Reentry Following COVID-19: Concerns for Singers

Published ahead of print 1

Journal of Singing, published ahead of print

https://doi.org/10.53830/VAPD6085

National Association of Teachers of Singing

CARE OF THE PROFESSIONAL VOICE

Robert T. Sataloff, Associate Editor

David Meyer

Lynn Helding

Tom Carroll

Christine Petersen

John Nix

Allen Henderson

Jeremy Faust

Reentry Following COVID-19:

Concerns for Singers

David Meyer, John Nix, Lynn Helding, Allen Henderson, Tom Carroll, Jeremy Faust, Christine Petersen

INTRODUCTION

       in its subtitle: “Concerns

for Singers.” While the COVID-19 pandemic has wreaked devas-

tation upon disparate types of people around the world, singers,

and those who teach and collaborate with them, are a vulnerable

cohort within this larger global health crisis. This vulnerability is due to a

number of facts about the SARS-CoV-2 virus, beginning with its three main

routes of transmission as outlined by the U.S. Centers for Disease Control

and Prevention (CDC): (1) inhalation of very ne respiratory droplets and

aerosol particles; (2) the deposition of virus-containing droplets and particles

on exposed mucous membranes in the mouth, nose, or eye by direct splashes

and sprays; and (3) touching mucous membranes with hands that have been

soiled either directly by virus-containing respiratory uids or indirectly by

touching surfaces with virus on them.

The CDC has further explained that “the risk of SARS-CoV-2 infection

varies according to the amount of virus to which a person is exposed” and

notes that the two main variables concerning this amount are distance and

time.

Regarding the former, how far away an individual is from the respira-

tory droplets of an infected person, combined with the observation that the

concentration of the virus is diluted by both gravity (heavier drops fall) and

mixture with air, illustrates why the CDC states that “the available evidence

continues to demonstrate that existing recommendations to prevent SARS-

CoV-2 transmission remain eective. These include physical distancing.”

The parameter of time exerts a similar dilution of viral viability and potency.

Yet using those same parameters of distance and time, the CDC also notes

that “transmission of SARS-CoV-2 from inhalation of virus in the air farther

than six feet from an infectious source can occur [emphasis added] under

certain preventable circumstances,” one of which is “Prolonged exposure to

these conditions, typically more than 15 minutes.”

The CDC report goes

on to note two other factors that increase the risk of SARS-CoV-2 infection.

• Enclosed spaces with inadequate ventilation or air handling within which

the concentration of exhaled respiratory uids, especially very ne droplets

and aerosol particles, can build-up in the air space.

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David Meyer, John Nix, Lynn Helding, Allen Henderson, Tom Carroll, Jeremy Faust, Christine Petersen

• Increased exhalation of respiratory fluids if the

in fec tious person is engaged in physical exertion or

increases the intensity of their voice (e.g., exercising,

shouting, singing).

It has been shown that there are signicantly higher

emission rates for singing compared to mouth breathing

and speaking.

This nding plus the CDC report indicates

that the typical voice teacher who instructs singers on a

back to back hourly schedule in a one on one setting, oen

in a small room with poor ventilation, may be especially

vulnerable to COVID infection, particularly from unvac-

cinated students and collaborators (e.g., pianists). Indeed,

voice teachers in these situations could be considered

“sitting ducks” for multiple respiratory illnesses, from the

common cold to inuenza, but the virulence of the SARS-

CoV-2 virus and the mortality rate of COVID-19 illness

are without modern precedent: in the United States, a

country with 331,449,281 persons

, 33,558,862 cases of

COVID-19 and 602,275 fatalities

have been reported as

of June 22, 2021. These gures indicate that one in ten

persons contracted the virus in the US, and of those who

contracted COVID-19, one in 56 died from the illness.

This ongoing global health crisis has added a height-

ened level of urgency to a list of concerns for singers. As

noted by this team of authors in a previous article with the

same subtitle, that list of concerns includes the COVID-19

sequelae most likely to disrupt or permanently damage

those functions that are necessary for singing.

The degree to which voice teachers can protect

themselves from communicable diseases like COVID-

19 begins with the amount of personal agency they

wield. Self-employed singing teachers possess a large

degree of autonomy regarding their work environment,

including the degree and length of time to which they

may be exposed to the SARS-CoV-2 virus; so do sing-

ers who volunteer for a community or church choir.

Notwithstanding the emotionally difficult choices

involved with avoidance or complete cessation of sing-

ing activities, the fact remains that such people do have

choices. Yet teaching faculty at music conservatories

or teachers in commercial music companies may have

few, if any, choices about their teaching environments.

In anticipation of a return to in-person teaching and

learning, a growing number of colleges and universities

are requiring vaccination against COVID-19 for faculty,

sta, and students who intend to pursue in-person stud-

ies on campus this fall.

Yet reentry to live interaction

for institutionally based teachers and singers is less clear

cut than this requirement might suggest, rst by allowing

vaccine hesitant students to decline the vaccine, osten-

sibly for health or religious reasons. A number of other

factors complicate reentry, including vaccine hesitancy

among nonstudent sta and faculty colleagues, changing

CDC guidelines and recommendations, foreign students

who have had vaccines not authorized by the FDA, and

university administrations and commercial studios so

anxious to return to in-person teaching and learning to

recoup the economic losses of the past year that they

have issued directives to employees forbidding them

from inquiring about vaccination status among their

students and collaborators.

This article aims to provide resources to help sing-

ers safely and ethically navigate a return to in-person

instruction by considering the following:

(1) Vaccination and Voice Teachers

• Monitoring Local Levels of SARS-CoV2 Incidence

• Safety of Vaccination

• Vaccination and SARS-CoV-2 Variants

(2) Mask Use Recommendations

(3) Aerosol Risk Update

(4) Environmental Risk Factors and Mitigation

• Risk Factors in Studio Voice Instruction

• Environmental Risk Mitigation

— Increasing Air Changes Per Hour

— CO

Meters

— Air Changes Between Lessons/Rehearsals and

Lesson Duration

(5) FERPA, HIPAA, and Vaccine Hesitancy

(6) Psychological Risks Associated with the Pandemic

and Reentry

• The General Psychological Impact of the COVID-

19 Pandemic

• The Physiological Impact of Stress, Anxiety, and

Trauma on Voice

• Resources and Advice in Support of Mental Health

(7) Risk Assessment

VACCINATION AND VOICE TEACHERS

[Disclaimer: the following vaccination information and

risk estimates are for Pzer-BioNTech and Moderna

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Care of the Professional Voice

complete (2 shot) vaccinations. Johnson and Johnson

Janssen, AstraZeneca, Sputnik V, and Sinovac vaccines

will have diering levels of ecacy against emerging

variants. For more information, consult your healthcare

provider.]

