinely presented but the speaker would invariably indicate that the paper had been submitted. The value of pre-prints was usually a function of the credibility/reputation of the senior investigator.

    • This is a review of available literature. The entire premise behind the paper’s argument is to urge caution because there are NOT peer-reviewed and published studies concerning COVID-19 and wind instruments. That should absolutely urge more caution until we know more about safety, since initial evidence shows a higher-than-normal risk for wind musicians.

  • We have had flu viruses every year. Every year or so we have a new virus which is often more dangerous than known ones. We have a good herd immunity for flu viruses. We will develop a good herd immunity for Covid 19 and the derivatives. We are surrounded by viruses every day. If cleaning, spitting and blowing into instruments as well as singing was so dangerous the music profession would not have survived as long as it has. We are losing our sense of perspective and we need to get back to normal ASAP.

    • I realize that reading the full article is well beyond your limit of concentration but it invalidates every bogus idea you insist on spewing. Please feel free to infect yourself as quickly as possible just don’t waste the medical care required by others who are taking appropriate precautions.

      • Amos. If the lockdown were lifted completely tomorrow I would be first to volunteer to attend a concert with no social distancing. If you really think that you, as an audience member, are in danger from a musician on stage playing an instrument then you truly have fallen for project fear. We will look back on our behaviour with deep embarrassment.
        The elderly (over 70) and those with pre existing conditions should be offered the opportunity to isolate and shield. The rest of us and especially the young should be outside living and loving and working. Life is dangerous. You ‘follow the science’. Allow me to live my life.

        • You are welcome to live your life as you wish but if you want to be a member of society you have no right to endanger others by wantonly disregarding sound public health guidelines. You have no right to smoke in public spaces, yell fire in a theater and you especially have no right to knowingly or unknowingly infect others with a highly contagious/transmissible virus for which there is no vaccine.

    • Spot on. The average person is a carrier of about 8-10 viruses at any given time. That’s what our immune systems are for, and they actually work quite well for most things. The extreme panic and paranoia over this virus with an IFR of about 0.016 (in the range of flu) is purely political and media driven.

      • Covid-19 is certainly not the Black Death: no credible source has suggested that it might kill a third or half of the population. But the fact that it has already killed 1 in 3000 people in the U.S. (to take only the statistic in this paper), and that it’s far from over, makes it much more serious than all but the very worst strains of influenza: 1918-20, or the first appearance of H1N1, in 1957, which killed 116,000 in the US (2 in 3000 people). Covid-19 looks set to surpass the 1957 epidemic in lethality, at least in the U.S.

        It’s true that H1N1 is no longer as lethal as it was — thanks in part to vaccines and in part to herd immunity — but if we have the wherewithal to reduce the lethality of our first exposure to SARS-CoV-2 using epidemiological controls and, eventually, therapeutics and vaccines, it’s only reasonable to do so.

        Of course, the effects of economic deprivation on public health must be balanced against epidemiological benefits of the shutdown: the goal is to minimize *overall* damage to peoples’ lives.

        In the music world, individual audience members can and should determine their own risk tolerance freely (assuming they have the evidence on which to do so). It’s a different matter for the musicians, who (a) may face higher health risk, playing in close proximity to each other, but (b) face economic hardship when deprived of performing opportunity. The need for good data is arguably much greater for the musicians than for others, and this preprint frames the question properly, identifying the issues most urgently in need of quantitative determination.

      • Your IFR is garbage and the notion that viruses can be lumped together imbecilic. I’d much rather deal with a cold virus than ebola, SARS or HIV.

    • In the mean time do you tell your parents or grandparents that you are quite happy to sacrifice them on the altar of herd immunity?

    • We should get back to normal and just isolate the people who are at risk. We know the people who have high mortality from COVID by now. Half the people who get it have no symptoms at all. We could reach herd immunity by fall. Look at this headline from last week:
      “Health official: No new COVID-19 cases from Missouri parties
      Missouri’s top health official says no additional cases of the new coronavirus have been reported stemming from the crowded pool parties at Missouri’s Lake of the Ozarks over the Memorial Day weekend.”
      https://abcnews.go.com/Health/wireStory/health-official-covid-19-cases-missouri-parties-71069249

  • Thank you for posting this. I fully understand that instrumentalists are desperate to perform again for personal and financial reasons. I am too!

    But until there is real scientific testing or a vaccine, I don’t believe the health and lives of music makers should be at an unknown risk. When it can be quantified and understood, much like the flu and other viruses mentioned by a commenter above, then we will have enough information to make decisions responsibly.

    I don’t think that we should be making decisions of that magnitude based on misters and tissue paper “testing”.

    • No one is forcing people to go to concerts. If the audience most likely to get ill stays away it’s their choice. Don’t make instrumentalists sacrifice their lives if you’re afraid to step foot out of your house. This is pathetic, demoralizing and visionless. No study looks for HOW to resume! They are looking for reason not to resume. With this attitude there will be no orchestras to return to after the a “cure” or “vaccine” which isn’t even guaranteed.

