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Wind Ensemble Infectious Disease Risks: A Microbiological Examination of Water Key Liquids in Brass Instruments

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Abstract

Objective: To determine whether the fluids that wind instrument players release onto rehearsal hall floors pose a risk to band members or others using the rehearsal area. Methods: Thirty samples were obtained from five types of brass instruments (trumpet, French horn, trombone, baritone, tuba). These were processed as environmental cultures. Results: Twenty-three samples grew Alcaligenes faecalis. Three trumpet specimens, one French horn specimen, and one trombone specimen grew oral flora from their samples. One sample grew a species which is generally considered to be a fecal contaminant. Conclusions: Most large brass instruments (trombone, euphonium, and tuba) do not contain oral bacteria. French horns and trumpets may have oral bacterial flora in their accumulated liquid. Most instruments will have Alcaligenes faecalis. In general the liquid from water keys does not pose an environmental hazard to persons with normal immune systems. Bands are highly inclusive and diversified. There may be special situations in which players are prone to infection or have cancer or immune disorders, which would require attention for the prevention of infections.
16 TPHA Journal Volume 67, Issue 2
Original Public Health Research
Wind Ensemble Infectious Disease Risks: A Microbiological Examination of Water Key
Liquids in Brass Instruments
James Mobley, MD, MPH, FAAFP1, Cynthia Bridges, PhD2
1Health Authority, San Patricio County Department of Public Health, Sinton, Texas
2Chair, Department of Music, Del Mar College, Corpus Christi, Texas.
E-mail: jmobley@swbell.net
ABSTRACT
Objective: To determine whether the uids that wind instrument
players release onto rehearsal hall oors pose a risk to band members
or others using the rehearsal area.
Methods: Thirty samples were obtained from ve types of brass in-
struments (trumpet, French horn, trombone, baritone, tuba). These
were processed as environmental cultures.
Results: Twenty-three samples grew Alcaligenes faecalis. Three
trumpet specimens, one French horn specimen, and one trombone
specimen grew oral ora from their samples. One sample grew a spe-
cies which is generally considered to be a fecal contaminant.
Conclusions: Most large brass instruments (trombone, euphonium,
and tuba) do not contain oral bacteria. French horns and trumpets
may have oral bacterial ora in their accumulated liquid. Most in-
struments will have Alcaligenes faecalis. In general the liquid from
water keys does not pose an environmental hazard to persons with
normal immune systems. Bands are highly inclusive and diversied.
There may be special situations in which players are prone to infec-
tion or have cancer or immune disorders, which would require atten-
tion for the prevention of infections.
Key Words: band, water key, spit valve, Alcaligenes
INTRODUCTION
Every day thousands of brass instrument players empty their water
keys (also known as 'spit valves') after playing their instruments.
This liquid may be released on a used newspaper, a cloth, the rug, or
the oor. Little thought is given to whether the liquid released may
potentially harbor pathogenic organisms even though there is a 'Spit
Valve Etiquette' among some brass players.1,2 Although no instances
of disease outbreaks among high school bands have been recorded by
the Texas Department of State Health Services or the Centers for Dis-
ease Control and Prevention,3,4 there remains a possibility of disease
transmission. If the uid released from a water key has a signicant
component of oral bacterial ora, then there is a possibility of an
infectious disease outbreak. If the uid released from a water key is
predominantly sterile condensed vapor, there would be less concern
over managing these uid releases. Football and other sports teams
have experienced infectious diseases including viral meningitis and
Methicillin-resistant Staphylococcus aureus (MRSA).5,6 Schools
have also experienced outbreaks of Norovirus causing vomiting and
diarrhea.7
LITERATURE REVIEW
No articles were found that addressed the microbiology of water key
discharges.
In 1956, Bryan introduced the concept of players with reduced re-
sistance to infection being more vulnerable to musical instruments
causing disease. He also discussed the possibility that a contaminated
instrument could reintroduce infection in the same individual.8 He
demonstrated the presence of oral bacterial ora on both mouthpiec-
es and reeds.
In 1959, Walter and Chaffey published a study of bacterial growth
in mouthpieces. They refer to reports of "such accumulations in the
shank of the mouthpiece that tones have been impaired and blowing
has been difcult."9 The authors speculate that silver might retard
bacterial growth on mouthpieces.