A high rate of vaccination is the only path toward

the safest possible “new normal” within 2021. We can

never achieve zero risk for a viral infection that is likely

to remain in low levels of circulation for the foreseeable

future. However, vaccination can and does render SARS-

CoV-2 comparable to many other respiratory infections

that we routinely encounter in its likelihood to cause

illness or death. Without vaccination, SARS-CoV-2 is

without a doubt a far deadlier and more dangerous

virus than those other pathogens, such as inuenza or

respiratory syncytial virus.

Safe in-person teaching and

learning is best facilitated by high rates of SARS-CoV-2

vaccination in any given community, as this decreases

viral spread and the potential creation of variant viruses

and lowers the frequency of severe disease.

Voice teachers are at higher risk forallviruses that

spread through droplets or are in the air because of small

studio size and the resultant concentration of exposure

to droplets or virus aerosols in that studio.

However,

because most teach one person at a time, the mathemati-

cal odds of exposure for solo voice teachers in any given

day, week, or month will remain low (as compared to

other higher-population density locations such as public

transit or large packed lecture halls). While a small num-

ber of vaccinated people can become infected from solo

voice lesson settings, an even smaller number is likely to

go on to experience substantial disease.

Monitoring Local Levels of SARS-CoV-2 Incidence

There are multiple user friendly resources to monitor the

local SARS-CoV-2 incidence (number of infections over

a given period of time) and get a sense of one’s personal

risk of exposure, usually per 100,000 people. A popular

source has been the COVID-19 Dashboard provided

by the Center for Systems Science and Engineering

(CSSE) at Johns Hopkins University (available at

https://coronavirus.jhu.edu/map.html). The New York

Times has provided similar maps and data about both

case incidence and vaccination rates, using the Johns

Hopkins data as well as locally sourced data (available

at https://www.nytimes.com/interactive/2021/world/

covid-cases.html). In addition, many states and coun-

ties within the United States have data dashboards, but

these are beginning to be removed in some locations;

users are advised to check whether the information has

been recently updated.

Safety of Vaccination

The technology used in all of the currently approved

vaccines in the United States is based on decades of

peer reviewed, validated science, including use of

mRNA vaccines.

The evidence provided from these

studies in animals, clinical trials in people for previ-

ous vaccines, and the data from hundreds of millions

of people now vaccinated is that the risk of an adverse

event, or a “severe vaccine reaction” like anaphylaxis or

death is less than 0.002%.

The annual risk of death in

an automobile crash or from a rearm related incident

far exceeds this value.

All of the published data to date

indicate that COVID-19 vaccines approved for use in the

United States are safe and eective during pregnancy.

The impact of a COVID-19 infection on a pregnant

woman, on the other hand, is notable. COVID-19 has

been associated with a 25 to 30-fold increase in maternal

mortality.

Vaccination safely prevents infection and

disease in pregnant women. In addition, some antibod-

ies generated by vaccination are found in breast milk,

which likely provides some degree of passive, short term

protection to breastfed infants.

Vaccination and SARS-CoV-2 Variants

Some SARS-CoV-2 variants of concern may reduce the

success rate of vaccinations; this reduction in success

has not been confirmed for the Pfizer and Moderna

vaccinations.

However, if overall hospitalization rates

remain low in a community, the composite risk among

vaccinated persons is manifestly not different than

historical risks we accept from other endemic respira-

tory viruses, most of which typically cause mild or even

moderate self-limited disease in most targets, but which

in some instances can cause serious disease (i.e., in those

with other health risks). Given that, the opportunity for

arts organizations to “return to normal” and “stay open”

should not hinge on the presence of a small number of

breakthrough cases, even serious ones, but rather on

hospitalization patterns. If rates of hospitalization are

at historically normal levels and vaccination rates are

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David Meyer, John Nix, Lynn Helding, Allen Henderson, Tom Carroll, Jeremy Faust, Christine Petersen

high, live performing arts should remain safe. However,

if variants emerge that evade the protection provided

by vaccines such that there are once again spikes in

hospitalization (in any age group), a return to stricter

mitigation measures may become necessary.

MASK USE RECOMMENDATIONS

Persons who meet all the following criteria do not need

to routinely wear masks in indoor group settings: those

who are fully vaccinated, who do not have special risks

(such as a profound immunocompromised state seen in

those who are bone marrow transplant or solid organ

transplant recipients who take antirejection medica-

tions),

and who are living in areas with low COVID-19

incidence, and when the overall majority of the group

is greater than 70% vaccinated.

While it is possible

for vaccinated people to become infected, the likeli-

hood of spreadfromsuch persons is low,

especially in

asymptomatic infections (unlike unvaccinated asymp-

tomatic infection, in which spread has been frequently

documented).

Even though vaccinated individuals with

breakthrough infections could theoretically spread the

virus to a small number of people, vaccination of any

potential contact provides a great deal of protection.

People who are vaccinated, but who have prolonged

and frequent exposure to unvaccinated persons, may

reasonably choose to wear a mask to prevent break-

through infection to others. Mask wearing in this setting

would be less necessary if unvaccinated persons are

required to be routinely tested, with mandatory isola-

tion or quarantine of any people testing positive as well

as their contacts and/or in areas of very low incidence

of COVID-19.

Rapid antigen tests are highly eective

in detecting the presence of contagious virus in a test

sample and provide information that is available in time

to be safely relied upon for decision-making and removal

of potentially infectious persons from the group.

The

CDC and WHO recommend that unvaccinated people

continue to wear masks and physically distance them-

selves when inside with others. Most recently, the WHO

has recommended the continuation of mask-wearing by

all individuals.

As the global public health body, this

advice is grounded in the need to prevent spread of new

viral “mutants” or variants of concern that can arise in

locations with very low vaccination rates globally that

may be able to avoid or “escape” the protection provided

by immune responses produced by vaccination.

This masking requirement, while most appropriate

globally, should be considered necessary indoors in areas

of the United States with local/county level COVID-19

vaccination rates of less than 70% of all adults, but is also

strongly recommended in crowded locations elsewhere

inside and out. It is best practice to have an informal

conversation with students and colleagues about vacci-

nation to establish what precautions should be taken to

protect all parties. In addition, based on the remarkable

downward trends of inuenza globally as well as within

the United States in the last year due to mask wearing

and social distancing,

healthcare professionals and

public ocials are indicating that to prevent having the

u or other serious viral infections (like RSV in small

children), they are seriously considering regular mask

use starting in the late fall and continuing through the

high transmission period of February.

Those who sing

or are around people singing regularly might also take

this into consideration as a wise precaution.

AEROSOL RISK UPDATE

As opposed to direct transmission through a handshake

or other direct person to person contact, indirect trans-

mission, and specically airborne transmission, is now

accepted as the dominant form of SARS-CoV-2 trans-

mission.

The airborne route occurs during phonation,

coughing, sneezing, and certain medical procedures,

among other activities. There are three size ranges of

particles that contribute to infection transmission: drop-

lets, the largest particles, and by denition greater than

5 microns (); medium sized particles of 1 to 5 ; and

small particles of 1  or smaller.