      The feeble should stay home and the strong continue.

  • “COVID-19 is a severe and dangerous disease”

    This false premise is driving the Covid insanity and paranoia, and the notion that all life, everything everywhere form now until the end of time has to be driven by “Covid considerations”. The fact is, that it is not particularly severe or worrisome, certainly not some new Black Death. The response had been purely political from the beginning. It has an IFR of about .016, in the range of flu. Over 80% of people exposed to it are asymptomtic, 95% require no medical intervention at all to get over it. The vast majority of deaths have been with the extremely aged or those with underlying conditions that would put them at greater risk even for flu. The real scandal has been elder abuse – lack of proper care and protection in nursing homes. There is no evidence whatsoever that lockdowns were of any use, but abundant evidence that they have been more destructive in countless ways than the virus itself. Wake Up, People!

  • This preprint sets out the scope of the problem and the limits of current knowledge very clearly. Aerosol generation and persistence is obviously the most immediate concern, and it’s evident that the state of knowledge is inadequate. Another area where secure guidance is not yet possible — surprisingly, perhaps — is the basic aspects of cleaning and disinfecting reeds, etc.

    The paper’s suggestions seem eminently reasonable, given the uncertainties, and the need for individuals to act in accordance with their own sense of risk and risk tolerance is clear.

  • “Might”, “might”, “might”. The authors are very honest.
    They say they don’t know anything. They just made a compilation of articles who made suppositions.
    “This risk is not quantifiable at the moment. Several centers in the US are investigating aerosol production from wind instrumentalists; these include University of Colorado at Boulder, Colorado State University, Rice University, and University of Maryland”.
    So, after reading this paper, we don’t know anymore, but we are waiting a first serious and scientific study. Hope it will be Colorado and Maryland universities.

    • I agree…the author really hasn’t spoken to many musicians (I am one). Sharing reeds? Sharing mouthpieces? Not in my world!

  • Looking on the bright side (and writing from personal experience), regularly playing brass/wind will probably improve your lung function well above the average for the general population and enhance your ability to cope with any infection. So playing in isolation can only be considered a Good Thing.

  • So hasn’t this always been so? There have always been viruses and I’m sure there always will be
    So we stop having music to soothe our souls?
    Might as well stop living !
    Build your God given immune system and let it do it’s job and fight these viruses !
    We cannot shut down the world again !

  • The results reported in this manuscript is one incremental step towards understanding as much as we can at present about this new virus and how and where it can be spread.

    Scientific knowledge is never got at by one big step from not knowing anything (A) to a complete picture/knowledge (B). To go from (A) to (B), there are many incremental steps in between and even going backwards when confronted with insurmountable obstacles or unintentional mistakes. The results from each incremental step by one group are reviewed by fellow scientists and published in respectable science journals. The other scientists in the field in the world can then critically examine the results- either citing other supporting evidence or showing there are still flaws in the analyses or theory. One can say that science takes a zig-zag way from (A) to (B). The zig-zagings are bigger at the beginning when the topic is first examined but eventually converge to something called the accepted knowledge that is the end result of a long series of hammering by scientific critics. The valid results that could withstand the long list of critics have the greater probability to be not horribly wrong!

    People outside the scientific circle have little understanding of the zig-zagings that happen in the “genteel” atmosphere of journals and conferences. But in the present hot-house atmosphere of the press reporting the research results on coronavirus at warp speed, the non-scientists and people with their ideological agendas accuse the scientists of not agreeing or not knowing what they are doing. They don’t realize or don’t want to admit, that every piece of technology we use or hold in our hands is the results of a very very very VERY long sequence of researches many of which have been faulty but discarded and then end up with something that does not blow up in one’s face, not always anyway!

    The quasi indispensable technology everyone holds in his hand, the smartphone, is the result of a very very long history of research. With a certain arbitrariness, let me pick 1947 as the start date of our modern IT. It was the year the solid state transistor was invented. Our smartphones have millions of them. The size of the first transistor is about the size of a coffee mug. Now 73 years hence, your smartphone won’t blow up in your face 99.9% of the time, thank goodness. But in the previous 73 years, heated discussions, competitions, accusations of sloppy research, etc etc have taken place in research journals and research conferences out of view from man-on-street. And it is these men-on-street that are enjoying the fruit of the blood, sweat and tears of the works that have led to it. Is it a fair criticism of science that after the invention of the solid state transistor, that a version of our smartphone, e.g., the first iPhone, was not available in 1948, 1949, …?

    I think the odds are quite good that in 73 years or even 50 years time, we will understand much more about covid-19. In the mean time, Father Time will let the history of this virus to unfold. I am betting my farm on it that it will not be a straight line.

