Risk assessment of a coronavirus infection in the field of music

second update from May 19, 2020

Prof. Dr. med. Dr. phil. Claudia Spahn, Prof. Dr. med. Bernhard Richter

Head of the Freiburg Institute for Musicians' Medicine (FIM), University Hospital and

University of Music Freiburg

With the cooperation of the following colleagues and departments at the university hospital

Freiburg:Dipl.-Biol. Armin Schuster, Technical Hospital Hygiene (Institute for

Infection prevention and hospital hygiene, head Prof. Dr. med. H. Grundmann)

Prof. Dr. med. Hartmut Hengel (Medical Director of the Institute of Virology)

Prof. Dr. med. Hartmut Bürkle (Medical Director of the Clinic for Anaesthesiology and

Intensive care)

Preamble

Since the first risk assessment published on April 25, 2020, more have been done

Questions - due to the dynamic situation of the corona pandemic - raised. With the gradual loosening of the so-called lockdown since 6.05.20 - depending on the The state is sometimes very different - the questions from the area the professional music and the lay music more and more pressing, how and when musical activities can be continued. These concern the Church chant in worship as well as organized forms of singing and Making music in amateur music as well as the professional music practice of Orchestras, choirs, bands and ensembles in theaters, concert halls and opera houses as well as at other venues.

There are common and similar questions regarding the musical genres. A singing and instrumental lessons are particularly important Conservatoires, music schools and other educational institutions too. With the expansion of the number of people, which according to the framework in some Federal states are allowed to assemble, group formations now make music

into focus in orchestra, big band and choir. This increases the complexity of the discussing questions. Especially for the professional musicians questions about comparability with other work situations, for example to what extent the risk of infection when working in an open-plan office differs from that Rehearsal work of an orchestra differs. The in individual federal states in

The prospective readmission of the audience also announces further questions. Basically, musicians apply nationwide and in the individual Federal regulations (assemblies, contacts, minimum distance and Oral Nose Protection (MNS)), which is specified in the ministries and with the Health departments (as well as possible other competent authorities and the institutions

statutory accident insurance).

Here it represents a big one Challenge, appropriate recommendations for specific and different situations in professional and amateur music as well as into develop classical and popular music. In this context professional assessments, such as this one, information for decisions to act deliver which elsewhere - at the political and institutional level - must be taken.

First scientific studies and technical discussions under Experts have emerged in the past few weeks. Also lie of different ones Present current risk assessments for musicians and singers

(including Charité (Mürbe et al. and Willich et al.), DGfMM (Firle et al.), by Kähler

& Hain, as well as the German Health and Prophylaxis Working Group Orchestra Association (DOV) with commentary by the Association of German Companies and Company doctors VDBW AG stages and orchestra (Böckelmann et al.). We as authors strive to be scientific in this paper Results as completely as possible according to the current status in our assessment

to involve. The goal remains to use the latest assessments adapt scientific results and build consensus on them. We include the results of the investigation in our risk assessment Wind players and singers initiated by the Bamberg Symphony Orchestra and was carried out on 5.5.2020 and in which the authors of the FIM were involved. The company Tintschl BioEnergie- und Strömungstechnik AG was responsible for the measurements instructed. All wind instruments, recorder and Saxophone and singers (classical singing and popular singing styles) in the Investigation included. There were both qualitative experiments Flow visualization as well as quantitative measurements of air velocities in performed at different intervals. The presentation of the measurement results as well their discussion will be published in a further update.

In areas where there is no scientific knowledge yet, the statements continue to provide technical assessments from the perspective of the authors This paper is therefore still a snapshot, the in the further course according to the current state of existing regulations and new scientific knowledge will be reviewed and adjusted. In order to increase the quality and reliability of the present risk assessment, we have an interdisciplinary working group at Freiburg University Hospital Colleagues from the Institute for Infection Prevention and Hospital Hygiene (Head Prof.

Dr. med. H. Grundmann), Prof. Dr. med. Hartmut Hengel (Medical Director of the Institute of Virology) and Prof. Dr. med. Hartmut Bürkle (Medical Director of the Clinic for Anaesthesiology and Intensive Care Medicine). The colleagues mentioned have helped shape this paper from their respective specialist perspective and checked.

Since the outbreak of the corona pandemic, we have all had increasing experience regarding the epidemiologically important factors in the spread of SARSCoV-2. The Robert Koch Institute and politics in Germany have from the beginning made it clear that the goal of the measures to be taken is the slowdown and curbing the spread of infection. Is guiding with the measures

to reduce the risk of infection with SARS-CoV-2 as much as possible. Also a risk assessment regarding specific questions regarding music practice In our view, should therefore be based on the additional risk posed by the practice of music arises. This orientation towards existing general standards seems important to us to enable policymakers to derive appropriate recommendations for action in the music field. The risk assessment presented here follows the concept of risk management with the aim of identifying specific risks in the field of music and

to offer risk-reducing measures at the same time. This could make it flexible concepts of one adapted to the respective musicians and music situations Risk management developed and the issues related to the Practicing music appropriately integrated into the overall social framework

Will. In the sense of a flexible risk adaptation, one could also between in the future Differentiate between infection and disease risk and differentiated Precautions according to the disposition of the musicians (Previous illnesses, age, etc.). The local and temporal epidemiological situation (e.g. in a city or Community) could be responsible for strategies to prevent infection when shared Get attention with music. For example, the collective risk of a choir rehearsal

in the future using a COVID-19 tracing app - which is currently still under development -, better assess. Even if there are currently no sufficient basics and tools for one such differentiated risk adaptation across society and in In the present paper, the authors try to take a first step on the way there.