Woolnough-King surveyed woodwind and brass instruments in
1994-1995. He refers to a 1957 outbreak of tuberculosis in a British
military band. He found Streptococcus and Staphylococcus species
in the instruments. He opined, "high infective doses of these patho-
gens, caused by growth inside the mouthpieces, may explain why
musicians suffer frequently from throat infections."10
In 2001, Ahlèn reported the case of a fteen-year-old Norwegian
baritone player who developed recurrent pneumonia. The recurrenc-
es coincided with episodes of playing the baritone. She improved
clinically when she travelled to the United States and did not play her
horn. When she returned to Norway and began playing, the pneumo-
nia returned. Sputum cultures grew Chryseobacterium meningosep-
ticus. Chryseobacterium was also obtained from the horn. The author
states that the "microbiological survey presented strongly points to a
connection between the patient's baritone horn playing and her mul-
tiple bouts of pneumonia."11
Bridges has previously examined bacterial ora in the lead pipes
of brass instruments.12 She found mostly non-pathogenic oral ora;
however, potentially pathogenic Bacillus, Staphylococcus, Strepto-
coccus, and Pseudomonas species were identied.
In 2010, the Fauquier Ear Nose & Throat Consultants of Virginia dis-
cussed musical instruments and infection in their blog. They describe
the "well known medical principle being bacteria grows in dark wet
areas." They recommend not sharing instruments, drying the instru-
ment after use, not playing an instrument while sick, cleaning the
mouthpiece daily, and washing brass instruments in the bathtub.13
Glass, et al conducted a study of the bacterial ora of band instru-
ments in 2010. They identied 295 bacterial isolates. Also 16 yeast
isolates and 61 mold isolates were obtained. The authors describe the
isolates as being "opportunistic, pathogenic, and/or allergenic." More
isolates were obtained from the mouthpiece and fewer were obtained
toward the bell. The authors state that the band teacher "conrmed
that at any given time, more than 50% of her band students had some
respiratory issues (asthma, bronchitis) that required therapy."14
WBZ Television (Boston CBS) reporter Joe Shortsleeve reported on
a proposed law to require sterilization of musical instruments. He
reported that the Centers for Disease Control and Prevention had no
record of diseases being transmitted through musical instruments. He
questioned the motives of the bill's supporters to force schools to use
an expensive instrument sterilization service.4
TPHA Journal Volume 67, Issue 2 17
OBJECTIVE
To determine if uid released from water keys contains oral bacterial
ora and therefore represents a potential health threat.
DESIGN, SETTING, AND PARTICIPANTS
Study design was a descriptive ecologic study. Instruments cultured
were brass instruments from the Del Mar College Wind Ensemble
and the Veterans Band of Corpus Christi. The Del Mar College Wind
Ensemble is comprised of college students, most of whom are aged
18-24 years in age. The Veterans Band of Corpus Christi is made
up exclusively of military veterans, most of whom are aged 65-90
years in age. Samples were obtained from the water keys (or slides)
of ve types of brass instruments: trumpets, trombones, baritones/
euphoniums, tubas, and French horns. The results were analyzed by
type of instrument.
MATERIALS AND METHODS
The musicians were informed of the purpose and design of the study.
Since this was a descriptive study with no intervention, there was no
risk to the instruments or the musicians from the study. The identity
of the instrument owners was blinded to protect anonymity. Swabs
were taken from the water keys of brass instruments in the Del Mar
College Wind Ensemble and the Veterans Band of Corpus Christi.
French horn players had the option of emptying a slide or using a
water key if they had one. (Most French horns do not have a wa-
ter key. A tuning slide is removed to dump the accumulated liquid.)
The swabs were processed as environmental specimens by Clinical
Pathology Laboratories, Austin, Texas. Since there was no interven-
tion and instruments were tested anonymously, Institutional Review
Board approval was not requested.
A total of 30 specimens were processed. Since twenty-three of thirty
samples grew a similar morphology (Oxidase Positive, Gram Nega-
tive Rod), one of these specimens was further processed to identify
the species of rod. Culture results were obtained and categorized by
instrument.
RESULTS
Twenty-six samples were obtained from the Del Mar College Wind
Ensemble and four samples were obtained from the Veterans Band.
Twenty-three samples grew Alcaligenes faecalis. Three samples
grew two species. Bacilli were identied in 27 samples (77%), cocci
in six (17%) and no growth in two samples (6%). Two instrument
groups (euphonium and tuba) grew only Alcaligenes faecalis. All
ve instrument groups grew Alcaligenes faecalis in at least some of
their specimens. Three trumpet specimens, one French horn speci-
men, and one trombone specimen grew oral ora from their samples.
One sample grew a species which is generally considered to be a
fecal contaminant (Citrobacter).
Table 1. Instruments
INSTRUMENT
NUMBER
PERCENT
Euphonium
4
13
French Horn
4
13
Trombone
7
23
Trumpet
12
40
Tuba
3
10
TOTAL
30
Table 2. Species by Instrument
INSTRUMENT
BACTERIA
NUMBER
Euphonium (4)
Alcaligenes faecalis
4
French Horn (4)
Alcaligenes faecalis
2
Bacillus not B. anthracis
1
Staphylococcus aureus
1
No growth
1
Trombone (7)
Alcaligenes faecalis
6
Streptococcus viridans
1
Trumpet (12)
Alcaligenes faecalis
7
Gram negative Bacillus
1
Citrobacter koseri
1
Gram positive bacillus
1
Alpha streptococcus
1
Streptococcus viridans
1
No growth
1
Tuba (3)
Alcaligenes faecalis
3
Total (30)
32
* One specimen (French Horn) grew Staphylococcus aureus and Bacillus
not B. anthracis
Two specimens (Trumpet and Trombone) group A. faecalis and S. viridans.