Airborne transmission

can occur by any of these three particle sizes, however

the medium sized particles pose the greatest risk, despite

the recommended six feet of physical distancing being

followed.

Room size, the number of infected people in

a space, the activity being performed in the room, and

room ventilation all play a role in risk of transmission

and will be discussed elsewhere in this article.

Large droplets tend to dominate in a cough, as opposed

to typical speech. Small particles, less than one , carry

little virus but can oat around for hours. Thus, medium

particles contribute to the majority of disease transmis-

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Care of the Professional Voice

sion.

Less than ve microns in size, the medium particles

then dry and shrink in the air, concentrating their viral

load as so-called “droplet nuclei” and oat for hours in

a space, thus creating the need for proper mitigation by

those considering using that space.

Breathing, speaking, and singing lead to aerosoliza-

tion of typically small particles that originate in the

bronchioles and alveoli of the lungs. A uid lm burst

occurs as we exhale, leading to these small particles being

released from the lungs.

There is also some evidence

that the larynx, the vocal folds, and possibly the oral

cavity produce a majority of medium-sized particles

through a similar method of uid lm burst, which is

why speaking and singing contribute to the viral load

in a closed space.

When speech or singing is louder,

more aerosolization occurs.

Lung volume seems to

directly correlate with expelled viral load: adolescents

and adults have been shown to produce more aerosols

than children.

Face masks have been integral in mitigating the

spread of the SARS-CoV-2 virus to some extent; how-

ever, there is no conrmatory conclusion of this due to

conicting data on the eciency of wearing face masks

to prevent the spread.

We do know that strict social

distancing and wearing masks reduces transmission and

thus mitigates risk. Short range airborne transmission,

meaning transmission through the air from one person

to another, of droplets less than 100  likely is more com-

mon than typical droplet transmission when distances

are 0.2 m or less during normal talking or 0.5 m or less

during coughing.

Droplets will fall to the oor short

of these distances if they are 100  or larger, whereas

droplets and particles smaller than this size will move

through the air to potentially infect another person in

proximity.

Thus, six feet of distance may not be enough

in certain situations.

It has been demonstrated that unmasked transmis-

sion can occur farther than six feet apart, up to 10

meters when the infected person is unmasked.

previously discussed, there is some conicting data on

mask use, as it is also demonstrated that two meters of

distancing is probably safe if both parties are masked.

Small and medium particles can move up to ve meters,

obviously longer than two meters or six feet of distance.

As a caveat to this, Issakov et al. demonstrated that

there is a decrease in concentration of particles in the

direction of airow.

ENVIRONMENTAL RISK

FACTORS AND MITIGATION

Risk Factors in Studio Voice Instruction

Studio voice instruction consists of one to one sessions

between a singing teacher and a student, with the pos-

sible addition of a collaborative pianist in the teaching

space. While this intimate setting allows artists to explore

their potential without public scrutiny, this same inti-

macy can leave teachers, students, and other collabora-

tors vulnerable to respiratory infections.

Singing, and

in particular more robust types of singing that feature

high sound pressure levels, has been shown to be a high

aerosol generating activity.

Instruction occurs in vari-

ous sized venues and ventilation conditions; teachers

outside of academia may work in shared studios or in

places of residence, while those in academic settings may

teach in practice rooms (graduate assistants, adjunct

faculty) or faculty oces. In the U.S., no standards exist

regarding academic instruction room size; the major

accreditation handbook only states “Space allotted to any

music unit function must be adequate for the eective

conduct of that function,” and “All instructional facili-

ties shall be accessible, safe, and secure, and shall meet

the standards of local re and health codes.”

As such,

teachers, students, and pianists may interact in rooms

too small for physical distancing measures and with

variable or unknown ventilation. Both shared rooms and

individual oces have a number of frequently touched

surfaces, such as doors, piano keys, music stands, etc.,

which may serve as fomites. Teachers and pianists usu-

ally interact with multiple students per day, oen in close

succession, with each student having a unique health

history and hygiene habits that are oen not disclosed

to the teacher or pianist.

Environmental Risk Mitigation

Given the previously mentioned conditions, teachers of

singing, voice students, and pianists could be considered

at greater risk for transmitting the SARS-CoV-2 virus

and other upper respiratory contagious illnesses than

the general population. However, several relatively low

cost changes to the teaching and rehearsing environment

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David Meyer, John Nix, Lynn Helding, Allen Henderson, Tom Carroll, Jeremy Faust, Christine Petersen

may reduce much of this increased risk. The changes

include increasing the number of air changes per hour

(ACH) in the teaching or rehearsal space; increasing

the amount of outside fresh air brought directly into the

room; using HEPA ltration units; using CO

meters to

track room ventilation in real time; allowing air change

time between lessons and rehearsals, and modifying les-

son durations according to the vaccination status of the

individuals involved and the community infection level.

Each of these changes/interventions is detailed below.

Increasing Air Changes Per Hour. Air changes per

hour (ACH) is dened as the volume of air added to or

removed from a space in one hour divided by the vol-

ume of the space.

Higher ACH values provide better

dilution or removal of potential infectious aerosolized

particles, reducing exposure time and therefore lowering

risk.

Means for increasing air changes include natural

ventilation with outside air, recirculated air that is l-

tered, and the use of portable high eciency particle air

(HEPA) lters.

Of these, admitting outside air through

the opening of windows or outdoor air dampers is the

most desirable,

although building design, external tem-

peratures, and local air quality levels may preclude this.

Modern buildings typically feature heating, ventilation,

and air conditioning (HVAC) systems that introduce

fresh air and exhaust a percentage of the recirculated

air continuously. In the United States, recirculated air is

ltered for particulate removal with no less than a MERV

8 lter.

Thus, the stated ACH in public buildings is a

mix of fresh air changes and ltered air, with the ltered

air considered as equivalent air changes based on the

eciency of the building’s ltration.

Portable HEPA

ltration units also are a viable, cost eective ($100–250

as of July 1, 2021) and exible means for increasing the

total ACH. Filters meeting the HEPA standard must

remove at least 99.97% of particles from the air that

passes through with a diameter = 0.3microns, with

filtration efficiency increasing for particle diameters

smaller and larger than 0.3microns.

HEPA lters thus

are theoretically capable of capturing small SARS-CoV-2

viral particles (0.1 microns) as well as medium sized

particles and droplet nuclei (<5 microns).

A key means

to quickly determine the suitability of a HEPA unit for a

teaching space is the Clean Air Delivery Rate (CADR).

By comparing the HEPA lter’s CADR in cubic feet per

minute with the room’s volume, an equivalent ACH

value for the lter can be determined; this can be added

to the fresh and recirculated ACH values to determine

the total ACH for the space.

