Key Words
INTRODUCTION
- Hamner L
A choir decided to go ahead with rehearsal. Now dozens of members have COVID-19 and two are dead. Los Angeles Times. Available at:https://www.latimes.com/world-nation/story/2020-03-29/coronavirus-choir-outbreak. Accessed June 1, 2020.
A Conversation: What Do Science and Data Say About the Near Term Future of Singing.
Enquirer DJH Cincinnati. Will COVID-19 silence singers until there's a vaccine? The Columbus Dispatch. Available at:https://www.dispatch.com/news/20200511/will-covid-19-silence-singers-until-theres-vaccine. Accessed June 1, 2020.
COVID-19 IS LIKELY SPREAD BY RESPIRATORY PARTICLES
PHONATION PRODUCES DROPLETS AND AEROSOLS
ENVIRONMENT AFFECTS RISK
CDC. Social Distancing: Keep Your Distance to Slow the Spread. Centers for Disease Control and Prevention. Accessed June 2, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html
- Chu DK
- Akl EA
- Duda S
- et al.
- MacIntyre CR
- Wang Q
- Hamner L
Japan's live music clubs emerge as new coronavirus transmission sites. Reuters. Available at: https://www.reuters.com/article/us-health-coronavirus-japan-music-idUSKBN20X0WU. Accessed June 3, 2020.
PPE HELPS PREVENT VIRUS SPREAD
- Chu DK
- Akl EA
- Duda S
- et al.
- MacIntyre CR
- Wang Q
Covid-19: Should cloth masks be used by healthcare workers as a last resort? The BMJ. Available at: https://blogs.bmj.com/bmj/2020/04/09/covid-19-should-cloth-masks-be-used-by-healthcare-workers-as-a-last-resort/. Accessed June 2, 2020.
CDC. Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19). Centers for Disease Control and Prevention. Accessed June 3, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html
- Chu DK
- Akl EA
- Duda S
- et al.
AGE, RACE, INCOME LEVEL, AND HEALTH COMORBIDITIES AFFECT RISK
- Rentsch CT
- Kidwai-Khan F
- Tate JP
- et al.
DISCUSSION
Stevis-Gridneff M, Jakes L. World leaders join to pledge $8 billion for vaccine as U.S. Goes It Alone. The New York Times. Available at: https://www.nytimes.com/2020/05/04/world/europe/eu-coronavirus-vaccine.html. Accessed June 3, 2020.

Centers for Disease Control and Prevention. Appendices in the guideline for disinfection and sterilization in healthcare facilities (2008). Published July 22, 2019. Accessed June 15, 2020. Available at:https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html
Source-Connect Now / Source Elements. Available at: https://now.source-elements.com/#!/. Accessed June 20, 2020.
SoundJack: Real Time Online Music. Ian Howell, DMA. Available at:https://www.ianhowellcountertenor.com/soundjack-real-time-online-music. Accessed June 20, 2020.
Setting up a realtime physically distant rehearsal. Art Song Central. Available at: https://artsongcentral.com/2020/setting-up-a-realtime-physically-distant-rehearsal/. Accessed June 20, 2020.
- 1.Rehearse outside when possible. Inside, open windows and doors and use ventilation strategies such as fans to blow air away from the singer(s).
- 2.Use PPE, at least cloth face masks. Singing is possible with a mask. Masks can cause breathing challenges for some, and this may affect especially singers with underlying pulmonary dysfunction.
- 3.Rehearse alone, remotely, or in smaller groups. When with others, physical distancing of six feet or more appears paramount.
- 4.Rehearse in shifts or smaller sections, if possible, ideally in separate locations. Consider having a few representatives from each voice part and, if necessary, change the repertoire to accommodate.
- 5.Shorten rehearsal times. There is no absolutely “safe” duration of for rehearsal, and so organizations should do everything they can to limit rehearsals to the shortest possible time period.
