David Meyer, Michael M. Johns, Adam D. Rubin, Aaron M. Johnson, Robert T. Sataloff, Jonathan M. Bock, Herbert Steven Sims, Matthew R. Naunheim, Philip A. Doucette, Ian Howell, Trineice Robinson-Martin, Priya Krishna, Matthew Hoch, Claudio F. Milstein, Michael J. Pitman, John Nix, Ingo R. Titze, and Thomas L. Carroll
While the novel coronavirus outbreak has profoundly altered health care systems across the globe, it has also affected similar change and devastation on the social, educational, and cultural communities upon which many rely, including communities of choral singers, solo performers, conductors, voice teachers, and the professionals that collaborate with them. Even as citizens of the most heavily impacted countries took to their balconies to serenade first responders and health care workers, singers of most genres who typically perform in ensembles have been told to not carry on their beloved practice. This message, promoted by the lay media and by early reports of “super-spreading” of the virus at choral events in the United States and abroad,1 , 2 has been reinforced by expert and nonexpert opinion regarding the transmissibility of SARS-CoV-2 through droplets and aerosols, the generation of respiratory particles when singing, and concern about the interpersonal interactions that routinely accompany vocal performance, both in groups and in one-on-one teaching situations. Unfortunately, there is a paucity of data about both how SARS-CoV-2 is transmitted by singing and how to bring communities of singers back together safely. The data available about disease spread through vocalization, most of which preceded the current pandemic, address primarily transmission of disease through droplets and aerosols and are specific neither to this virus nor to singing.3, 4, 5, 6 Specifically, there is a lack of data addressing how to congregate and sing safely in choral environments such as churches, concert halls and practice spaces, as well as stages, theatres and other venues. In addition, protective measures such as safest distancing between singers, wearing masks or other personal protective equipment (PPE), using larger rehearsal or performance spaces, reducing the number of singers inside a certain enclosed space, reducing the duration of rehearsals or performances, and using real time air and surface cleaning methods such as increased ventilation, UV-C light and HEPA filtration specific to a singing environment among other topics have not been studied well enough to provide evidence on which to base advice to the singing community. Opinion on these matters is plentiful and often divergent. A recent webinar with a panel of experts in the world of voice care and singing left the audience with the message, “There is no safe way for singers to rehearse together until there is a COVID-19 vaccine and a 95% effective treatment in place.”7 , 8 Although, this may ultimately prove to be accurate, evidence-based practice (defined as an approach to health that integrates scientific research, patient preferences and values, and clinical expertise to make the best recommendations possible) does not allow for such a definitive conclusion to be made at this time.9 It must be understood, that these recommendations and decisions are made not only on what scientific information is available but on intuition and unsystematic experience that is often biased and inaccurate. We do not understand all the risks posed by COVID 19 to ourselves, friends, family and colleagues, who wish to resume educational, performance, communal and congregational singing safely. Evidence-based practice demands that we critically evaluate our current state of knowledge to come up with the best possible information to disseminate. In this article, we review the information that exists relating to singing and COVID-19. This paper is intended to provide guidance based on what we know: the best available data, analyzed and scrutinized by a panel of experts in the medical, behavioral and basic science world of voice care, of whom many are professional singers, choir directors or teachers of singing. While it may not be able to afford any definitive answers, this work will offer suggestions of best practices for those singing groups that are willing to mitigate risk knowing that the risk cannot be brought to zero. Finally, this report will hopefully stimulate the larger voice research community to study the emerging consensus on safe resumption of singing and pursue scientific understanding of COVID-19.