Basic information

The main transmission of viruses that cause respiratory infections generally occurs through droplets and aerosols that are used when coughing and sneezing arise and in the opposite over the mucous membranes of the nose, mouth and deep respiratory tract when inhaled and possibly via the conjunctiva of the eye be included. In this context, droplets are larger particles

to understand (diameter of more than 5 microns). Sometimes they can be that big be visible in the coughing or sneezing process and felt on the skin. A Aerosol (artificial word from ancient Greek ἀήρ, German 'air' and Latin solutio 'Solution') is a heterogeneous mixture of very small particles in a gas (Diameter of less than 5 microns) that cannot be done without technical aids

are visible. A Finnish group from Aalto University in Helsinki around Ville Vuorinen conducted a computer simulation of the spread of aerosols in one closed space (supermarket) by (Vuorinen et al. 2020). If an infected If a person coughs viruses when coughing, the simulation assumes that the viruses are still detectable in the air after several minutes, even if the sick person has already left. Other people can then Breathe in airborne viruses. The viruses also get onto surfaces, of which they mainly come through Touch these contaminated surfaces with your hands, which then clean the Touching the face, can be transferred - provided that they are yours by this time Have kept the ability to infect (contact transfer).

The transmission paths are shown schematically in Figure 1.

Risk assessment from April 25, 2020 a distance between singers and brass players from 3 to

5 m1 and the administrative professional association (VBG) demands since the sample operation April 27 even a safety distance of 6 m for singing or excessively speaking

and with wind instruments of at least 12 m in the blowing direction. The Robert Koch Institute (RKI) said in a press conference on April 28 that she was singing Flying droplets particularly far. But these distances are appropriate and correct the statement from the RKI?

Experiments

Prof. Dr. Christian Kähler and his assistant Dr. Rainer Hain have to clarify the questions

detailed experimental investigations with a professional singer and Lecturer at the Mozarteum in Salzburg (Marion Spingler), two amateur choirs, five professional musicians from the orchestra of the State Theater on Gärtnerplatz in Munich (Michael Meinel (clarinet), Uta Sasgen (flute), Ursula Ens (oboe), Cornelius Rinderle (Bassoon), Michael Herdemerten (trumpet)) and a lay brass player (Max Schaefer (Trumpet, trombone, euphonium)) at the Bundeswehr University in Munich carried out. The aim of the investigation was to measure both the spit-like (ballistic)

Spread of larger droplets as well as the flow-related spread of small ones Determine droplets (aerosol) while making music. For this purpose the from the Mouth and droplets of saliva escaping from the wind instruments and those when exhaling Moved air is illuminated with a laser and with special digital cameras recorded. The evaluation of the recorded image series was carried out with a Computer program implemented to quantitatively determine the movement of the droplets and the air determine and determine the area that can be contaminated by the droplets.

At what distance does singing become dangerous? The experiments of Prof. Kähler and Dr. Hain clearly show that the air when singing only is set in motion in the immediate vicinity of the mouth, see https://youtu.be/0JmcjRhV-rs. With the professional singer, the experiments have shown that there is almost no air movement at a distance of around 0.5 m,

regardless of how loud the tone was and what pitch was sung. A Virus spread through the air flow generated during singing is therefore above this limit beyond that extremely unlikely. Amateur musicians who usually do not sing that of professionals used diaphragmatic breathing, but rather use natural breast breathing not even beyond this area.

1. Transmission paths of SARS-CoV-2

Basic information

The viruses also get onto surfaces, of which they mainly come through Touch these contaminated surfaces with your hands, which then clean the Touching the face, can be transferred - provided that they are yours by this Have kept the ability to infect (contact transfer).

Specific information about SARS-CoV-2

The spread of the corona virus (scientific name: SARS-CoV-2) as According to current knowledge, the cause of the COVID-19 disease can be found droplet infection or via aerosols (Meselson et al. 2020). According to the Robert Koch Institute on April 17, 2020, three studies were conducted Aerosols containing coronavirus RNA in air samples of patient's exhaled air

or detected in the room air in patient rooms (Leung et al. 2020; Chia et al. 2020; Santarpia et al. 2020). Contact transmission of the virus is also possible. A transmission through

contaminated surfaces is particularly in the immediate vicinity of the Infected people cannot be ruled out (ECDC 2020) because SARS-CoV-2 is capable of reproduction Pathogens can be detected in the environment under certain circumstances (van Doremalen et al. 2020). To what extent here is an infection through the eyes is probable, cannot yet be conclusively assessed (Zhou et al. 2020). In addition to the air we breathe, saliva and other relevant infectious materials are To name respiratory secretions. In direct patient care, it was found that an above-average number of ear, nose and throat doctors and Anesthesiologists / intensive care physicians and nurses in these areas COVID-19 suffer from endoscopic examinations and interventions of the Carry out oral and pharynx and possibly intensive contact with everyone

had these three forms of transmission (German ENT Society 2020;

Ruthberg et al. 2020).

