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Wind Ensemble Infectious Disease Risks II A Microbiological Examination of Condensate Liquids in Woodwind Instruments

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Objective: To determine if the condensation that forms from playing woodwind instruments contains bacterial fl ora that could represent a health threat to others using the rehearsal area. Methods: Thirty-seven fl uid samples were obtained from seven types of woodwind instruments (fl ute, oboe, bassoon, clarinet, bass clarinet, alto saxophone, tenor saxophone). These were processed as environmental cultures. Results: Thirteen bacterial species were recovered including three gram positives and ten gram negatives. Two species were cocci, nine were bacillus and two coccobacillus. Thirteen samples had no growth. The isolates were predominantly aquatic and either normal fl ora, opportunistic pathogens or both. Conclusions: The liquids which are released by woodwind instruments, generally do not pose a threat. There may be some situations in which the secretions could be harmful, such as exposure to these fl uids by persons with immunosuppression, cancer, HIV or chronic diseases.
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6TPHA Journal Volume 68, Issue 4
Original, Peer-Reviewed Public Health Research
Wind Ensemble Infectious Disease Risks II
A Microbiological Examination of Condensate Liquids in Woodwind Instruments
James Mobley, MD, MPH, FAAFP1, Cynthia Bridges, PhD2
1San Patricio County Department of Public Health, Sinton, Texas
2Department of Music, Del Mar College, Corpus Christi, Texas
jmobley@swbell.net
ABSTRACT
Objective: To determine if the condensation that forms from
playing woodwind instruments contains bacterial fl ora that
could represent a health threat to others using the rehearsal
area.
Methods: Thirty-seven fl uid samples were obtained from sev-
en types of woodwind instruments (fl ute, oboe, bassoon, clar-
inet, bass clarinet, alto saxophone, tenor saxophone). These
were processed as environmental cultures.
Results: Thirteen bacterial species were recovered includ-
ing three gram positives and ten gram negatives. Two species
were cocci, nine were bacillus and two coccobacillus. Thir-
teen samples had no growth. The isolates were predominantly
aquatic and either normal fl ora, opportunistic pathogens or
both.
Conclusions: The liquids which are released by woodwind in-
struments, generally do not pose a threat. There may be some
situations in which the secretions could be harmful, such as
exposure to these fl uids by persons with immunosuppression,
cancer, HIV or chronic diseases.
Key Words: band, condensation, saliva, woodwind, bacteria,
immunosuppression
INTRODUCTION
This paper is the second in a series of studies that examine the
possibility of disease transmission from the fl uid that accumu-
lates in musical instruments and is released into the rehearsal
room environment. 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, colleg-
es, and universities. During these rehearsals and practice ses-
sions, wind instruments are warmed from room temperature to
body temperature. Through this process, condensation forms.
It either evaporates or drips onto the ooring or other furnish-
ings. In these band and orchestra rehearsals large groups of
people are exposed to the condensate from wind instruments.
Unlike brass instruments, woodwind instruments are made
from a variety of materials. Flutes are generally nickel or sil-
ver; oboes, bassoons, and clarinets may be made from plastic
or wood; saxophones are made of brass. Woodwind instru-
ments produce tones by the movement of air over a reed caus-
ing it to vibrate or by blowing air across an aperture. On single
or double reed instruments, the vibrating reed is made of cane,
a very porous material, which collects moisture and substrate
and may support bacterial growth. The bacterial content of
mouthpieces and reeds of woodwind instruments has been
studied by many researchers,2-5 but little is known regarding
the bacterial content of the fl uids released from the instru-
ments onto the rehearsal hall fl oor. Enough concern about
transmission of disease from instruments existed for the Mas-
sachusetts Legislature to enact H4384, an instrument steriliza-
tion bill which was signed into law January 7, 2015.6
Is the bacteria that has been found on reeds and mouthpieces
transported into the instrument and, subsequently, into the en-
vironment by the force of the air or the dripping of the uid
from the reed into the instrument? There is usually no water
key on woodwind instruments (some saxophone models being
the exception) so the uid accumulates inside the instrument
and drips to the oor. In the case of saxophones and bassoons,
the water accumulates in the bow (saxophone) or boot joint
(bassoon). The player has to empty the uid to prevent it from
interfering with the tone quality of the instrument. If the fl uids
are predominantly condensate with little or no oral bacterial
ora, then there would be less concern regarding the possibil-
ity of disease transmission.
