Chest infection incidence in wind musicians: a survey

Introduction

According to Marshall et al (1), up to 100% of musical instruments harbour bacteria, mould and/or yeast, and reed instruments (for example, clarinet, oboe, bassoon) fair worse in density of microbes present than flutes or trumpets due to the reed of the instrument. Reeds cannot be wiped dry and sanitised due to the natural material of the reed and the risk of potential damage when cleaning. Not systematically drying an instrument after playing significantly increases the number and total concentration of fungi present (p <0.05) (2).

The survival of potentially pathogenic bacteria applied to reeds has been investigated (1). All species of bacteria persisted for a maximum of 24–48 hours except mycobacterium which survived over 13 days. Mycobacterium has been linked with hypersensitivity pneumonitis (HP) (3, 4).

The first documented evidence of HP in a wind instrument musician (WIM) details a case study of suspected ‘saxophone lung’ in 1988 (5). A 67-year-old saxophonist displayed a two-week history of dyspnoea, coughing and chest tightness. No pathological reasoning for his symptoms were identified until the saxophone mouthpiece was cultured, revealing the presence of fungi (candida albicans, candida famata and cryptococcus). Following treatment, the saxophonist recovered and had no reoccurrence of symptoms since washing the mouthpiece with soap and water regularly. Further cases of HP in WIMs in the bassoon (4), bagpipe (6), trombone (3) and further saxophonists (7) have been published.

Blood samples from WIMs were obtained to detect specific antibodies against potential microbes present in wind instruments. 80% of WIMs had antibodies consistent with the microbes present in their instruments (2). Antibodies were significantly more present in WIMs than in healthy non-exposed controls (p <0.001) (2).

To prevent the survival of microbes in wind instruments an effective cleaning regime is recommended (2). Existing cleaning guidelines recommend that the mouthpiece of a wind instrument should be brushed 15 times within 30 seconds using a detergent or sanitiser solution to reduce microbial load (8). Soumagne et al (2) reported that just 13% (n = 5) of 40 wind musicians used a detergent or sanitiser after playing. There are currently no standardised guidelines for instrument hygiene.

Considering the evidence that wind instruments provide an environment for the growth of microbes that could lead to a chest infection (CI) (1, 2, 3, 4, 5, 6, 7, 8) WIMs should be aware of their potential increased risk.

A CI is classified as acute bronchitis (inflammation of the bronchi) or pneumonia (inflammation in the alveoli) (9). Overall incidence of community-acquired CIs is 49–54 per 1000 adults per year in the U.K. (10, 11).

Therefore, in this research study we investigated the incidence of CIs in a group of WIMs in the U.K. and compared our findings to the U.K.’s general population. Secondary aims were to investigate knowledge of CI symptoms and to explore their instrument cleaning practice.

Method

Sample

All students auditioning for a university wind instrument orchestra in Nottingham were invited to participate in a questionnaire. Inclusion criteria was any auditionee over the age of 18, of at least grade eight (musical) standard that practiced a minimum of four hours per week. Participants were excluded if they did not have English reading and writing skills.

Questionnaire and data collection

A bespoke questionnaire was designed with four domains (demographic, incidence, instrument hygiene and knowledge). Incidence asked participants to recall how many CIs they had been diagnosed with (by a general practitioner) in the previous five years. Instrument hygiene consisted of how frequently a participant’s instrument was cleaned, the method of cleaning and instrument cleaning education they had received either by a teacher, manufacturer, or other source. Knowledge included asking the participants to identify the main symptoms listed associated with a CI (such as ‘persistent cough’ or ‘increased temperature’) and increased risk groups listed (such as ‘pregnant women’ and ‘those with weakened immune systems’). The questionnaire contained open and closed questions. Ethical approval was granted by the University of Nottingham Medical School Ethics Committee (reference number: 58-1807).