- 6.Limit extraneous activities (eg, breaks, socializing, food etc).
- 7.Wipe down items that have been set up or touched by others before and after use (chairs, scores/paper music, instruments, music stands, etc).
- 8.Screen for symptoms, including fever, upper respiratory infection symptoms such as coughing and nasal congestion, loss of smell and taste. Take temperatures of singers prior to entering the rehearsal space. Remember that some infected patients will not have any symptoms.
- 9.Avoid direct contact (eg, hand-shaking, joining hands).
- 10.Practice meticulous hygiene. Wash or disinfect hands before, during and after rehearsals. Singers should not touch their face as part of a warm up exercise or singing instruction method (or anytime unnecessarily).
- 11.Sick singers should stay home as should singers who have been around a COVID-19 positive patient. Exposed singers should self-quarantine for two weeks.
CONCLUSIONS
REFERENCES
- High SARS-CoV-2 attack rate following exposure at a choir practice — Skagit County, Washington, March 2020.MMWR Morb Mortal Wkly Rep. 2020; 69https://doi.org/10.15585/mmwr.mm6919e6
A choir decided to go ahead with rehearsal. Now dozens of members have COVID-19 and two are dead. Los Angeles Times. Available at:https://www.latimes.com/world-nation/story/2020-03-29/coronavirus-choir-outbreak. Accessed June 1, 2020.
- Singing and the dissemination of tuberculosis.Am Rev Respir Dis. 1968; 98: 297-300
- Size distribution and sites of origin of droplets expelled from the human respiratory tract during expiratory activities.J Aerosol Sci. 2009; 40: 256-269
- Aerosol emission and superemission during human speech increase with voice loudness.Sci Rep. 2019; 9: 2348
- Modality of human expired aerosol size distributions.J Aerosol Sci. 2011; 42: 839-851
- A Conversation: What Do Science and Data Say About the Near Term Future of Singing.2020 (Available at:)https://www.nats.org/cgi/page.cgi/_article.html/Featured_Stories_/NATS_COVID_Resources_PageDate accessed: June 1, 2020
Enquirer DJH Cincinnati. Will COVID-19 silence singers until there's a vaccine? The Columbus Dispatch. Available at:https://www.dispatch.com/news/20200511/will-covid-19-silence-singers-until-theres-vaccine. Accessed June 1, 2020.
- Evidence based medicine: what it is and what it isn't.BMJ. 1996; 312: 71-72
- A novel coronavirus from patients with pneumonia in China, 2019.N Engl J Med. 2020; 382: 727-733
- Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19).2020: 40 (Available at:) (Accessed June 2, 2020)
- Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1.N Engl J Med. 2020; 382: 1564-1567
- Detection of airborne severe acute respiratory syndrome (SARS) coronavirus and environmental contamination in SARS outbreak units.J Infect Dis. 2005; 191: 1472-1477
- Influenza virus in human exhaled breath: an observational study.PloS One. 2008; 3: e2691
- Infectious virus in exhaled breath of symptomatic seasonal influenza cases from a college community.Proc Natl Acad Sci USA. 2018; 115: 1081-1086
- Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals.Nature. 2020; : 1-4https://doi.org/10.1038/s41586-020-2271-3
- A field indoor air measurement of SARS-CoV-2 in the patient rooms of the largest hospital in Iran.Sci Total Environ. 2020; 725138401
- Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient.JAMA. 2020; 323: 1610-1612
- Transmission of 2019-nCoV infection from an asymptomatic contact in Germany.N Engl J Med. 2020; 382: 970-971
- Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China.Sci China Life Sci. 2020; 63: 706-711
- Temporal dynamics in viral shedding and transmissibility of COVID-19.Nat Med. 2020; 26: 672-675
- Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.JAMA. 2020; 323: 2052-2059
- The coronavirus pandemic and aerosols: Does COVID-19 transmit via expiratory particles?.Aerosol Sci Technol. 2020; 54: 635-638
- Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations.2020 (WHO/2019-nCoV/Sci_Brief/Transmission_modes/2020.1)
Fears AC, Klimstra WB, Duprex P, et al. Comparative dynamic aerosol efficiencies of three emergent coronaviruses and the unusual persistence of SARS-CoV-2 in aerosol suspensions. medRxiv. Published online April 18, 2020:2020.04.13.20063784. doi:10.1101/2020.04.13.20063784
- The size distribution of droplets in the exhaled breath of healthy human subjects.J Aerosol Med. 1997; 10: 105-116
- The size and the duration of air-carriage of respiratory droplets and droplet-nuclei.J Hyg (Lond). 1946; 44: 471-479
Workman AD, Jafari A, Welling DB, et al. Airborne aerosol generation during endonasal procedures in the era of COVID-19: risks and recommendations. Otolaryngol Neck Surg. Published online May 26, 2020:0194599820931805. doi:10.1177/0194599820931805
- Toward understanding the risk of secondary airborne infection: emission of respirable pathogens.J Occup Environ Hyg. 2005; 2: 143-154
- Whisper and phonation: aerodynamic comparisons across adduction and loudness.J Voice Off J Voice Found. 2017; 31: 773.e11-773.e20
- Acoustic interpretation of resonant voice.J Voice Off J Voice Found. 2001; 15: 519-528
- A theoretical study of F0-F1 interaction with application to resonant speaking and singing voice.J Voice Off J Voice Found. 2004; 18: 292-298
- Some phonatory and resonatory characteristics of the rock, pop, soul, and Swedish dance band styles of singing.J Voice. 2011; 25: 532-537
- The effects of amplification on vocal dose in teachers with dysphonia.J Voice. 2019; 33: 73-79
- Voice amplification as a means of reducing vocal load for elementary music teachers.J Voice Off J Voice Found. 2011; 25: 441-446
- Origin of exhaled breath particles from healthy and human rhinovirus-infected subjects.J Aerosol Med Pulm Drug Deliv. 2011; 24: 137-147
CDC. Social Distancing: Keep Your Distance to Slow the Spread. Centers for Disease Control and Prevention. Accessed June 2, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html
- Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis.The Lancet. 2020; 0https://doi.org/10.1016/S0140-6736(20)31142-9
- Physical distancing, face masks, and eye protection for prevention of COVID-19.The Lancet. 2020; 0https://doi.org/10.1016/S0140-6736(20)31183-1
- What settings have been linked to SARS-CoV-2 transmission clusters?.Wellcome Open Res. 2020; 5: 83
Japan's live music clubs emerge as new coronavirus transmission sites. Reuters. Available at: https://www.reuters.com/article/us-health-coronavirus-japan-music-idUSKBN20X0WU. Accessed June 3, 2020.