Meters. Carbon dioxide (CO

) meters can be used

to measure carbon dioxide levels in parts per million in

a teaching space. While CO

meters are not regarded

as providing accurate information about the viral load

in a room, they can provide cost eective ($100–165 as

of July 1, 2021) real-time information on the fresh air

ventilation in a room, which can be an analog of the

ACH rate and by extension the ability to dilute or remove

potentially infectious aerosolized particles.

levels

rise with poor fresh air ventilation, an increased number

of persons in a room, and increased physical activity level

of persons in the room.

Based on available evidence,

the authors recommend a CO

level of 800 ppm be used

as a threshold level of good air quality. When levels

exceed 800 ppm, more fresh air should be admitted.

Air Changes Between Lessons/Rehearsals and Lesson

Duration. A nal means to make inexpensive environ-

mental changes to reduce infection risk is allowing air

changes between lessons/rehearsals

and reducing

lesson/rehearsal durations.

The former provides time

for the room ventilation to dilute or remove potential

infectious particles, and the latter reduces the total

number of particles emitted in a lesson. Teachers and

pianists are advised to know the ACH of their teaching/

rehearsal spaces. At 6 ACH, one air change occurs every

10 minutes. The authors recommend at least one air

change (fresh air or ltered equivalent) aer each lesson

and advise limiting lesson lengths to 30 minutes if the

singer is unvaccinated.

FERPA, HIPAA, AND VACCINE HESITANCY

There are two United States federal laws currently in the

forefront of considerations among educators, admin-

istrators, studio owners, and others as they prepare

for the liing of COVID-19 restrictions and in-person

collaboration. The Health Insurance Portability and

Accountability Act of 1996 (HIPAA) was created to

protect sensitive patient health information from being

disclosed without the patient’s consent or knowledge.

The US Department of Health and Human Services

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Care of the Professional Voice

issued the companion HIPAA Privacy Rule to actually

implement the requirements of HIPAA, which addresses

several issues, including the use and disclosure of indi-

viduals’ protected health information by entities subject

to the Privacy Rule.

A major goal of the Privacy Rule is to ensure that

individuals’ health information is properly protected

while allowing the ow of health information needed

to provide and promote high quality health care and to

protect the public’s health and well-being. The Privacy

Rule strikes a balance that permits important uses of

information while protecting the privacy of people who

seek care and healing.

The second federal law, the Family Educational Rights

and Privacy Act (FERPA) protects the privacy of student

education records and applies to all schools that receive

funds from the US Department of Education.

The

intersection of these two federal privacy laws is causing

confusion for teachers and administrators in the era of

COVID-19. It is rather simple to clarify the rst of these

(HIPAA) for voice teachers. Because HIPAA only applies

to specic health care entities such as insurance provid-

ers, health care clearinghouses, health care providers

and their business associates, voice teachers who do not

work in a clinical environment on a medical team should

not be concerned with violating HIPAA. If employers,

supervisors, or even clients themselves attempt to use

HIPAA as a justication to prevent a voice teacher from

discussing vaccine hesitancy with voice students, they

are in error. The only exception to this is voice teachers

who work in a clinical environment.

FERPA is another misunderstood statute in the

COVID-19 era. In March 2020, the US Department

of Education issued a “Frequently Asked Questions

(FAQs)” document to clarify issues about FERPA and

COVID-19.

First, FERPA only applies to educational

records maintained by an institution. Learning about

a student’s vaccination status through a social media

post or casual conversation is not a violation of FERPA.

Further, because the US Department of Health and

Human Services declared COVID-19 a Public Health

Emergency in January 2020, there are emergency pro-

visions under the FERPA “health or safety emergency

exception” that allow an educational agency to make

determinations on a case by case basis inclusive of the

totality of circumstances. Teaching in one on one set-

tings in studios is such a unique setting that a case could

be made to share information.

Under the FERPA health or safety emergency exception,

an educational agency or institution is responsible for

making a determination, on a case-by-case basis, whether

to disclose PII [personally identifiable information]

from education records, and it may take into account

the totality of the circumstances pertaining to the threat.

... If the educational agency or institution determines

that there is an articulable and signicant threat to the

health or safety of the student or another individual and

that certain parties need the PII from education records,

to protect the health or safety of the student or another

individual, it may disclose that information to such par-

ties without consent.

Some entities and institutions are issuing policies

and guidelines claiming that asking persons (including

students) about their vaccination status is a violation

of one or both of these US privacy laws; some are even

doing this without explicitly using HIPAA or FERPA as

justications, but vaguely referring to potential viola-

tions of privacy via “coercive or pressuring behavior.”

At best, such policies may be in error, and at worst,

are justifications used to wield control over impor-

tant information and those who have access to it.

Communications like these when sent to employees

seem to indicate that there are no exceptions, while

the reality is that there may be a number of allowable

exceptions to privacy laws like FERPA. Indeed, the

FERPA “health and safety emergency” exception is the

mechanism within which justiable exceptions are made.

Nevertheless, faculty should exercise sensitivity and

diplomacy when inquiring about vaccine status among

students, especially in institutional settings. Primarily

these are concerns centered on religious and disability

discrimination rather than protected health information.

Therefore, it is important that singing teachers in each

of the following settings fully understand the excep-

tions provided for under the FERPA “health or safety

emergency exception.”

Independent studio teachers are not subject to either

HIPAA or FERPA, but should establish studio policies

based on their setting and personal risk prole. They

should know the current age limits for vaccination eli-

8 J  S

David Meyer, John Nix, Lynn Helding, Allen Henderson, Tom Carroll, Jeremy Faust, Christine Petersen

gibility and adjust their studio policies accordingly via

eective communication with clients, and/or underage

students and their parents or guardians, and monitor

and enforce their policies when necessary.

Voice teachers and collaborative pianists at institu-

tions without a vaccination requirement should con-

tinue promoting vaccination using advocacy messaging

provided by their institution or professional associations.

The joint statement issued by the NATS Voice Science

Advisory Committee, the American Choral Directors

Association, Chorus America, the Barbershop Harmony

Society, the Performing Arts Medicine Association, the

Pan American Vocology Association, Opera America,

and the National Collegiate Choral Organization is

one example.

Almost all institutions have developed

elaborate vaccine advocacy campaigns vetted by their

legal oces and distributed using print and social media.

Therefore, a faculty member may be viewed as an excel-

lent team player by using these resources to advocate that

everyone, including their private students, be vaccinated.

Faculty should further note that there are multiple ways

to discover the status of students while steering clear of

privacy concerns; for example, faculty may negotiate

vaccine status through an intermediary party, such as

their campus student or employee health service who

can provide an “all clear” rather than divulge individual’s

health information.

Finally, it is likely that many teachers already know the

status of most of their students either through students

volunteering that information in conversation or on

social media channels.