A pilot study was completed on eight individuals (previous members of the university wind instrument orchestra). Data gathered from the pilot study was not included in the final analysis but used to inform the final version of the questionnaire. The feedback from the pilot study was to reorder the groups at risk of CIs so that it was not a leading question.

An information sheet and questionnaire were distributed to potential consenting participants following their audition and volunteers were asked to complete the questionnaire a quiet room. Participants were asked to post their completed questionnaires into a collection box; consent was assumed if they completed the questionnaire and posted it in the collection box. Potential participants were advised on the information sheet that their participation was voluntary, and all data anonymous.

Analysis

Data was inputted into computer password protected documents. Data was stored until the study was completed, and then destroyed. Data was analysed using SPSS and Microsoft Excel version 1812. Relationships between diagnosis of asthma and CIs were completed with Pearson correlation and were reported as weak, moderate or good. Incidence of CIs was compared to the U.K. general population. The text from open questions was subject to thematic content analysis using Braun et al framework (12) to identify themes from participants. Thematic analysis involved six steps: familiarisation with the data by line-by-line analysis (HD), generation of initial codes (HD), identification of themes (HD) identified themes were approved and discussed with another researcher (HD and KH), each theme was defined and refined (HD and KH) and themes written up (HD).

Results

54 surveys completed (response rate 92%) and two excluded (due to participants being below musical grade eight standard). All questions were completed (question completion rate 100%).

Demographics

The mean ± standard deviation age of participants was 20 ± 1 years and 54% were female. Table 1 highlights the most frequently played instrument was the flute. 23% of participants had a diagnosis of asthma confirmed and managed by their general practitioner.

Table 1: Frequency of wind instrument played.

Incidence of CI

The mean number of CIs reported was 0.9 for the 54 participants. 31 percent (n = 16) reported experiencing at least one CI in the previous five years as diagnosed by their general practitioner and prescribed antibiotic treatment, see Figure 1. The mode and median number of CI reported was zero.

See Figure 1: Incidence of CI in previous five years.

A weak relationship existed (r = 0.03; p = 0.83) between having an asthma diagnosis and at least one CI in the previous five years. A weak relationship existed (r = 0.11; p = 0.46) between having an asthma diagnosis and the number of CIs reported in the previous five years.

Wind instrument hygiene

48% of participants reported cleaning their instrument following each play (n = 25), see Table 2. The most frequently reported method of cleaning was a pull through cloth (n = 36, 69%), followed by bathing the instrument (n = 11, 21%) (see Table 3 for example responses). Only 42% (n = 22) respondents had been taught how to clean their instruments.

Table 2: Frequency of instrument cleaning reported.

Table 3: Example responses for method of cleaning themes.

Knowledge

Each respondent could correctly identify a minimum of two CI symptoms listed in the questionnaire. Only one respondent (2%) could correctly identify all seven symptoms listed in the questionnaire. The most frequent correctly identified symptom was ‘persistent cough’ (n = 50, 96%), followed by ‘coughing up yellow/green phlegm’ (n = 43, 83%). The most frequent incorrect response was ‘shivers’ (n = 20, 39%).

Wind instrument musicians were identified by 39% (n = 20) of respondents at being potentially at increased risk of a CI, despite the survey investigating this issue.

Discussion

This questionnaire reported that 31% of experienced at least one CI in the previous five years. Less than 50% clean instruments following each play and 39% of participants reported that WIM were at an increased risk of CIs.

Incidence

No literature to the researchers’ knowledge investigates CI incidence. In the general U.K. population, community-acquired CIs occur in 49–54 per 1000 adults per year (8, 9). In this study, 31% of participants reported at least one CI in the previous five years. To compare this with the general U.K. population, this could calculate at an average of 62 per 1000 adults per year.