2. Specific risk aspects in the field of music

2.1 Systemic options for risk reduction in the music field Before a song and instrument specific as well as setting specific Risk assessment takes place, should systemic ways of risk reduction

preceded that can be applied in the music field. These are playing from our point of view especially for formations with a larger number of people (choir, Orchestra, Big Band) play a crucial role. The following Figure 2 gives an overview of possible measures for

Risk reduction. We see measures in three areas as meaningful here:

a.) In-coming control

b.) Air / room / duration parameters

c.) Individual protective measures

The areas a.) And c.) Can be behavior prevention, the area b.) assign to ratio prevention.

a.) In-coming control

An in-coming control can be the collection and intensive control of several relevant features include:

• An increased health hazard may appear after the list of previous illnesses RKI can be assessed (RKI list of risk groups for severe courses1).

• The assessment of the risk of being a virus carrier based on a personal Contact analysis for the previous 5-6 days and the clarification whether symptoms suspected of COVID19 are present can be carried out using standardized questions (as Questionnaire or App2) regulate access to rehearsals / lessons / concerts and the Self-protection and external protection will increasingly improve in the future.

• Musicians in all areas of music should pay strict attention to non-specific ones Disease symptoms such as fever plus respiratory problems (dry cough, Catarrh) or with more typical symptoms such as acute loss of smell and Avoid any contact with other musicians until by SARS-CoV-2 PCR examination of the nasopharyngeal smearInfection was excluded.

In case of proven infection, entry from another country or contact with a corona-infected person must comply with the currently valid quarantine rules be respected. In the event of symptoms, you should definitely contact your family doctor be included. In the case of music lessons for children and adolescents The legal guardians should also be given intensive information that they are their children at the first signs of suspected corona or mild Don't send symptoms to class. Students should also be on this Circumstance. This also applies analogously to educators, who should not be teaching in these circumstances. For older or through People at risk of previous illnesses (see risk list of the RKI) also currently apply Particularly strict precautionary measures in the area of active music practice.

• Another possible measure that is financially favorable and practical is the Temperature measurement as an additional screening before making music with others. A majority of COVID-19 sufferers showed at the University Hospital Freiburg an elevated temperature associated with acute respiratory problems. From Robert Koch Institute, on the other hand, uses temperature measurement as a screening method in the input screening e.g. No longer recommended at airports as only 42% of the Infected people in Germany had an elevated temperature (> 37.5 °) (Epidemiological bulletin RKI 20/2020).

Asymptomatic, fever-free virus eliminators cannot be measured using temperature measurement. Both a standardized survey and fever measurement could Improve musicians' attention to the hazard aspects and increase compliance when implementing protective measures. The standardized survey is also part of the hygiene concept for elective Treatment of outpatients since the gradual opening of the clinics from 4.05.2020, as it is carried out at the University Hospital Freiburg. These simple ones Measures are practicable in terms of effort and are very well received. For the professional music sector (operas, concerts, theater) could use it

In addition, detailed hygiene concepts are used, depending on the facility should be developed and checked by the company doctors (Böckelmann et al.2020). These concepts could be based on existing concepts in professional sports lean on.

b.) Room / air / duration parameters

The epidemiological findings from the course of the SARSCoV-2 pandemic already show that room and air conditions and the duration of the exposure contribute the risk of infection is probably decisive for the accumulation of people influence (Leung et al. 2020; Chia et al. 2020; Santarpia et al. 2020; Liu et al. 2020).

Singing and playing music outdoors

Infections are likely to occur primarily in people who have been in for a long time in closed rooms. In a study by Qian et al. in January and February 2020 to a total of 7,324 cases of infected people in China Authors found that only in one case was evidence of an infection outdoors existed (Qian et al. 2020). It is suspected that aerosols are faster outdoors

distribute, the inactivation process of the pathogens is greatly accelerated (UV, ozone,

Hydroxyl radicals, nitrogen oxides) and therefore the overall effect Infection risk is much less. If the minimum distance is observed, the risk for singing and playing music outdoors can therefore be assessed as very low.

The open air situation is therefore the first for making music with several people

Choice. Especially with a view to the coming weeks and months, in which the gradual opening will take place, which are summer months, that appears

Playing music outdoors is practicable and even particularly attractive. There is one here

long cultural tradition, just think of the ancient amphitheater. The term choir (ancient Greek χορός choros) originally referred to the dance floor of one Amphitheater where people also sang. Brass music in rural areas too traditionally takes place outdoors. In the pop and rock area there are concerts in the Free the prevailing setting. For the audience, the ruling

Assembly rules are observed or creative solutions (e.g. so-called concert promenades, i.e. change concerts) are found.