Unvaccinated or immunocompromised teachers and

collaborative pianists at institutions should contact

their Human Resources or appropriate oce on cam-

pus to negotiate accommodation. It could be possible

for such teachers to use the FERPA health or safety

emergency exception to justify certain parameters of

requested accommodations, such as: knowing the vac-

cination status of all students they are expected to teach;

receiving the institution’s assurance of the safest possible

work environment in terms of room size, ventilation,

masking, lesson length, and/or CO2 monitoring or other

factors impacting the safety of the teacher; and establish-

ing protocols for each category of student (vaccinated,

unvaccinated, and/or immunocompromised).

Voice teachers and pianists at institutions with a vac-

cination requirement may view FERPA with minimal

concern because the institution is requiring all to be

vaccinated. Many of these institutions are allowing

exemptions for unvaccinated individuals based on health

concerns or religious convictions. In such cases, teach-

ers should work cooperatively to establish protocols for

safe teaching in these unique settings as listed below for

“Vaccinated teachers at institutions.”

Vaccinated teachers and pianists at institutions should

realize they are signicantly protected by being vac-

cinated. Nevertheless, due to their unique one on one

teaching setting, oen in small spaces, teachers in this

setting are strongly encouraged to:

• follow the recommendations for “Voice teachers and

collaborative pianists at institutions without a vaccina-

tion requirement” (above);

• request informed discussions with appropriate

authorities on campus;

• prepare for such discussions by studying the FERPA

“health or safety emergency exception” (previously

referenced in this section);

• start the discussion with the claim that in order to

provide a safe environment in these unique spaces, it

is vitally important to know the vaccination status of

each student they are expected to teach;

• provide a customized solution for each category of

student (vaccinated, unvaccinated, and/or im muno -

compromised);

• mention the FERPA “health or safety emergency excep-

tion” as justication for your request of the release of

PII (personally identiable information).

These steps should open the door to discussion

to protect the health and safety of all who enter the

voice studio.

PSYCHOLOGICAL RISKS ASSOCIATED

WITH THE PANDEMIC AND REENTRY

COVID-19 has posed serious direct threats to physical

health and general wellbeing, and also has triggered

psychological problems for many, including anxiety,

depression, and post-traumatic stress disorder. While

voice teachers are not (typically) licensed mental health-

care providers, we must consider the psychological scars

Published ahead of print 9

Care of the Professional Voice

of the COVID-19 epidemic as we return to in-person

instruction. This section will examine the following:

the general psychological impact of the COVID-19

pandemic, the physiological impact of stress, anxiety,

and trauma, and resources and advice to support sing-

ers’ mental health.

The General Psychological Impact

of the COVID-19 Pandemic

Studies examining the psychological impact of the

COVID-19 are emerging. Qiu et al. developed the

COVID-19 Peritraumatic Distress Index (CPDI) and

used it with a sample of over 53,000 persons in China.

They examined the frequency of anxiety, depression,

specic phobias, loss of social functioning, and other

psychological factors related to the pandemic. Nearly a

third of the study’s respondents reported symptoms of

peritraumatic distress during the pandemic lockdown

in China. Similar levels of distress were reported in

Italian,

French,

and Filipino studies,

Iranian,

and

Brazilian

studies reported moderate to severe distress

in over 60% of their participants. While CPDI levels in

many of these studies declined when lockdown periods

were lied, meta-analyses of trauma literature have pre-

dictively linked severe levels of peritraumatic distress to

subsequent psychopathology.

COVID-19 peritraumatic distress was more severe in

certain populations. Studies found that persons 10–30

years of age experienced very high levels of distress,

possibly due to their increased consumption of social

media

and news related to the outbreak.

Gender also

appears to have been a factor, with female identifying

respondents showing signicantly higher CPDI scores

than male identifying counterparts.

Previous studies

also suggest that female identifying persons may be more

likely to develop posttraumatic stress disorder and may

be more generally vulnerable to the eects of stress.

Highly educated persons tended to have more severe

COVID-19 peritraumatic distress.

American uni-

versity students experienced high levels of depression

(43.3%), high anxiety scores (45.4%), and high levels of

PTSD symptoms (31.8%) in a study by Liu et al.

They

reported that increased levels of loneliness, COVID-19-

specic worry, and low distress tolerance were associated

with clinical levels of depression, anxiety, and PTSD

symptoms.

In a study of university students in China,

Tang et al. found that extreme pandemic fear was a sig-

nicant risk factor for peritraumatic distress, followed

by short sleep durations.

Alqudah et al. found that

university students in Jordan experienced severe anxiety

(40.6%) and mild to moderate anxiety (23.5%) due to

the shi to distance learning, quarantine isolation, and

increased student workload.

In short, the COVID-19 pandemic’s psychological

impact is unprecedented in the modern era; it is global

in scope, has received extraordinary documentation due

to smartphones and social media, and has created high

levels ofanticipatory anxiety due to the expected course

and spread of the virus.

Horesh and Brown suggest

it should therefore be treated as a new type of mass

trauma, and hypothesize that it has exacerbated exist-

ing mental health disorders and created a new wave of

stress-related disorders.

Persons who are particularly

vulnerable include those who are young, identifying as

female, university students, and those who frequently

consume social media/news concerning COVID-19.

This describes the majority of our collegiate singers.

The Physiological Impact of Stress,

Anxiety, and Trauma on Voice

The vocal instrument is biological and physiological,

and singers’ voices are sensitive to the eects of stress.

Psychologically, the voice is central to many singers’

sense of self,

and many nd it dicult to decouple

“who I am” from “what I do.” This point was clearly

described by Stohrer.

Singers are both the instrument and the player. Unable

to put the instrument back in its case and leave it in the

corner, a singer must carry it around, exposing it to ...

all the current viruses.

When identity and singing are inseparably linked, the

loss of performance opportunities can cause consider-

able distress.

Stress has physical consequences. Prior to the pan-

demic it was estimated that 50% to 70% of all visits to

a physician’s oce were due to stress related illness.

Stress can alter oral and vocal fold secretions, heart rate,

and gastric acid production,and is associated with head

and neck tension, decreased ability to concentrate, and

chronic fatigue.

Vocal fold pathologies (e.g., reflux

laryngitis and arytenoid irritation) can have etiologies

10 J  S

David Meyer, John Nix, Lynn Helding, Allen Henderson, Tom Carroll, Jeremy Faust, Christine Petersen

linked to increased gastric acid secretions caused by

stress,

and high levels of anxiety may increase the risk

of benign voice disorders.

Chronic stress has been

linked to more dangerous problems such as asthma,

depression of the immune system, and myocardial

infarction.

Making matters worse, the risk of ath-

erosclerotic cardiovascular disease is exacerbated by

quarantine conditions due to physical inactivity.

Thus,

the stressful conditions singers have experienced during

the COVID-19 pandemic may have serious long lasting

physical aereects.

Stress and anxiety can negatively affect control of

voice and respiration.

100

Muscular spasms in the larynx

have been observed due to the laryngeal nerve’s sensi-

tivity to emotional distress.