  • I’m sorry, but this is not a full assessment of anything. It cites and includes no measurements of how far droplets spray, repeats the story of the choir rehearsal events without including the additional information that has come out about other behaviors besides the singing that made them into such super-spreading events, and slams the numerous German and Austrian studies for not being peer-reviewed despite the fact that they all generally reached the same conclusions. Peer review takes time. Duplication of results is still significant. Let’s not repeat months-old opinions like those expressed at that NATS webinar when there is newer, more evidence-based information available every day.

  • Is there some website or contact to find information about the study planned in Rice University? The ones in Colorado and Maryland are presented online but Google doesn’t seem to know more about that one…
    Thanks

  • Mask idea: positive airpressure flowing thru a tube from a battery-operated ionizing carbon (w/infrared?) filter unit on our belts, into a very light clear plastic bubble around our heads with an openable-closeable hole to talk/sing or play through. So if everyone nearby was inhaling only air cleaned by the units, it wouldnt matter if a few asymptomatics were spreading viruses when they talked, sang, or played, because the positive air pressure inside the head bubbles would keep aerosols out of everybody’s air supply, and cleaned air would inflate them. Only it would be a shame if the bubbles broke!]

  • OMG! How about some science and music? First, the v. is not an instrument — it’s sole purpose is noise-making and the object is to blow as hard and long as possible. It is a straight bore device.

    Now for musical instruments: Except for the flute, the air column is captured by the bore, and except for the oboe, the bore has turns. Thus, the aerosols [if any] in the flow will encounter a [typically] cooler surface and condense — hence the “spit.” It is relatively easy to capture any aerosols emitted by using Schlieren photography — a workable lab setup can cost anywhere from almost $0 to, more typically, about $2000. Also, Petrie dishes could be used at the bells of all but flutes to capture aerobe samples. Here, the cost is almost nil.

    Flutes can be tested at the mouthpiece. If flutists emit adrobes, a wind screen as used on microphones might suffice.

    Reeds can be sterilized by soaking them in hydrogen peroxide diluted. I’ve used this for years on my bassoon reeds as it extends their life. If I were sharing a reed, I might use full strength drugstore H2O2 briefly.

  • Firstly – thank you for summarizing available body of knowledge.

    Secondly – I believe based on experience and study – that the production of aerosols is not the major issue, rather it is the TRANSPORT of potential aerosols from one individual to another that is important and along with the likelihood of that transport resulting in exposure that are the two more relevant questions. (Although aerosol production must first be present.)

    Based on basic engineering and fluid mechanics, aerosols of virus size cannot be “blown” to another person’s respiratory zone. The based F=ma equation does not allow for that transport to occur. So, then, how does the virus spread:

    1) Very close contact
    2) Building or other ventilation processes that actually move (what would otherwise be stagnant aerosols) to another person’s respiratory region. This has already been well-documented for Covid-19.

    Thus, wind instruments represent – at worst – the same transmissivity as other indoor activities and would be dependent upon the airflow throughout the space in which the musicians (and audience) is engaged.

    Now having stated this, the application of this information to solve the potential problems is difficult. Deep breathing of fresh air is needed. One could put large fans to have large air circulation rates, say in an outdoor setting, but the noise and wind could physically impeded performance.

    What would be more interesting to study, is: Do the instruments themselves remove the virus (much as the human airway is the first step in preventing respiratory disease)? I think there is a high probability the interior surface of instruments like the french horn could remove much of the virus – but this is speculation and performing the study would be difficult and probably unethical to perform in any reasonably accurate setting.

    So in short, the risk is likely similar for any non-mask wearing group in a given ventilation scenario, i.e. outdoor performances due to turbulent dispersion of particles would likely be substantially lower risk, esp if members of the ensemble were spread out, than a close indoor setting. It has been demonstrated that the risk is fairly high, making regular testing (and tracing) the best method of reducing risk as has been demonstrated in most other major developed countries.

    In short, the risks are likely similar to athletes (deep-breathers) in appropriate indoor/outdoor venues who may not be able to wear masks to perform albeit music or sport. There may be a potential for less spread due to the nature of some specific instruments, but it is unlikely to be a rationale mode of study (compared to say better/more vaccine studies/development)

  • Misleading and inaccurate title. It’s not a full assessment.

    Furthermore, the article shares nor suggests anything that’s solution based and there are a number of ideas that ensembles and orchestras are considering, all of which have been discarded by this article, while failing to accept the simple truth which is that you cannot eliminate risk entirely. Solutions will be about mitigating and minimizing, not eliminating risk. The covid situation should not be a reason to get rid of performing arts but it seems the UK govt are hell bent on using it thus.

  • I truly believe this is a ludicrous example of finding obsticals rather than solutions. If we look at any aspect of life there is a risk involved. There would be risks associated with singing and playing wind instruments pre covid19. As for the ‘chior’ that would certainly be different to say, a rock show or any contemporary musical theatre show where everyone has a microphone and in ear monitoring so ‘projection’ as such is not needed as opposed to resonance for tone rather than volume. The same would apply to wind instruments. Again, pour energy into testing, vaccination and yes! Hygienic stage and dressing room protocol but, for god’s sake nannies. Let the show go on!

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