LITERATURE REVIEW
Previous research has focused on the possibility of instru-
ments causing disease to the person playing the instrument.
There has been no research to discover if there is a risk to
others from uids released into the rehearsal halls. In 1956
Bryan tested reeds and mouthpieces from seventy-fi ve band
members for bacterial content and found predominantly oral
ora.2 He believed these mouthpieces to be dangerous and
that disease transmission through sharing of the instrument
was possible. Walter and Chaff ey in 1959 tested mouthpieces
for bacteria in an attempt to identify an eff ective cleaning
method. They primarily worked with brass mouthpieces but
did test one saxophone mouthpiece and concluded that bacte-
ria in the mouthpiece might remain viable for several days.3
Woolnough-King took samples from the mouthpieces of wind
instruments and the players’ noses and throats in 1994. Both
streptococci and staphylococci were present in high numbers
at seventy-two hours after use of the instrument.4 He con-
cluded that staphylococci and beta-hemolytic streptococci
may grow in the mouthpiece after use and storage. Glass et
al conducted a study of the bacterial ora of band instruments
in 2010. They identifi ed 295 bacterial isolates. They swabbed
two oboes, two clarinets and two saxophones. Oboes grew
twenty-one species of bacteria, clarinets twenty-seven and
saxophones twenty-two.5 In an interview published in Science
Daily, Dr. Glass associated contaminated instruments with
asthma and yeast lip infections.7 Metzger et al described a
case of hypersensitivity pneumonitis (‘saxophone lung’) in
a 48-year old amateur saxophone player in 2010.8 Molds re-
covered from the saxophone were consistent with antibodies
TPHA Journal Volume 68, Issue 4 7
in his serum. The saxophone player’s respiratory condition
improved after he began cleaning and drying his instrument.
As a part of this investigation, fi fteen other saxophone play-
ers and their instruments were examined. Fungus colonization
was found in thirteen of fi fteen instruments. Examination of
the saxophone players did not reveal evidence of infection or
sensitization to the molds. In an associated editorial, Cormier
stated that hypersensitivity pneumonitis (‘saxophone lung’)
from contaminated instruments may decrease lung function,
making it diffi cult for a wind musician to continue playing.9
‘Saxophone lung’ was rst reported in 1988 by Lodha and
Sharma.10 The case report in Chest described a 65-year old
saxophone player admitted to the hospital for shortness of
breath and bloody sputum. The reed was thought to be the
most likely source of infection since Candida albicans and
Candida famata species were found on the mouthpiece. This
musician improved when he stopped playing his saxophone
and when he began to clean his instrument and mouthpiece
regularly. In 2011, Dr. Stuart Levy of Tufts University School
of Medicine studied survival of bacteria, mold and yeast in
clarinets, utes and saxophones. Viable species were found
on all instruments. The study did not look at the risk to oth-
ers from the condensate secretions from the woodwind instru-
ments.11 Both the Clafl in University Department of Music and
Butler University School of Music musician manuals discuss
the need for cleaning and not sharing instruments and mouth-
pieces. However no mention is made of the risks from fl uids
which accumulate on the rehearsal room fl oors.12, 13
OBJECTIVE
To determine if the condensation that forms from playing
woodwind instruments contains bacterial fl ora that could rep-
resent a health threat to others using the rehearsal area.
DESIGN, SETTING AND PARTICIPANTS
The study design was a descriptive ecologic study. Samples
were taken from woodwind instruments from the Del Mar
College Wind Ensemble, the Corpus Christi Municipal Band
and the Veterans Band of Corpus Christi. The Del Mar Col-
lege Wind Ensemble is comprised of college students, most
of whom are aged 18-24 years. The Corpus Christi Municipal
Band is a group of mostly adult musicians many of whom are
band directors. The Veterans Band of Corpus Christi is made
up exclusively of military veterans, most of whom are aged 65
to 90 years. Seven types of instruments were sampled, clari-
net, bass clarinet, alto saxophone, tenor saxophone, ute, oboe
and bassoon. All musicians were informed of the purpose and
design of the study. Samples were obtained from the location
most likely to discharge fl uids. The swabs were processed as
environmental specimens by Clinical Pathology Laboratories,
Austin, Texas. Since this was an environmental study with no
intervention, there was no risk to the instruments or the musi-
cians from the study. Institutional Review Board approval was
not requested. Culture results were obtained and categorized
by instrument.