Singing and making music in closed rooms

• Ventilation: Finds singing and playing music in closed rooms natural ventilation instead, regular experience seems to be the experience and thorough ventilation is an important factor in reducing risk. So much for the rooms have mechanical ventilation (ventilation and air conditioning systems, HVAC), is a reduced risk of infection from aerosols (aerosols are used in

natural ventilation via the air change in the range of approx. 0.5–2 / h even with closed windows removed, for air conditioning systems e.g. in concert halls or halls the air exchange rate is approx. 4-8 / h).

• Room size: The size of the room and the number of rooms in the room Persons as well as the length of time in which the persons are in a closed Space seem to play an important role (Tellier 2006). A bigger one Number of people who have been in confined and poorly ventilated for a long time Spaces held up in the outbreaks in Ischgl and Heinsberg To have favored spread.

In relation to making music together, very large spaces such as Church rooms, concert halls or city halls can also be used as rehearsal rooms.

• Rehearsal period: In addition to the sufficient room size, short rehearsal phases also have an effect (e.g. 15 minutes, see also Robert Koch Institute, as of April 16, 2020 Contact person tracking for respiratory diseases through the Coronavirus SARS-CoV-2) with pauses during which ventilation is carried out, probably reducing risk.

c.) Individual protective measures

• Mouth and nose protection: Wearing a mouth and nose protection (MNS) (or one Mouth-nose covering) from our point of view, especially in the field of music is an important way to reduce risk. about that it is used, although e.g. when singing or playing a string, pluck or keyboard instrument can be spontaneously felt as inappropriate or annoying. When wearing MNS or masks (filtering half masks) is made infectiological point of view differentiated whether a protection of a person from a Infection by droplets or other people's aerosols is sought

(Self protection) or whether the spread of infectious material by a person to others (third party protection) is the goal. The material of the medical face masks, type II (according to DIN EN 14683: 2019-6), which are currently readily available as MNS, absorbs ≥92% of the particles ≥3 µmDiameter. Thus, they represent a sensible measure for external protection, but also offer relevant self-protection (according to ICT measurements, they last e.g. Particles ≥0.5 µm back to approx. 80–90% and particles ≥0.3 µm to approx. 70–80%).

The correct mask fit also plays an important role here, especially with the forced exhalation, an exit from the side of the masks Air particles can occur (Mittal et al. 2020). In recent studies it was shown that wearing such masks will prevent the spread of droplets and Can effectively reduce aerosols (Leung et al. 2020).

• Distance rule: Compliance with the distance rule also appears in the music operation is very important to us to protect against droplet contamination. Because their compliance requires great attention, physical closeness and social attachment intuitive part in music situations, and because singing and making music is not enough out of a rigid body position, but a certain movement in the Require space, in our view, the distance between people should be 2 meters.

By maintaining a radial distance of 2 meters for an individual is at a number of several people in a closed room at the same time As a positive additional effect, this rule only works in small rooms fewer musicians can stop. For larger formations, the Compliance with this rule requires a larger room size. This can be a radial minimum distance of 2 meters help not only to reduce the risk of Transmission through droplets, but also increased risk Accumulation of aerosols indoors could be reduced. The Compliance with the distance rule does not replace regular ventilation and temporal reduction of the sample duration.

• Specific measures: fall within the scope of individual protective measures further specific aspects for individual instruments (e.g. spit protection and Partitions between singers and accompanists)

2.2 Vocal and instrument-specific risk assessment

2.2.1 vocals

General risk assessment of singing

As already described, the transmission paths of SARS-CoV-2 are between the risk of infection from virus-containing droplets and virus-containing aerosols differentiate. In addition, there are the important transmission paths via hand / nose / Mouth contact and if necessary hand / eye contact.

Droplets: Droplets quickly sink to the bottom due to their size and weight

and reach a maximum distance of 1 meter. This is the basis of the Distance rule of 1.5 meters in everyday situations (shops, offices, etc.).

Is there an increased risk of droplet infection when singing? In voice physiology it has long been described that in phonation (Sound production when singing) before the mouth opening of the singing no essential Additional air movement occurs because sound waves are physically flowless spread: The flame of a burning candle does not move in front of the mouth of one

Singer, even if he sings loudly. This observation was made possible by the measurements at the Bamberg Symphony Orchestra three singers to be confirmed again. The one right in front of the singer's mouth and the one Art nebulae led by singers was singing in different ways Pitch and volume and vocal styles not visibly distracted. At a forced articulation with plosive sounds were slight swirls in the close range to observe. When measuring air speed by sensors at a distance

However, no air movement could be measured from 2 meters from the singing. This distance of 2 meters can be used as a safety distance for the Droplet infection can also be viewed with forced articulation.

