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COVID-19 Risk Assessment for Flutists

Jun 17, 2020, 11:27 AM by National Flute Association

The following is an excerpt adapted from a preliminary article for wind musicians. It has not been formally peer reviewed but has been internally vetted by physicians.

by Adam T Schwalje MD, DMA; Henry T Hoffman MD



June 10, 2020

Superspreading events early in the COVID-19 pandemic attest to its infectivity and virulence for musicians: infections in choir members included 102 of 130 participants in Amsterdam and 52 of 60 in Washington state, with several deaths following. Because of similarities to singing, there is concern that flutists might also be at additional risk. It is vitally important to be clear about the current uncertainties in COVID-19 risk assessment for flutists.

Background
Infections with SARS-CoV-2 number more than 7.3 million worldwide, with over 400,000 deaths reported as of June 10, 2020, and likely many more infections unreported. It is likely that COVID-19 is several times more deadly than influenza, which itself is a dangerous disease.

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 farther into the lungs. Larger droplets will not remain airborne beyond a 6-foot radius, but if an infected individual coughs in a small room, for example, the air in the room can remain infectious for some time (ibid).

Flutists and SARS-CoV-2
Despite the ongoing pandemic, a few orchestras are already back to work, and many music programs and ensembles are planning to resume operations. How might we mitigate risks for ourselves, our colleagues, audiences, students, and families?

Some groups have put out detailed guidelines that purport to reduce risk of transmission of SARS-CoV-2. Others have put out optimistic but concerning blanket statements that do not to be appear to be scientifically supported. For example, in a widely-circulated YouTube video that has since been removed, it was reported 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.” There is a background risk of spreading SARS-CoV-2 in daily life, depending on one’s activities. Wind playing and teaching likely carries additional risk, though this is not possible to quantify with current knowledge. Short of implementing complete isolation (i.e., playing and teaching from home), risk mitigation strategies are not likely to reduce this risk to “essentially 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.

Flutists who 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, several recent, pseudoscientific assessments of risk and risk-mitigation strategies for wind musicians are in wide circulation. The good news is that there also are ongoing scientific studies on these questions.

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 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.

Specific Risks of Wind Playing
The Issue of Aerosols 
Risks of playing a wind instrument probably differ from those involved in singing, though there are similarities. The flute, for example, creates a strong airflow. 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, published in 2011, investigated the vuvuzela and found significant aerosol production. 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. 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 U.S. 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 flute playing might also be risky: Flutists play headjoints, blow out tone holes, clean their instruments with swabs, 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 strategy is use of shields of plexiglass surrounding flutists. 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; however, after 30 minutes, during which aerosols mixed with surrounding air, the face shield was found to be ineffective.

The risk of aerosol production posed by flute 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. 

Music Education 
Less experienced players are more likely to have leakage of air around the embouchure and 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.

Small practice rooms might easily be filled with aerosol, which might 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. It is unclear how 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 flute 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.


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. He holds the DMA in bassoon performance from the University of Cincinnati College−Conservatory of Music, where he studied with the late William Winstead. Schwalje 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. 

Henry Hoffman is Professor of Otolaryngology at the University of Iowa Hospitals and Clinics. 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 Head and Neck Protocols and has published more than 200 scientific works. 

This article has not been peer reviewed. There is no external funding source. It represents the general opinions of the authors 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.

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

The entire article submitted to the NFA, with information pertaining to reed woodwinds and more background on COVID-19, can be found at the Iowa Protocols. The NFA thanks the authors for their contribution.

About The Blog

COVID-19 Risk Assessment for Flutists

Jun 17, 2020, 11:27 AM by National Flute Association

The following is an excerpt adapted from a preliminary article for wind musicians. It has not been formally peer reviewed but has been internally vetted by physicians.

by Adam T Schwalje MD, DMA; Henry T Hoffman MD



June 10, 2020

Superspreading events early in the COVID-19 pandemic attest to its infectivity and virulence for musicians: infections in choir members included 102 of 130 participants in Amsterdam and 52 of 60 in Washington state, with several deaths following. Because of similarities to singing, there is concern that flutists might also be at additional risk. It is vitally important to be clear about the current uncertainties in COVID-19 risk assessment for flutists.

Background
Infections with SARS-CoV-2 number more than 7.3 million worldwide, with over 400,000 deaths reported as of June 10, 2020, and likely many more infections unreported. It is likely that COVID-19 is several times more deadly than influenza, which itself is a dangerous disease.

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 farther into the lungs. Larger droplets will not remain airborne beyond a 6-foot radius, but if an infected individual coughs in a small room, for example, the air in the room can remain infectious for some time (ibid).

Flutists and SARS-CoV-2
Despite the ongoing pandemic, a few orchestras are already back to work, and many music programs and ensembles are planning to resume operations. How might we mitigate risks for ourselves, our colleagues, audiences, students, and families?

Some groups have put out detailed guidelines that purport to reduce risk of transmission of SARS-CoV-2. Others have put out optimistic but concerning blanket statements that do not to be appear to be scientifically supported. For example, in a widely-circulated YouTube video that has since been removed, it was reported 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.” There is a background risk of spreading SARS-CoV-2 in daily life, depending on one’s activities. Wind playing and teaching likely carries additional risk, though this is not possible to quantify with current knowledge. Short of implementing complete isolation (i.e., playing and teaching from home), risk mitigation strategies are not likely to reduce this risk to “essentially 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.

Flutists who 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, several recent, pseudoscientific assessments of risk and risk-mitigation strategies for wind musicians are in wide circulation. The good news is that there also are ongoing scientific studies on these questions.

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 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.

Specific Risks of Wind Playing
The Issue of Aerosols 
Risks of playing a wind instrument probably differ from those involved in singing, though there are similarities. The flute, for example, creates a strong airflow. 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, published in 2011, investigated the vuvuzela and found significant aerosol production. 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. 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 U.S. 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 flute playing might also be risky: Flutists play headjoints, blow out tone holes, clean their instruments with swabs, 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 strategy is use of shields of plexiglass surrounding flutists. 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; however, after 30 minutes, during which aerosols mixed with surrounding air, the face shield was found to be ineffective.

The risk of aerosol production posed by flute 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. 

Music Education 
Less experienced players are more likely to have leakage of air around the embouchure and 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.

Small practice rooms might easily be filled with aerosol, which might 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. It is unclear how 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 flute 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.


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. He holds the DMA in bassoon performance from the University of Cincinnati College−Conservatory of Music, where he studied with the late William Winstead. Schwalje 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. 

Henry Hoffman is Professor of Otolaryngology at the University of Iowa Hospitals and Clinics. 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 Head and Neck Protocols and has published more than 200 scientific works. 

This article has not been peer reviewed. There is no external funding source. It represents the general opinions of the authors 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.

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

The entire article submitted to the NFA, with information pertaining to reed woodwinds and more background on COVID-19, can be found at the Iowa Protocols. The NFA thanks the authors for their contribution.
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