Table 3. Bacterial Types
BACTERIA
PERCENT
Alcaligenes faecalis
70
Alpha Streptococcus
3
Bacillus not B. anthracis
6
Citrobacter koseri
3
Gram negative bacillus
3
No growth
6
Staphylococcus aureus
3
Streptococcus viridans
6
Total
Table 4. Bacterial Morphology
BACTERIA
PERCENT
Bacillus
82
Coccus
18
Total
Table 5. Gram Stain Distribution
BACTERIA
PERCENT
Gram Stain Positive
77
Gram Stain Negative
17
No growth
6
Total
DISCUSSION
Alcaligenes faecalis, found in twenty-three of the thirty samples,
is an environmental microbe which exists in soil and water.15 It is
frequently recovered from high moisture environments in hospitals.
Although it is not usually a pathogen, it has been associated with eye
infections, cystic brosis patients, and severely ill hospital patients.16
Most large brass instruments (trombone, euphonium, and tuba) did
not contain oral bacteria in this sample of water key liquids. One
trombone grew an oral bacterium (Streptococcus viridans). French
horns and trumpets show more variability in their bacterial ora, pos-
sibly because of the shorter distance between the mouthpiece and the
trumpet water key or the French horn slide.
18 TPHA Journal Volume 67, Issue 2
This is a small data set that provides at best a glimpse of the bacterial
milieu of wind instruments. Reed instruments have a different com-
position and design and should also be cultured. In general the liquid
from the water keys of brass instruments does not pose an environ-
mental hazard to persons with normal immune systems.
RECOMMENDATIONS
Bands are exceptional as student activities in that they are highly
inclusive and diversied. Often, students with mental, physical, or
emotional conditions that prevent participation in athletics or other
activities can participate in and be enriched by band music. While
most band students are healthy and unlikely to be put at risk by band
activities, there may be special situations in which players are prone
to infection or have cancer or immune disorders, which would re-
quire attention for the spread of infections. Although this study was
designed primarily for students, community bands and musical or-
ganizations with older participants, especially the elderly, might be
more vulnerable to the spread of infection.
Many band directors have felt that their students have a higher than
usual incidence of upper respiratory infections, but no ecological
studies comparing musicians with age match cohorts have been done
to demonstrate this risk factor.10,14 Although the Centers for Disease
Control and Prevention and the Texas Department of State Health
Services have no record of disease outbreaks in bands, bands are
vulnerable during travel when they share food and close spaces. A
contagious disease outbreak could reduce a band to ineffectiveness.
Band directors should be alert for unusual patterns of disease or in-
fection in band members. Good health practices should be a regu-
lar part of musical instruction. Good health practice should include
cleaning institution-owned instruments before reissuing them to an-
other student.
ACKNOWLEDGEMENTS
Thanks to Abel Ramirez, conductor, Del Mar College Wind Ensem-
ble, and Ram Chavez, conductor, Veterans Band of Corpus Christi.
Thanks to Dan Hardy, MD, and Rhonda Brown, MT, ASCP, of Clini-
cal Pathology Laboratories, for their assistance with cultures. Thanks
to Leslie Dillon, RN, of Medical Arts Clinics for coordination and
scheduling.
REFERENCES
1. Spit Valve Etiquette. Wildtone Web Site. http://www.wilktone.com/?p=3440.
Posted April 12, 2012. Accessed July 11, 2014.
2. Spit Valve Etiquette. The Trombone Forum Web site. http://tromboneforum.
org/index.php?topic=54739.0. Posted 2011. Accessed July 11, 2014.
3. Heines V. Texas Department of State Health Services. Personal communica-
tion. June 10, 2014.
4. Shortsleeve J. I-Team: Music Teachers Question Motive Behind Instrument
Sterilization Bill. WBZ Web site. http://boston.cbslocal.com/2012/08/27/i-
team-music-teachers-question-motive-behind-instrument-sterilization-bill/.
Posted August 27, 2012. Accessed July 15, 2014.
5. Baron R, Hatch M, Kleeman K, MacCormack J. 1982. Aseptic meningitis
among members of a high school football team. An outbreak associated with
echovirus 16 infection. JAMA 248(14):1724-1727.
6. Information on Staphylococcal Infections for Athletes. University Interscho-
lastic League Web site. 2014. https://www.uiltexas.org/health/info/information-
on-staphylococcal-infections-for-athletes. Accessed July 11, 2014.