Aerosols: Infectious agents that can reproduce are transformed into aerosols in the respiratory tract integrated, e.g. the chickenpox virus, influenza viruses, measles virus, mycobacterium

tuberculosis and obviously also SARS-CoV-2. It has been shown that aerosol formation increases with increasing volume when speaking increases (Asadi et al. 2019). So far there are no aerosols in singing scientific investigations. When aerosols emerge from the Mouth opening is expected to be due to the lower specific density (approx. 37 ° C and> 95% relative humidity) rise first, and then with the Mix room air. The sedimentation plays with aerosols below one

Particle size of approx. 4 µm practically no longer matters. Is there an increased danger from aerosols when singing? Basically, it must be assumed that when singing as well as when

Breathing or aerosols can occur when talking, which transmit viruses can (Fabian et al. 2019). Overall, the measurement of aerosols is one metrological challenge.

inhalation

To what extent there is an increased risk of infection from singing through deep inhalation has not yet been scientifically investigated.Slime production For singers, it can also be significant outside of sound production Slime productions are coming. On the one hand, it is not uncommon for Singing in to observe that more mucus is produced, which then by Coughing or clearing of the throat is removed from the respiratory system. Likewise it can prolonged play due to overloading the respiratory tract Mucus formation come.

Conclusion General risk assessment with regard to the singing process Based on the relationships and results presented, we assume that by singing about droplet transfer while maintaining a distance there is no increased risk of 2 meters. Based on the latest measurement results it does not appear necessary to overfill the distance with 3-5 meters as we are in the first risk assessment dated April 25, 2020. To what extent aerosol formation and spread, specifically changed by singing

Singing process is currently difficult to assess. It is also still unclear what influence deep breathing during singing has on a possible infection. As a consequence of the existing knowledge, we believe it is necessary To propose protective measures. These are in the individual forms and Settings in which singing occurs are described.

Forms of singing

Individual singing lessons With solo singing there is a deep inhalation and exhalation with the

Sound production. The extent to which this increases the risk of infection remains to be seen

as far as we know, has not yet been scientifically examined. Even if in the singing phonation the direct airflow is not strong like our newest Measurements can be assumed, it is to be assumed that a spread of Viruses are caused by aerosols. In solo singing, in the formation of

Consonant spit particles, i.e. droplets, expelled. The short range this droplet has been described above.

A direct transfer by droplets can also be done by setting up Reduce plastic partitions. This could already be done in some institutions existing soundproofing screens can be used as makeshift barriers. In addition, it makes sense to us that educators during the One-to-one tuition wear additional mouth-nose protection (MNS) when the Students sing. If protective masks for the non-medical area are available, wearing an FFP-2 mask can pose a possible risk of infection in the Also reduce the sense of self-protection.

In strict compliance with the safety measures (according to the latest measurements in particular a distance of 2 meters (see above)) and the presence of the space requirements (sufficient room size, ventilation breaks every 15 Minutes and especially between the individual students) can be left out in our view, reduce the risks in individual lessons. However, it cannot be derived from this updated risk assessment that Teachers or teaching staff may be required to take private lessons as Give or participate in face-to-face classes. If the structural and

organizational requirements are not met or the people involved belong to a risk group, in our opinion, the lessons should not be considered Presence teaching, but done digitally.

Choir singing

When choral singing, there are basically the characteristics of the above Singing process. Because of the formation of aerosols by every singer it must be assumed that there is a

Larger number of people in higher indoor areas containing virus-containing aerosols

Accumulate concentration (Liu et al. 2020). The ventilation quality also plays a role here

an important role (Li et al., 2020). Also the question of the duration, i.e. how long one

Choir rehearsal, plays for the expected particle concentration in a room

Aerosols play a role: in longer periods the particle concentration can increase

Values increase than in shorter ones.

About the spread of SARS-CoV-2 infections after choir samples different

Choirs and services are reported several times. On May 12th was for one of these

Outbreaks in a choir in the United States (Skagit County, Washington) in one scientific publication reports (Hamner et al. 2020). The message about a The choir sent a high infection rate to the health authorities on 03/17/2020. The choir rehearsal, which presumably leads to infection with a high Infection rate occurred, took place on March 10th, 2020. Of the 61 choir members, the on the rehearsal on 10.03. participated, 53 fell ill, three had to be treated in hospital two died. The median age of the singers was 69 years (range = 31–

83), the three hospitalized had two or more known Pre-existing illness. The contagion via aerosols is considered one in the publication probable source of infection discussed. However, others will too Influencing factors critically examined. The distances between each Singers were small with 6-10 inches (about 15-25 cm) between the chairs. The duration of the entire rehearsal was approx. There was a break snack of 15 Minutes. It also had the putative index person as the primary source of infection on March 10th is considered, at the time of this sample visit since March 7th. Symptoms, the person also had on 3.03. participated in the rehearsal. To reduce the risk of infection from aerosols in the choir situation, you can on the one hand, mouth and nose protection are worn, as already stated above. On the other hand, singing appears in very large rooms, such as concert halls or church rooms, as very cheap. Regular ventilation of the room approx. every 15 minutes or the use of rooms with an HVAC system are important Risk reduction measures. It appears with regard to risk minimization best if you can sing outdoors (see also systemic Risk reduction).