- Role of ventilation in airborne transmission of infectious agents in the built environment - a multidisciplinary systematic review.Indoor Air. 2007; 17: 2-18
- Natural ventilation for reducing airborne infection in hospitals.Build Environ. 2010; 45: 559-565
- Natural ventilation for the prevention of airborne contagion.PLoS Med. 2007; 4: e68
- Infection Prevention and Control of Epidemic-and Pandemic Prone Acute Respiratory Infections in Health Care.World Health Organization, 2014: 133 (Accessed June 3, 2020. Available at:)
- The inactivating effect of monochromatic ultraviolet radiation on influenza virus.J Bacteriol. 1944; 48: 447-454
- Inactivation of the coronavirus that induces severe acute respiratory syndrome, SARS-CoV.J Virol Methods. 2004; 121: 85-91
- Photochemistry of nucleic acids in cells.J Photochem Photobiol B. 1992; 15: 277-298
- The history of ultraviolet germicidal irradiation for air disinfection.Public Health Rep. 2010; 125: 15-27
- Influenza virus infectivity is retained in aerosols and droplets independent of relative humidity.J Infect Dis. 2018; 218: 739-747
- Estimating the Nationwide Transmission Risk of Measles in US Schools and Impacts of Vaccination and Supplemental Infection Control Strategies.2020https://doi.org/10.21203/rs.3.rs-16529/v1
- Effect of negative air ions on the potential for bacterial contamination of plastic medical equipment.BMC Infect Dis. 2010; 10: 92
- Ionizing air affects influenza virus infectivity and prevents airborne-transmission.Sci Rep. 2015; 5: 11431
- Effects of temperature variation and humidity on the death of COVID-19 in Wuhan, China.Sci Total Environ. 2020; 724138226
- High temperature and high humidity reduce the transmission of COVID-19.ArXiv E-Prints. 2020; (2003:arXiv:2003.05003)
- COVID-19 transmission in Mainland China is associated with temperature and humidity: a time-series analysis.Sci Total Environ. 2020; 728138778
- Airborne spread of infectious agents in the indoor environment.Am J Infect Control. 2016; 44: S102-S108https://doi.org/10.1016/j.ajic.2016.06.003
- Mathematical assessment of the impact of non-pharmaceutical interventions on curtailing the 2019 novel Coronavirus.Math Biosci. 2020; 325108364
Covid-19: Should cloth masks be used by healthcare workers as a last resort? The BMJ. Available at: https://blogs.bmj.com/bmj/2020/04/09/covid-19-should-cloth-masks-be-used-by-healthcare-workers-as-a-last-resort/. Accessed June 2, 2020.
- Respiratory virus shedding in exhaled breath and efficacy of face masks.Nat Med. 2020; 26: 676-680
- Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province, China.JAMA Ophthalmol. 2020; 138: 575-578
Chen M-J, Chang K-J, Hsu C-C, et al. Precaution and prevention of coronavirus disease 2019 (COVID-19) infection in the eye. J Chin Med Assoc JCMA. doi:10.1097/JCMA.0000000000000334
CDC. Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19). Centers for Disease Control and Prevention. Accessed June 3, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. doi:10.1001/jama.2020.2648
- Covid-19 — navigating the uncharted.N Engl J Med. 2020; 382: 1268-1269
- Obesity and its implications for COVID-19 mortality.Obesity. 2020; 28 (1005-1005)
Price-Haywood EG, Burton J, Fort D, et al. Hospitalization and mortality among black patients and white patients with Covid-19. N Engl J Med. doi:10.1056/NEJMsa2011686
- Covid-19 by race and ethnicity: a national cohort study of 6 Million United States Veterans.MedRxiv Prepr Serv Health Sci. May 18, 2020; (Published online)https://doi.org/10.1101/2020.05.12.20099135
Stevis-Gridneff M, Jakes L. World leaders join to pledge $8 billion for vaccine as U.S. Goes It Alone. The New York Times. Available at: https://www.nytimes.com/2020/05/04/world/europe/eu-coronavirus-vaccine.html. Accessed June 3, 2020.
Centers for Disease Control and Prevention. Appendices in the guideline for disinfection and sterilization in healthcare facilities (2008). Published July 22, 2019. Accessed June 15, 2020. Available at:https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html
Howell I, Gautereaux K, Glasner J, et al. Preliminary Report: Comparing the Audio Quality of Classical Music Lessons Over Zoom, Microsoft Teams, VoiceLessonsApp, and Apple FaceTime. Ian Howell, DMA
Source-Connect Now / Source Elements. Available at: https://now.source-elements.com/#!/. Accessed June 20, 2020.
SoundJack: Real Time Online Music. Ian Howell, DMA. Available at:https://www.ianhowellcountertenor.com/soundjack-real-time-online-music. Accessed June 20, 2020.
Setting up a realtime physically distant rehearsal. Art Song Central. Available at: https://artsongcentral.com/2020/setting-up-a-realtime-physically-distant-rehearsal/. Accessed June 20, 2020.