HORAL SINGING seems to be a highly dangerous activity in a post-COVID world—that seemed to be the message from the recent NATS/ACDA webinar. Reading the article by Dr. Nelson seemed to confirm our worst fears, but as a Hong Kong doctor who has been singing for over 25 years with one of the oldest choirs here, I want to share some of my thoughts and experiences, since we practiced and sang with the last epidemic (SARS, the elder brother of COVID-19 maybe) 17 years ago. As an anesthesiologist, I have the privilege (together with ICU doctors and ENT doctors) of seeing our instrument (of my patients) very often, sometimes on a daily basis. That actually puts me at a very high risk at work. Although we are physically connected to the mainland, we only have around 1126 cases and 4 deaths so far.[1] Let me share a few thoughts about how we managed this time to stave off disaster so far and how this may be relevant when choirs start rehearsing again.
Introduction
SARS in 2003 was a terrible shock and wakeup call: of the 299 deaths, we lost 4 doctors (2 each from private and public sectors), together with 1 nurse and 3 healthcare assistants. We traced and isolated contacts, fixed our plumbing, wore masks universally and cleaned our hands obsessively. Although Dr. Nelson’s article reported the results of viral recovery despite masking, there are suggestions that the infection was acquired due to aspects of choir practice unrelated to singing.[2] Perhaps the most surprising item on the list above related to plumbing. Toilets are a big risk for many reasons. One of the clusters related to a Buddhist prayer room here during COVID recovered virus on the tap handle, but more of that later. A supercluster during SARS was due to viral shedding in the stools of an infected person, and because of plumbing problems in the group of high rise apartments, he ended up infecting numerous people living on different floors in both his block and one of the adjacent blocks. The uninfected residents all got shipped off to a holiday village for isolation. Plumbing problems may not matter if people are living in individual houses, but the other habit we all got used to, is to put the toilet down before flushing. PERIOD! Flushing can aerosolize the virus shed in stools to infect the next person using the same cubicle.
Washing of Hands
Moving onto hand washing, the matter is not only on when to clean but also how to clean. Every time you touch the outside of your mask, after taking off your mask, gloves, outside clothes or whatever, you need to clean your hands. And of course after touching things like handrails on public transport, doorknobs, lift buttons … etc.: they have all been shown to harbor virus. Your also need to clean before you use your hands to put anything (food, pills etc.) into your mouth, put on your mask or you need to touch your eyes or nose. (Gosh I am sounding like someone suffering from an obsessive compulsive disorder). This is just an application of the principles we use in taking off our personal protective equipment at work – assume everything is capable of infecting you and clean hands after removing every item. Given that you won’t be able to wash your hands at every turn, you need to carry some sort of handy disinfectant on you. Alcoholic hand rubs (and gels, they don’t spill) are the ones most often encountered.[3] Another alternative is the use of hypochlorous acid,[4] which can be bought or you can make at home it using water and salt.[5] This has the advantage of not being flammable and being suitable for clothes and surfaces … etc.
Drying of Hands
Drying hands after washing is the next area of concern. Most people would not want to flood the earth with used paper towels after hand drying, but hand dryers are actually not safe. We have known from SARS (2003) that they can blow viruses everywhere. Since the end of this January, we had put plastic bags over our fans in our workplace, but the hand dryers in the public toilets in the hospital are still operational. This is rather mad! You might also want to use a towel to touch the tap and door handles with. In Hong Kong, there is widespread installation of automatic taps, but foot or knee controls are also used in the operating theaters. We also have long tap handles to let us use our elbows to shut them off after scrubbing our hands. No one wants to contaminate themselves with virus in the act of switching off the water tap.
Mask Wearing
Lastly we come to masks. They serve two functions: cutting down on the chances of having viruses in the surrounding air going down your lungs, but more importantly preventing those who have (or might have) the virus from getting them into the air in the first place. This is why the original recommendation to wear masks if you are sick (or fell that you might be sick) is NOT wrong. The problem is asymptomatic infections.[6] They are also the reason why masks with expiratory valves are a very bad idea. You protect yourself but won’t mind infecting others – very selfish! I have never tried singing in an N95 mask, but I have no doubt that results would not be brilliant. We practiced with masks on, around 1.5m apart during SARS and we were all fine. Another protection people might consider is eye shields. If you wear glasses, there is already some protection, but people who don’t can buy these at hardware shops etc.
As you can see from the above, a whole package of integrated infection control measures can ensure danger is kept to a minimum. This may seem very daunting at first, but we survived. Performing with masks may look odd too, but that must be a whole lot better that the whole choir falling ill. Opera performances are another problem altogether. Choir practice is restarting very soon here in Hong Kong. Hopefully the above measures can keep choral cluster events to a minimum. The future for choral singing will look a lot less gloomy, and years down the road, we might ask ourselves what the fuss was all about.
NOTES FROM THIS ARTICLE:
[1] As of 19th June 2020
[2] Cf. this article.
[3] Small quantities are allowed on planes for personal use, and a limit exists for transport in your luggage carried in the aircraft hold. Please go the airline or IATA website to check if and when you need to fly.
[4] A chemical related to bleach, which is not harmful at the levels found in these sprays.
[5] Methods can be found on Google. There are several videos on this on YouTube. There are also devices made into spray bottles so you can fill it with salt and water and make it to use in the same bottle.
[6] China admitted at some point that they excluded asymptomatic infections from their stats. At the time, those were half the number of confirmed cases, making 1 in 3 infections asymptomatic.