Furthermore, in rehearsal practice, a division of the probationary periods into short one Contribute 15 minute intervals to minimize risk. To switch off a droplet transmission, the chorus must also be in the breaks The usual distance rule of social distancing is observed, also to protect against Droplet transmission should be carried on MNS. In our view, special care must also be taken to ensure that it is in Pause situations not to hand contacts or contacts via surfaces (e.g. through Passing on of notes etc.) comes. Regular hand washing is thorough

very important, especially touching the face and rubbing the eyes should be avoided.

A general further risk reduction is personal in-coming control (see above). Sneezing and coughing should be avoided as far as possible and intercepted in the crook of the elbow

will.

Singing in the service Community chant appears when the distance rule of 2 meters and stretcher are observed possible from MNS, since it can be assumed that by singing

there is no increased risk of infection compared to speaking. Also find Services usually take place in large to very large rooms.

2.2.2 BLOW INSTRUMENT GAME

Risk assessment regarding the wind instrument play

With the exception of flute instruments (recorder and flute) occurs in experienced Wind instrument players at the contact between the mouth of the player and the the respective mouthpiece (bowl, single and double reed) no air. At some wind instruments emit air from the keys at certain tones, Wind instruments have a sound opening e.g. in the form of a funnel. The Wind instruments are to be considered individually because of their peculiarities. As a commonality - apart from the flutes - it can be said that the sound is through Vibrations of the lips of the mouth (brass instruments) arise or through Tubes or leaves in the mouthpiece (reed instruments under the Woodwind instruments) is interrupted. Comparable to streaming just like

small amounts of air per unit time from the instrument's horn Wind players. The current measurements with the Bamberg Symphony Orchestra Dipl. Ing. Schubert from Tintschl support these assumptions.

Due to the transmission paths of SARS-CoV-2 described above, between the potential risk of infection from virus-containing droplets and virus-containing droplets Differentiate aerosols when blowing. There are also the important ones Transmission paths via hand contact and hand / eye contact.

Droplets: Droplets quickly sink to the bottom due to their size and weight and reach a maximum distance of 1 meter. This is the basis of the Distance rule of 1.5 meters in everyday situations (shops, offices, etc.). There is an increased risk when playing a wind instrument

Droplet infection?

Because of the contact between the player and the respective mouthpiece in the Brass instruments and woodwind instruments with a simple reed (Clarinet and saxophone) and double reed (oboe, bassoon) with mastery

No air leaks from the instrument can escape from the player’s mouth while playing no droplets are released directly into the environment. It is different with the Flute instruments (flute, recorder). Especially when it comes to the flute Blow air directly from the mouth of the player into the mouthpiece Environment and droplets can be released. The measurements at the Bamberg symphonists show that in terms of the parameter Air speed at the sensors that are in 2 meters in extension of the Mouthpiece were placed, no more air movement could be measured. Thus, at this distance, droplet infection transmission is very highly unlikely. On the recorder, the lips surround the flute’s beak, so that no droplets can get into the surroundings. Droplets could on the other hand, when the air flow is broken at the labium of the head piece. At Measurements by the Bamberg Symphony Orchestra included air movements No more playing the recorder in the labium area at a distance of 1.5 meters measurable. Thus, at this distance, droplet infection transmission is very highly unlikely.

Condensed water: Condensed water arises from the fact that warm, moist breathing air in the

Instrument whose inner walls are significantly colder than water drops condensed. At Any aerosols contained in this process are greatly reduced (air washer principle). If it is the breath of a virus carrier, the question arises whether and to what extent this condensed water, which in brass instruments in Play breaks must be drained, contains viruses and is therefore potentially infectious. Measurements regarding the viral load in the condensed water are still pending.

Aerosols: When aerosols emerge from the mouth opening, they rise because of their low specific weight of exhaled air upwards. They spread in Space, whereby sedimentation no longer plays a practical role. A reduction can only be due to the dilution with the existing in the respective room Air volume and through the given air change.

Is there an increased risk of aerosols when playing wind instruments?

Aerosols do not reach directly when playing wind instruments - except for the flute from the mouth opening into the room air. You get into the instrument body and through open flaps and / or the bell into the environment. Here are the to differentiate possible exit points of the wind instruments. At Brass instruments exhale air through the bell. At Woodwind instruments are only all at the lowest tone of the respective instrument Side holes closed, so that only in this case the air from the bell exit. Exceptions are the oboe and the cor anglais, which also include the deepest tone of the instrument still exits air through the last open side hole.

In addition, woodwind instruments change depending on the pitch played the air outlet through the first open side hole. Even when playing the flute and recorder, aerosol formation occurs exclusively in the Respiratory tract. With the flute, the air flow is too exhaled to compare. The air flow is deflected here in the sense of the Coanda effect. In the Recorder enclose the lips of the flute's beak and the airflow is at Broken labium of the headpiece.