RESULTS (Tables One through Six)
A total of thirty-seven specimens were processed. Sixteen
samples (43%) were obtained from the Del Mar College Wind
Ensemble, eighteen from the Corpus Christi Municipal Band
(49%) and three from the Veterans Band of Corpus Christi
(8%). The specimens grew thirteen diff erent species. Ten
specimens (77%) were gram negative, three (23%) were gram
stain positive. Two species (15%) were cocci, nine (69%) were
bacillus and two (15%) coccobacillus. Nine instruments grew
two species. Thirteen instruments had no bacterial growth in-
cluding eight utes and both oboes. We hypothesize that utes
had little bacterial growth because of their simple design and
TABLE 1: INSTRUMENTS
INSTRUMENT
NUMBER
PERCENT
Alto Saxophone
5
14%
Bass Clarinet
2
5%
Bassoon
2
5%
Clarinet
14
38%
Flute
11
30%
Oboe
2
5%
Tenor Saxophone
1
3%
Total
37
100%
TABLE 2: SOURCE OF SPECIMENS
ORGANIZATION
AGES
NUMBER
Delmar College Wind Ensemble
18-24
16
43%
Corpus Christi Municipal Band
21-75
18
49%
Veterans Band of Corpus Christi
65-90
3
8%
Total
37
100%
TABLE 3: SPECIES BY INSTRUMENT
INSTRUMENT
BACTERIA
NUMBER
Alto Saxophone
Chryseobacterium indologenes
1
Diphtheroids
1
Staphylococcus (coagulase
negative)
1
Vibrio alginolyticus
3
No growth
1
Bass Clarinet
Vibrio alginolyticus
2
Bassoon
Pseudomonas fluorescens/putida
1
Stenotrophomonas maltophilia
1
Vibrio alginolyticus
1
Clarinet
Acinetobacter lwoffi
2
Alcaligenes faecalis
3
Chryseobacterium indologenes
1
Diphtheroids
3
Pastuerella multocida
1
Photobacterium damsela
1
Pseudomonas fluorescens/putida
2
Streptococcus viridans
1
Vibrio alginolyticus
2
No growth
2
Flute
Hemophilus parainfluenzae
1
Staphylococcus (coagulase
negative)
2
Streptococcus viridans
1
No growth
8
Oboe
No growth
2
Tenor Sax
Chryseobacterium indologenes
1
Proteus penneri
1
8TPHA Journal Volume 68, Issue 4
TABLE 4: BACTERIAL SPECIES
BACTERIA
CHARACTERISTICS
Acinetobacter lwoffi
Aquatic. May be normal flora.
Associated with pneumonia and
meningitis
. Opportunistic for patients
with impaired immune systems.
18,19,20.
Alcaligenes faecalis
Found in moist areas including brass
instruments.1 Rarely a pathogen but can
cause infection in immunocompromised
individuals.21
Chryseobacterium indologenes
Rarely a human pathogen but infections
have been associated with a high
mortality rate.22 “Vast majority
associated with immunocompromised
patients.”23
Diphtheroids
Commonly regarded as contaminant but
may cause subacute bacterial
endocarditis in a haemodialysis patient.24
Hemophilus parainfluenzae
Normal flora in the human oral cavity.
Generally has low pathogenic potential
but may become a patho
gen ‘when
impaired airway defenses delay bacterial
clearance.”
25,26
Pastuerella multocida
Found in the normal oral flora of dogs
and cats. Has been recovered from the
respiratory tract of humans. Associated
with infections from animal bites and
scratches.27
Photobacterium damsela
(formerly Vibrio damsela) Marine
bacterium. Causes infections and fatal
disease in a wide range of marine animals
and humans.
28
Proteus penneri
Nosocomial pathogen believed to cause
kidney stone formation. May cause
nosocomial infection in ICU and those
with respiratory and urinary tract
infections.29,30
Pseudomonas species
Uncommon cause of skin and soft tissue
infections.
May cause illness when
associat
ed with “trauma or
immunocompromised state.”