101

Traumatic experiences

(e.g., a global pandemic, the death of a family member,

a health/nancial crisis) can lead to voice symptoms

without underlying physical pathology.

102

Such symp-

toms were observed in a study of 313 Israeli collegiate

professors during the COVID-19 pandemic. The authors

found that psychological stress during the transition to

online teaching was associated with elevated levels of

voice problems. This was especially the case for those

who reported high levels of psychological stress.

103

Monti

et al. noted that emotional and psychological elements

can have a profound eect on a singer’s voice, and they

encourage singing teachers to be mindful that tech-

nical difficulties may have deeply rooted emotional

etiologies.

104

Trauma can also have a profound neurophysiologi-

cal eect on singers. When the brain perceives a threat

to survival (e.g., COVID-19 peritraumatic distress), a

“fight/flight/freeze” response may engage that shuts

down Broca’s area in the le frontal lobe of the cortex.

105

This profoundly inhibits one’s ability to put thoughts

and feelings into words, and can even mimic the eects

of a stroke or other physical lesion.

106

According to

polyvagal theory, perceived threats to survival may also

produce “a neural dissolution from systems of positive

social behavior and social communication,”

107

making

it dicult to feel connected to and safe around others.

108

Cues of safety and social engagement may ameliorate

these neurophysiological symptoms of trauma.

109

Singers around the world have experienced trauma

and loss related to the COVID-19 pandemic. This

trauma may be manifested in social phobias, music

performance anxiety, depression, and grief. The authors

of this paper hypothesize that epidemic levels of general-

ized anxiety, music performance anxiety, and depression

may be seen in singers during the forthcoming re-entry

phase of the pandemic.

Resources and Advice in Support

of Mental Health

There are numerous resources now available to support

the mental health of singers and teachers of singing.

Music performance anxiety (MPA) has been studied

extensively in the literature.

110

In The Musician’s Mind:

Teaching, Learning, and Performance in the Age of Brain

Science, Lynn Helding presents a useful review of the

MPA literature and discusses standard psychotherapies,

alternative therapies, and experimental therapies to

ameliorate its symptoms.

111

Depression is a common medical condition to con-

sider when working with singers. Nearly one in five

people will suer from major depression at some point

in their lives,

112

and this prevalence may increase follow-

ing the COVID-19 pandemic. Common speaking voice

symptoms of depression include a at aect, slowed

rate of speech, decreased length of utterance, lengthy

pauses, decreased pitch variability, mono-loudness, and

frequent use of vocal fry.

113

Discussing depression and

other mental health issues can be awkward,

114

but sing-

ers and teachers of singing are best served when these

discussions are normalized. Pedagogues are encouraged

to cultivate professional relationships with mental health

care providers. As always, “when in doubt, refer out.”

Integrating an awareness of and sensitivity to trauma

in pedagogic practice may benet singers as they return

to in-person instruction. While trauma awareness initia-

tives are becoming more common in schools,

115

similar

initiatives are generally lacking in higher education.

116

Literature on the therapeutic eects of singing, particu-

larly with survivors of abuse and trauma, is an excellent

starting place.

117

Jess Baldwin’s “Incorporating Basic

Trauma Awareness into the Voice Lesson” also oers

readers useful advice.

118

She recommends teachers pri-

oritize self-regulation (see also Van Eekelen et al.),

119

develop a plan and communicate it, establish connection

rituals, choose connection over productivity, validate

students’ feelings, break tasks into smaller segments,

show appreciation for eort, focus on positive resources,

Published ahead of print 11

Care of the Professional Voice

and be aware of the student’s self-regulation (see also

“student self-ecacy” in Crocco and Meyer)

120

while

encouraging calm, fun, and connection in the lesson.

Additional information on goal setting, journaling, and

the use of psychology to build connection in the voice

studio may be found in Meyer and Helding’s “Voice

Pedagogy: Practical Science in the Studio: ‘No-Tech’

Strategies.”

121



We all likely have experienced pandemic-induced loss.

Many continue to suer the lingering eects of trauma,

anxiety, depression, and grief. Singing instructors must

consider the psychological scars of the COVID-19 epi-

demic as we return to in-person instruction, because

we do not teach voice, we teach people. When in doubt,

refer students and colleagues to mental and medical

healthcare providers, and consider building trauma

awareness into standard pedagogic practice.

RISK ASSESSMENT

In a 2020 publication written by many of the present

authors,

122

several risk assessment tools and a deci-

sion assistance tool were provided. Here we provide

an updated risk/decision guidance chart (see Table1

below), which lists a number of moderately priced

environmental and behavioral interventions available

to the singing instruction community. Two levels of risk

are shown, and references are provided for each inter-

vention option. Other resources associated with a June

23, 2021 National Association of Teachers of Singing

webinar led by the authors, “Reentry aer COVID—

Concerns for singers,” can be found at https://www.

nats.org/cgi/page.cgi/_article.html/Featured_Stories_/

NATS_COVID_Resources_Page#webinars.

CONCLUSION

The SARS-CoV-2 pandemic has forced the singing voice

community to undergo rapid and substantial change.

Responses to the potentially life threatening situation

have included several key elements not discussed in this

article, chief among them being an explosion of remote

learning technologies, a reassessment of instructional

delivery methods (including synchronous in person and

online teaching as well as asynchronous work), and new

or expanded platforms for sharing live performances,

all of which were undertaken to reduce the risks associ-

ated with close personal contact. As the U.S. and other

Western countries continue to expand vaccination and

slowly emerge from COVID-19 restrictions, we have

reason for cautious optimism.

123

However, as they pre-

pare to return to in-person instruction and performing,

teachers, singers, and their collaborators should reex-

amine the unique risks that they collectively face at this

point in the pandemic.

We close with a plea for full vaccination and continued

patience (and, as warranted by local conditions, vigi-

lance) by the singing voice community. For those teach-

ers anxious about a return to in-person instruction, we

urge actively controlling what can be controlled: rst and

foremost, one’s own vaccination status; next, ensure that

the risk level within the teaching environment or rehearsal

studio is as low as possible; additionally, take proactive

behavioral steps such as those widely in use prior to the

availability of the vaccines, such as masking and distanc-

ing; nally, open a healthy and productive dialogue with

students and colleagues about vaccination and other

COVID-19 health issues, including mental/emotional

ones. For those teachers who are eager for “business as

usual,” we suggest that a prudent approach is still war-

ranted. The SARS-CoV-2 virus continues to mutate, and

infections remain prevalent among the unvaccinated.

There will likely be periods of greater and lesser public

health restrictions in the months and years ahead in

response to local conditions. We suggest maintaining the

many hygiene habits acquired during the last 18 months,

especially among the unvaccinated, not only for COVID-

19 mitigation, but also for other upper respiratory illnesses

that frequently aect the singing voice community. Simple

behaviors can make a marked dierence in reducing risks

to teachers, singers, and collaborative pianists: vaccinate,

ventilate, mitigate, and communicate.