It is physically assumed that it is in every wind instrument Surface contact with aerosol particles, where they are adsorbed, i.e. that the instruments basically give the particle concentration of the given Reduce aerosols. The longer the airway in the instrument, the greater the effect

is, the smaller the cross sections and the more curvatures are present. The Effect affects all particle sizes, but it is higher for larger particles than for smaller ones Particles, e.g. Viruses. As described above, the question arises to what extent thatThe instrument also acts as a filter for aerosols (due to condensation of Humidity and as a result of surface contact). Measurements are still pending. 25th As long as no clear results As long as no clear results are available, some authors recommend (see Kähler & Grove; Willich et al.) Either provide protection for brass instruments transparent material or tightly woven silk scarves (also pop protection) in front of the

Use the horns of the instruments. This could be pending further clarification cause a reduction of possibly escaping aerosols. A Plating over the bell in woodwinds seems from the above reasons mentioned less effective. To what extent there is an increased risk of infection due to deep inhalation when blowing has not yet been scientifically investigated.

From the recipient side, the question arises as to what extent virus-containing aerosols pass through the deep and often rapid inhalation when playing wind instruments in higher quantities and viruses are absorbed in higher concentrations in the respiratory system reach. No scientific studies have been carried out here to date. For brass players, it can also be significant outside of sound production Slime productions are coming. On the one hand it is not uncommon when importing observe that more mucus is produced, which is then caused by coughing or

Clearing the throat from the respiratory system. Likewise it can with longer Play by overloading the respiratory tract to increase mucus formation come.

Conclusion General risk assessment of wind instruments To the best of our knowledge, there are currently no wind players Measurements of the virus concentration in the exhaust air. However, it is known that the wind instrument play an intensive exchange of air in the lungs and

Airways with sometimes high air pressures required. To what extent the Viral load reduced by the airway in the instrument is currently unclear. Because of The latest measurement results do not appear to require a distance of 3-5 meters to exceed, as we still in the first risk assessment of April 25, 2020 had formulated. 2 meters seem to be sufficient as a minimum distance, because in this Do not remove any additional indoor air movement during the measurements by playing was determined and thus the risk of droplet infection if this was observed Distance is classified as very small. Blowers also cause condensation to form in the exhaled air

Instrument which is to be regarded as further potentially virus-spreading material. Here we recommend avoiding condensation on floors and Dispose of in a container or absorbent blotting paper. Furthermore wind players should not blow through the instruments for cleaning. The

Wind instruments should, if possible, be kept in separate rooms

outside of the teaching or music settings. When contacting Condensation or with the interior of the instrument (e.g. horn) is particularly important thorough hand hygiene (at least 30 seconds hand cleaning, i.e. verywash hands thoroughly with soap or, if necessary, use a Hand disinfectant).

Forms of wind instrument playing Individual lessons with wind players

In our opinion, the risk basically appears to be that of singers in the Individual tuition (see above) comparable. In addition, it makes sense to us that educators and students Mouth and nose protection (MNS) should be worn during individual classes if they are not play. Here is the correct handling of the masks according to the hygiene rules respect, think highly of. If protective masks are available for the non-medical area, wearing an FFP-2 mask could further increase the risk of infection to reduce.

Wind ensembles

Wind ensembles can have different numbers of players depending on the formation exhibit. The number of contributors must always be the currently valid one Comply with regulations. Smaller ensembles should also use the latest Measurements a minimum distance of 2 meters are observed, as in this Do not remove any additional indoor air movement during the measurements by playing was found. Rehearsal rooms should be as large as possible and it should be thorough and be ventilated regularly.

Since compliance with the distance rule is a very important measure (see section 2 c.)), Can make music in large rooms - in addition to concert halls is also on here To think church rooms - reduce the risk even more. In the summer Season we see an important way to play outdoors. For that there is a great tradition in the field of brass music. It can be assumed that aerosols spread faster outdoors Inactivation process of the pathogen is accelerated (UV, ozone, hydroxyl radicals, Nitrogen oxides) and overall the risk of infection is much lower. If the minimum distance for wind ensembles is observed, the risk is as to be assessed very low.

2.2.3 OTHER INSTRUMENTS

Keyboard, string, plucking, percussion instruments

From our point of view, with all other instrumentalists there is the Question of droplet infection or increased aerosol formation is not an increased one Risk from exercising music compared to other social situations, provided the applicable rules are strictly observed. The known risks apply. If there are several musicians in one room, the risk is a possible one Contamination by aerosols must be observed. In our view, the above applies listed measures (see paragraph 2 b.), in particular ventilation (after 15 minutes Rehearsal / instruction shock ventilation,) and sufficient room size and distance. A Thorough hand cleaning is particularly important.

Keyboard instrumentalists For pianists, the risk of contact transfer plays a role, if

different pianists play on the same instrument one after the other. In front Every player must therefore start the game for at least 30 seconds

Hand cleaning (i.e. very thorough hand washing with soap or, if necessary, application

a hand disinfectant). In our view, the Keys even cleaned with cleaning wipes before and after playing a person will. In our opinion, when performing repetition, care should be taken to ensure that a distance of 2 meters from the pianist to the other players, also during the accompaniment

should be taken by wind players or singers, because when making music It is not uncommon for spontaneous movements with the accompanist to occur. A Airborne droplets transfer from the wind instrument and mouth of the singer are not at this distance from the pianist according to our measurements fear. However, possible contamination by aerosols in the room cannot be ruled out.