7. Ofcials: Norovirus caused Richardson High School outbreak. My Fox
DFW Web site. http://www.myfoxdfw.com/story/24632242/norovirus-caused-
richardson-high-school. Posted: February 04, 2014. Accessed July 11, 2014.
8. Bryan A. 1956. Mouthpiece Hygiene. The Instrumentalist March: 20-24.
9. Walter W, Chaffey D. 2014. Bacteriological and Cleaning Studies on the
Mouthpieces of Musical Instruments. Applied Microbiology 1959;7(2):126-
130. Applied and Environmental Microbiology Web site. http://aem.asm.org/
content/7/2/126.citation. Accessed July 16, 2014.
10. Woolnough-King C. A microbiological survey into the presence of clini-
cally signicant bacteria in the mouthpieces and internal surfaces of woodwind
and brass musical instruments. University of Newcastle upon Tyne. 1994. Crizz
Web site. http://www.crizz.co.uk/micro/rst.html. Conducted 1994-1995. Ac-
cessed July 15, 2014.
11. Ahlèn C. A case of recurrent pneumonia in a wind instrument player - tip
of an iceberg?. Foundation for Scientic and Industrial Research. Trondheim,
Norway. 2001.
12. Bridges C. A Study of the Bacterial Flora in Selected Student Brass Musical
Instruments. University of Hawaii at Manoa, Honolulu, HI. 2005.
13. Can Playing a Wind/Brass Instrument Be a Source of Recurrent Infections?
Fauquier Ear Nose and Throat Consultants of Virginia Blog. http://fauquierent.
blogspot.com/2010/01/can-playing-windbrass-instrument-be.html. Posted Jan-
uary 7, 2010. Accessed July 15, 2014.
14. Glass R, Conrad R, Köhler G, Bullard J. Evaluation of the Microbial Flora
Found in Band Musical Wind Instruments (Woodwinds and Brass) and Their
Potential to Transmit Diseases (Final Report). Oklahoma State University.
2010.
15. Engelkirk P, Duben-Engelkirk J. Laboratory Diagnosis of Infectious Dis-
eases: Essentials of Diagnostic Microbiology. Lippincott Williams & Wilkins.
Baltimore. 2008. P 331.
16. Coenya T, Vandamme P, LiPuma J. Infection by Ralstonia Species in Cystic
Fibrosis Patients: Identication of R. pickettii and R. mannitolilytica by Poly-
merase Chain Reaction. Emerging Infectious Diseases. Vol. 8, No. 7, July 2002.
P. 692-696.
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... In part one Mobley and Bridges examined the bacterial content of fl uid released through the water keys of brass instruments. 1 Band and orchestra rehearsals and individual practice sessions occur daily in elementary schools, secondary schools, colleges, and universities. During these rehearsals and practice sessions, wind instruments are warmed from room temperature to body temperature. ...
... Found in moist areas including brass instruments. 1 Rarely a pathogen but can cause infection in immunocompromised individuals. 21 ...
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The Trombone Forum Web site
  • Spit Valve Etiquette
Spit Valve Etiquette. The Trombone Forum Web site. http://tromboneforum. org/index.php?topic=54739.0. Posted 2011. Accessed July 11, 2014.
Texas Department of State Health Services. Personal communication
  • V Heines
Heines V. Texas Department of State Health Services. Personal communication. June 10, 2014.
Music Teachers Question Motive Behind Instrument Sterilization Bill. WBZ Web sitei- team-music-teachers-question-motive-behind-instrument-sterilization-bill
  • J Shortsleeve
Shortsleeve J. I-Team: Music Teachers Question Motive Behind Instrument Sterilization Bill. WBZ Web site. http://boston.cbslocal.com/2012/08/27/i- team-music-teachers-question-motive-behind-instrument-sterilization-bill/. Posted August 27, 2012. Accessed July 15, 2014.
Mouthpiece Hygiene. The Instrumentalist March
  • A Bryan
Bryan A. 1956. Mouthpiece Hygiene. The Instrumentalist March: 20-24.
A microbiological survey into the presence of clinically significant bacteria in the mouthpieces and internal surfaces of woodwind and brass musical instruments
  • C Woolnough-King
Woolnough-King C. A microbiological survey into the presence of clinically significant bacteria in the mouthpieces and internal surfaces of woodwind and brass musical instruments. University of Newcastle upon Tyne. 1994. Crizz Web site. http://www.crizz.co.uk/micro/first.html. Conducted 1994-1995. Accessed July 15, 2014.
A case of recurrent pneumonia in a wind instrument player -tip of an iceberg
  • C Ahlèn
Ahlèn C. A case of recurrent pneumonia in a wind instrument player -tip of an iceberg?. Foundation for Scientific and Industrial Research. Trondheim, Norway. 2001.