ACKNOWLEDGEMENTS

The authors wish to thank the following professionals for

their expert feedback during the creation of this article:

• Rebecca Gayle Morrison, Ph.D., Clinical Psychologist

• Sarah Van Orman MD, Associate Vice Provost for

Student Health and Chief Health Ocer, University

of Southern California Student Health, and Clinical

Professor of Family Medicine, Keck School of Medi-

cine, USC

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David Meyer, John Nix, Lynn Helding, Allen Henderson, Tom Carroll, Jeremy Faust, Christine Petersen

TABLE 1. Environmental and Behavioral Risk Assessment.

ENVIRONMENT At Risk Safer Notes References

Air changes

per hour

(ACH)

<3 6 or more More air changes per hour

removes aerosols from the

teaching/rehearsal space,

reducing exposure time not

only to potential COVID

infections, but also cold and

flu viruses.

doi:10.1001/jama.2021.5053

Ability to

open win-

dows in

teaching

space

None Yes The ability to bring outside

air directly into the teach-

ing space is a key means

to reduce the number of

possibly infectious aerosol

particles in the room.

https://www.cdc.gov/coronavirus/2019-ncov/

community/ventilation.html;

https://osf.io/7rczy

HEPA filtra-

tion

None Yes (with a

room-size

appropriate

unit— sufficient

CADR for

volume of the

room)

HEPA filtration can be

a cost effective means to

increase the number of

equivalent air changes per

hour in a teaching space

that does not have windows.

JAMA and CDC references above;

see also https://www.ashrae.org/file%20

library/technical%20resources/covid-19/

in-room-air-cleaner-guidance-for-reducing-

covid-19-in-air-in-your-space-or-room.pdf;

https://pubmed.ncbi.nlm.nih.gov/33940414/

https://pubmed.ncbi.nlm.nih.gov/32662746/

https://pubmed.ncbi.nlm.nih.gov/32660218/

https://www.epa.gov/coronavirus/

air-cleaners-hvac-filters-and-coronavirus-

covid-19

https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC7711180/

https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC8084223/

Room size 100 square

feet or less

(10’ × 10’)

200 square feet

or more (14’ ×

14’)

The ability to distance one-

self from another person

who is singing depends

upon room size. Distancing

can reduce exposure risks

from directly expelled

particles (larger droplets)

containing COVID, cold,

and flu viruses.

See a calculator tool at: https://indoor-covid-

safety.herokuapp.com/;

additional calculator available at https://www.

mpic.de/4747361/risk-calculator?en;

https://www.jvoice.org/article/S0892–

1997(20)30245–9/fulltext

(table continues)

• Maura Copeland,Associate Vice President of Legal

Aairs, Georgia Southern University

• Lesley Persily, LPC (retired)

• Ronald C. Scherer, Ph.D., Distinguished Research

Professor, Department of Communication Sciences

and Disorders, Bowling Green State University

• Dr. Robert Sataloff, Professor and Chairman,

Department of Otolaryngology—Head and Neck

Surgery, Senior Associate Dean for Clinical Academic

Specialties, Drexel University College of Medicine

Published ahead of print 13

Care of the Professional Voice

TABLE 1. Environmental and Behavioral Risk Assessment (continued).

ENVIRONMENT At Risk Safer Notes References

meter

for real-time

monitoring

ventilation

None CO

meter

in singing/

rehearsal stu-

dio

meters provide a use-

ful real-time analog to the

number of local ACH. They

do not provide any infor-

mation about viral load, but

they are a useful measure

of the ventilation system’s

removal of expired air.

https://www.medrxiv.org/content/10.1101/20

20.10.26.20218354v1.full);

https://www.cdc.gov/coronavirus/2019-ncov/

community/ventilation.html;

https://pubmed.ncbi.nlm.nih.gov/32028176/;

https://www.health.state.mn.us/communities/

environment/air/toxins/co2.html;

https://www.epa.gov/sites/production/

files/2014–08/documents/indoorair20–247.

pdf;

https://pubs.acs.org/doi/10.1021/acs.

estlett.1c00183;

https://www.dhs.wisconsin.gov/chemical/

carbondioxide.htm

(table continues)

BEHAVIORAL

STEPS

At Risk Safer Notes References

Vaccination Teacher,

student, and

accompanist

are not vac-

cinated

Teacher,

accompanists,

and students

are all fully vac-

cinated

All three FDA-authorized

vaccines are readily avail-

able in the US. Vaccination

is safe, effective, and free.

Annual flu and pneumonia

vaccines are also recom-

mended.

https://www.fda.gov/emergency-

preparedness-and-response/

coronavirus-disease-2019-covid-19/pfizer-

biontech-covid-19-vaccine;

https://www.fda.gov/emergency-

preparedness-and-response/

coronavirus-disease-2019-covid-19/moderna-

covid-19-vaccine;

https://www.fda.gov/emergency-

preparedness-and-response/

coronavirus-disease-2019-covid-19/janssen-

covid-19-vaccine

Entrance

screening

No symptom

check for all

individuals

in the teach-

ing/rehearsal

space

Teachers,

accompanists,

and students

all self-screen

for COVID-

19 symptoms

before gather-

ing

Screening apps include:

https://covid19.apple.com/

screening/;

https://www.cdc.gov/

screening/index.html;

https://www.webmd.com/

coronavirus/coronavirus-

assessment/default.htm.

https://www.doh.wa.gov/Portals/1/

Documents/1600/coronavirus/Employervisit

orscreeningguidance.pdf;

https://www.cdc.gov/coronavirus/2019-ncov/

community/guidance-business-response.

html#anchor_1609683211941

Mask usage None Yes for all

unvaccinated

persons

CDC recommendations

include masking for all

unvaccinated persons

when gathering indoors.

Vaccinated persons with

reduced immune func-

tion may be encouraged to

continue masking by their

physicians. Masks can also

reduce the risk of cold and

flu virus transmission.

https://www.cdc.gov/coronavirus/2019-ncov/

daily-life-coping/participate-in-activities.html

14 J  S

David Meyer, John Nix, Lynn Helding, Allen Henderson, Tom Carroll, Jeremy Faust, Christine Petersen

TABLE 1. Environmental and Behavioral Risk Assessment (continued).