We see this in the sense of the risk reduction measures described above Wearing MNS in the sense of mutual external and self-protection of the players as an important opportunity for the accompanist and the instrumentalists and singers, with whom he / she makes music. The measures described above come for wind players for risk reduction in question.

String instruments, plucked instruments, drums The transfer or sharing of instruments should be possible be avoided. As with the pianists, the risk of a Transfer of contacts through hand cleaning and avoiding touching the face and eyes are reduced.

Chamber music ensemble / band Even in smaller ensemble formations of chamber music or bands, the above should Section 2. Detailed options for risk reduction through the incoming control, optimization of the parameters room / air / duration and the Individual protective measures must be observed. Compliance is also here The distance rule to protect against droplet contamination is very important. Since the Compliance with the distance rule requires close attention and physical proximity social attachment is an intuitive part in music situations, and there music making with movements around the body axis in space, the distance between people from our point of view be 2 meters. In addition, several apply when making music Persons in a closed room the risk-reducing protective factors for one Contagion through aerosols. These are: rooms as large as possible (enforced by radial distance of 2m around each musician), regular ventilation (after 15 minutes Rehearsal / instruction shock ventilation in closed rooms with natural ventilation) and the time reduction of the total sample times.

In addition, in chamber music ensembles and bands, as above, several times described to reduce the risk of an aerosol-borne infection from Mouth Protection (MNS) for musicians who do not play a wind instrument be worn. In our view, special care must also be taken to ensure that it is in Pause situations not to hand contacts or contacts via surfaces (e.g. by passing on notes etc.). Regular, thorough hand washing is very important, especially touching the face and rubbing the eyes should be avoided. Sneezing and coughing should be avoided and in the Elbow be caught.

Orchestra / big band

In large collections of musicians such as in the orchestra or in big bands are the measures described above for reducing risk to the respective Situation of the respective sound body.

Looking at the risks of droplet transfer and / or aerosols again to combine the risk-reducing measures so that one is possible great risk minimization can be achieved. With regard to the transmission of droplets between the individual musicians based on measurements by the Bamberg Symphony Orchestra and other working groups can be assumed that at a distance of 2 meters (radial) between the Musicians - also with the wind instrumentalists including the flute -

droplet transmission is not to be expected.

About the spread of aerosols in closed rooms during rehearsals and concerts however, there is no scientific evidence.

As long as this is the case, should In our view, the greatest possible risk reduction through a combination of measures to be taken. This should be in orchestra or big band - like already described for ensemble and choir - i.a. in regular ventilation (see paragraph

2 above) exist. Regular ventilation of the room every 15 minutes or the use of rooms with an HVAC system are important measures for Risk reduction. In terms of risk minimization, it seems the cheapest if you can play outdoors (see also systemic risk reduction).

In addition, MNS should be worn for external and internal protection. For brass players can - as long as the filter effect of the instruments has not been proven - appropriate textile protection must be attached to the horns. The question too the length of time, i.e. how long a rehearsal or concert lasts, plays for you in one Expected particle concentration of the aerosol plays a role: in longer ones Over time, the particle concentration can rise to higher values than in shorter ones.

This should be taken into account during rehearsals or concert programs. Sneeze and Cough should be avoided if possible and caught in the crook of the elbow. Especially with larger numbers of people, situations outside of the Orchestral activity / band plays an important role in a possible infection. Here is Take special care to ensure that there is no break in situations

Hand contacts or contacts via surfaces (e.g. by passing on notes etc.) comes. Regular, thorough hand washing is very important, especially Touching the face and rubbing the eyes should be avoided. The in-coming control mentioned under the measures above could be more consistent Handling represent an effective additional measure.

3. Risk management

Effective risk management usually requires precise risk analysis with associated likelihood of occurrence and knowledge of how effective are certain risk-reducing measures. We currently know a lot about Transfer through SARS-CoV-2 not yet, so risk management is currently

means an equation with many unknowns. This leaves room for that different target perspectives (disease rate vs. preservation of the music culture) and personal attitudes (risk-taking or risk-averse) to different Can lead recommendations for action. Individually, everyone has the right be allowed to decide what risk he or she is willing to take. As scientists, we want to help as many unknowns as possibleConvert variables of the equation into known variables.

In practice, from our point of view, optimal risk management would be like this look that each institution has its own for their specific music setting Risk management developed. It is expected that the risk of infection the more can be reduced more the higher the number of risk-reducing measures.

This procedure should be advised by the company doctors, health authorities etc. to be accompanied. As long as we don't have enough scientifically proven basics, in doubt, we have to overestimate rather than underestimate the possible risks. To this The overall risk of infection can be reduced as much as possible by combining risk-reducing measures. However, it must be clear It should be noted that according to the ALARP principle (As Low As Reasonably

Practicable) a residual risk remains that is currently not quantifiable.