31
Staphylococcus (coagulase neg)
Normally found on skin and mucous
membranes. May cause bacterial
endocarditis and urinary tract infections,
especially if indwelling catheters or
artificial heart valves.32.33
Stenotrophomonas maltophilia
Found in aqueous habitats. Also found in
respiratory tract infections and has a
significant case fatality ratio. “A
particular concern for
immunocompromised individuals.”34
Streptococcus viridans
Part of the normal flora of the oral cavity
and is associated with subacute bacterial
endocarditis. “May infect damaged heart
valves and leukemia patients.”35,36
Vibrio alginolyticus
Found in marine environments. Infection
may occur when traumatized skin is
exposed to seawater
or infected
animals.
37,38
TPHA Journal Volume 68, Issue 4 9
high silver content.
DISCUSSION
This is a small data set that provides at best a glimpse of the
bacterial milieu of woodwind instruments. Corpus Christi is
a warm humid environment. It is possible that the Texas cli-
mate could have infl uenced the types and amounts of bacte-
rial species recovered. Greg McCutcheon, director of bands
at Birdville Independent School District stated that “a hot,
humid climate like that in Texas can also wreak havoc with
brass instruments.”14 Also illnesses and health conditions of
the musicians may aff ect the bacterial content and pathoge-
nicity of instrument’s released fl uids. Woodwind instruments
comprise a very heterogeneous group resulting in a wide va-
riety of bacterial species recovered. Most are generally not
human pathogens but may become pathogenic in specifi c cir-
cumstances such as persons with impaired immune systems
or chronic disease. In general the liquid from the woodwind
instruments does not pose an environmental hazard to persons
with normal immune systems. Even so, it is important for mu-
sicians to maintain their instruments and to use at least some
consideration when ridding their instrument of the fl uids that
have accumulated. Some musicians, especially older ones,
may have health conditions which would make them vulner-
able to opportunistic bacterial infections.
Although musicians are generally healthy, there is the poten-
tial for signifi cant disease to spread through band members
and others using the rehearsal area. In 2015, The Cavaliers
Drum and Bugle Corps cancelled a performance because of
an outbreak of viral illness among the members.15 Bands and
wind ensembles are composed of a wide variety of individuals
ranging from preteens to octogenarians and older. The disci-
pline and physical demands of playing in a wind ensemble
have many benefi ts ranging from increasing memory capacity
and time management skills to improving mathematical abil-
ity, reading and comprehension.16 Some studies indicate that
students who take music lessons have increased intelligence
quotient (IQ) levels.17 Although there are numerous articles
detailing the risks of instrument playing, the authors of this
article believe the benefi ts of playing a wind instrument far
outweigh the risks.
RECOMMENDATIONS
Band directors and section leaders should be aware of their
members and especially if there are musicians or other partici-
pants who would be vulnerable to released uids. It is a good
musical and health practice to clean instruments regularly. By
drying the instrument after each practice session or rehearsal,
the moisture level is reduced which reduces the substrate that
supports bacterial growth.
Reeds can be cleaned via a few solutions that won’t render the
reed useless. Reeds should be stored in a reed case that will
maintain the proper amount of moisture needed to preserve
the quality of the reed. The proper storage of reeds allows
for the mouthpiece of the instrument to dry which will reduce
bacterial contamination and the scaling that frequently hap-
pens on plastic mouthpieces.
Good practices will reduce the amount and the diversity of
the bacteria found in the condensation that forms in the in-
strument. Instrumentalists should also consider a healthy life
style, including appropriate amounts of rest, proper hydration,
healthy eating, and frequent hand washing. These practices
coupled with maintaining a clean instrument should be help-
ful in cultivating a healthy woodwind section and in advanc-
ing the health of the entire ensemble. Care of musicians and
musical instruments will reduce the risk of self acquired in-
fections and spread of infection to other persons using the re-
hearsal area.
ACKNOWLEDGEMENTS
Thanks to Abel Ramirez, conductor, Del Mar College Wind
Ensemble, Ram Chavez, conductor, Veterans Band of Corpus
Christi and John Bridges, conductor, Corpus Christi Munici-
pal Band. Thanks to Dan Hardy, MD and Rhonda Brown, MT,
ASCP of Clinical Pathology Laboratories for their assistance
with cultures. Thanks to Leslie Dillon, RN of Medical Arts
Clinics for coordination and scheduling.
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PERCENT
Bacillus
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Coccus
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Coccobacillus
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