Wark (10) and NICE (11) are based on the general U.K. adult population including groups at increased risk of a CI, whereas this research study only included those aged 18–24, making it difficult to compare as the populations have different characteristics. It is known that groups including the elderly and pregnant women are at an increased risk of CIs (11), and this research study did not include these groups. Therefore, it could be argued there is a further increased incidence of CIs in the respondents of this questionnaire, as there are fewer people who would be considered at increased risk compared to the general adult population.

Recent studies (1–2) reported the presence of bacteria, mould and fungi in instrument mouthpieces, which may have the potential to cause CIs. Theses microbes can enter the body and trigger an immune response, causing WIMs to have antibodies consistent with the microbes present in their own instruments (2). Clinically, this means WIMs may have to seek treatment for CIs that could have been prevented by systematic cleaning. Therefore, clinicians should ask patients during a subjective examination if they are a WIM to exclude a potential factor causing their respiratory condition (7, 8, 13).

Wind instrument hygiene

There are no studies investigating the frequency of instrument cleaning and no standardised cleaning guidelines for frequency or method of cleaning. Walter et al. (8) recommended cleaning after each play with a brush and sanitiser to minimise bacterial count, whereas Soumagne et al. (2) recommend regular cleaning and systematic drying of the instrument. In this study 48% of participants reported cleaning their instruments ‘following each play’ and 69% used a pull through cloth to clean and dry their instrument. This suggests that despite recommendations to dry wind instruments after use (2) and clean following each play (8) many do not, leaving them at an increased risk of microbe inhalation (1, 2, 8).

No research was found on teaching WIMs methods of cleaning. 58% of participants in this study had never been taught a method to clean their instrument, despite this being a music teacher’s responsibility (14). Consideration of standardised cleaning guidelines and health education in instrumental lessons is recommended.

Knowledge

83% of participants identified ‘yellow/green phlegm’ as a symptom of a CI, compared to 48% of those with COPD with no prior education (15). As the characteristics of these populations are different, it is difficult to compare the groups, but it is the only available comparator.

Only 39% of participants identified that WIMs may be at an increased risk of CIs. There is no existing evidence investigating CIs in WIMs and WIMs may not be aware of the microbes that may be present in their instruments (1, 2).

Strength and limitations of the study

One strength of this research was the response rate of 92% which would be considered ‘excellent’ (16). Furthermore, the question response rate of 100% prevented non-response question surveys being excluded, therefore increasing the number of respondents included in the results.

This research study has potential limitations that could be addressed if this study was replicated. Only one university WIM population was surveyed, therefore results should be generalised to other WIM populations with caution. The participant information page stated the aim of the study for ethical reasons, so participants may have reported an increase in their incidence of CIs and reported that WIMs were at an increased risk of CI due to demand characteristics.

Conclusion

While the findings cannot be generalised to all WIMs, the incidence of CIs in this population of WIMs exceeded that of the general U.K. population. Sixty two CIs per 1000 people per year were reported in WIMs compared to the U.K. general population of 49–54 per 1000 people per year (10, 11). Furthermore, knowledge of CI symptoms was lacking. Hygiene practice among this WIM population did not meet recommendations given in previous studies and the majority had not been taught methods to clean their instrument(s). The findings demonstrate a need for standardised cleaning guidelines for instruments.

Further research should consider investigating the incidence of CIs in WIMs on a larger scale compared to a control group, with both amateur and professionals at varying ages and locations.

Key points

• Wind instrument musicians in this sample had an increased incidence of CI’s compared to the U.K. general population.

• Instrument hygiene and knowledge of CI symptoms was poor in this sample.

• Standardised cleaning guidelines for instrument cleaning would be beneficial.

Acknowledgements

The authors would like to thank the University of Nottingham Wind Orchestra auditionees for their support and interest in this study.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Holly Drover is currently funded by Leicestershire Health Inequality Improvement Doctoral Training Programme (funded by the Wellcome Trust), Department of Respiratory Sciences, University of Leicester, Leicester, LE1 9HN, U.K.

Conflict of interest

No conflict of interest.

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