BEHAVIORAL

STEPS

At Risk Safer Notes References

Distancing Guidelines

not being fol-

lowed

6 or more feet

for unvacci-

nated persons

CDC distancing recom-

mendations for vaccinated

persons have been removed

as of May 16, 2021; for

unvaccinated persons, 6

feet or more is still recom-

mended. Distancing can

also help reduce the risk of

cold and flu transmission.

https://www.cdc.gov/coronavirus/2019-ncov/

daily-life-coping/participate-in-activities.html

Lesson

length

greater than

30 minutes

maximum with

unvaccinated

persons

Recommendation based on

research at the University

of Colorado and the

University of Maryland.

https://scholar.colorado.edu/concern/file_

sets/9s161736t

Air change

time between

lessons

None At least one air

change

Increase if an unvaccinated

person sings unmasked or

if infection rates in commu-

nity are rising.

doi:10.1001/jama.2021.5053

Aerosol

producing

activities (lip

trills, rasp-

berries, straw

in water,

vigorous fric-

atives, etc)

Yes, especially

if unmasked

or unvacci-

nated

Not used in

lessons, but

can be encour-

aged for solo

practice in

well-ventilated

spaces.

Some SOVTs produce large

amounts of droplets; masks

may prevent the spread of

droplets but not finer aero-

sols. Some ‘singer friendly

masks’ may permit SOVT

use in highly ventilated areas

with vaccinated singers only.

Vaccination reduces the

chance of the singer shedding

viral particles. Cold and flu

viruses may also be spread

through lip trill and rasp-

berry use in group settings.

pending report from Colorado State

University Bioaerosol Emission study –

See https://smtd.colostate.edu/

reducing-bioaerosol-emissions-and-

exposures-in-the-performing-arts/

Cleaning

common

surfaces

between les-

sons

None Yes, using alco-

hol or other

anti-viral and

anti-bacterial

cleansers

Reduces the risk of expo-

sure through fomites on

hands.

https://www.who.int/westernpacific/

emergencies/covid-19/information/

transmission-protective-measures;

https://www.who.int/emergencies/diseases/

novel-coronavirus-2019/advice-for-public

Teacher and

students

cleaning

hands before

lessons

None Yes, using hot

soapy water or

alcohol-based

cleansers

Reduces the risk of expo-

sure through touching

common surfaces and then

touching the nose, eyes, and

mouth.

https://www.who.int/westernpacific/

emergencies/covid-19/information/

transmission-protective-measures;

https://www.who.int/emergencies/diseases/

novel-coronavirus-2019/advice-for-public

Age of stu-

dents taught

Unvaccinated

adults and

children

ineligible for

vaccination

Vaccinated

adolescents

and adults

Adults produce more aero-

sols, but are more likely to

be vaccinated; adolescents

and children (especially

under age 12) are less likely

to be vaccinated.

https://journals.plos.org/plosone/article/

authors?id=10.1371/journal.pone.0246819

Published ahead of print 15

Care of the Professional Voice

NOTES

1. US Centers for Disease Control and Prevention (CDC),

“Scientific Brief: SARS-CoV-2 Transmission, Updated

May 7, 2021”; https://www.cdc.gov/coronavirus/2019-

ncov/science/science-briefs/sars-cov-2-transmission.html

(accessed June 28, 2021).

2. Ibid.

3. Ibid.

4. Ibid.

5. Ibid.

6. Dirk Murbe, Martin Kriegel, Julia Lange, Hansjorg

Rotheudt, and Mario Fleischer, “Aerosol emission is

increased in professional singing” (August 26, 2020): 1;

https://depositonce.tu-berlin.de/bitstream/11303/11491/5/

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David Meyer, John Nix, Lynn Helding, Allen Henderson, Tom Carroll, Jeremy Faust, Christine Petersen

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Published ahead of print 21

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A leading scholar and researcher of the singing voice, Dr. David Meyer

is an active performer, teacher, clinician, and voice scientist. He serves

as associate professor of voice and voice pedagogy at Shenandoah

Conservatory, and is Director of the Janette Ogg Voice Research Center.

He is also a member of the Scientific Advisory Board of the Voice

Foundation and is Co-chairman of the Voice Science Advisory Committee

of the National Association of Teachers of Singing. In 2010 he received the

Van L. Lawrence Fellowship, a prestigious national award in recognition

of his contributions to the eld of teaching singing and the use of voice

science. Dr. Meyer’s students have won numerous awards and have sung

in major venues worldwide. Please seewww.davidmeyervoice.comfor

more information.

John Nix is Professor of Voice and Voice Pedagogy and chair of the voice

area at the University of Texas at San Antonio. His mentors include Barbara

Doscher (singing, pedagogy) and Ingo Titze (voice science). Current and

former students have sung with the Santa Fe, Arizona, Chautauqua, St.

Louis, Nevada, Omaha, and San Antonio opera companies, and two have

served as NATS Intern Program Master Teachers. In addition to his active

voice teaching studio, he performs research in voice pedagogy, literature,

and acoustics, having produced 46 published articles and 8 book chap-

ters; he also co-chairs the NATS Voice Science Advisory Committee, and

22 J  S

David Meyer, John Nix, Lynn Helding, Allen Henderson, Tom Carroll, Jeremy Faust, Christine Petersen

serves on t he Journal of Singing’s editorial board. Mr. Nix is editor and

annotator of From Studio to Stage: Repertoire for the Voice (Scarecrow,

2002), vocal music editor for the Oxford Handbook of Music Education

(Oxford University Press, 2012), and one of three general editors for the

Oxford Handbook of Singing (Oxford University Press, 2019).

Lynn Helding is Coordinator of Vocology and Voice Pedagogy and a

studio voice teacher at the USC Thornton School of Music.She is the

author ofThe Musician’s Mind: Teaching, Learning & Performance in

the Age of Brain Science,the chapter “Brain” inYour Voice: An Inside

View3rded. by Scott McCoy, and has served as an associate editor of

theJournal of Singing,where she created the “Mindful Voice” column

in theJournal of Singing, authoring it from its debut in October 2009

to the nal installment in October 2017. Helding’s voice science honors

include the 2005Van L. Lawrence Fellowship,and election to chair the

founding of the rst non-prot vocology associationPAVA, incorporated

in 2014 as a 501(c)(6) non-prot association. Helding’s stage credits

include leading roles with Harrisburg Opera, Nashville Opera, and Ohio

Light Opera. She has commissioned new works and refashioned tradi-

tional recitals into theatrical performance pieces presented throughout

the United States, Australia, England, France, Germany, Italy, Spain, and

Iceland. Helding studied voice at the University of Montana with Esther

England, in Vienna with Otto Edelmann, and at Indiana University with

Dale Moore, where she was the rst singer to pursue the Artist Diploma.

She earned her master’s degree in voice pedagogy from Westminster

Choir College of Rider University and completed theSummer Vocology

Instituteat theNational Center for Voice and Speech. Please seewww.

lynnhelding.comfor more information.

Allen Henderson holds degrees from Carson Newman College (BM),

The University of Tennessee (MM), and the College-Conservatory of

Music at the University of Cincinnati (DMA), where his minor was in Arts

Administration and he was winner of the prestigious Corbett-Treigle Opera

Competition. Prior to his appointment as executive director of NATS in

2008, he served as district and regional governor and was elected national

secretary/treasurer from 2006–2008. He also served as interim executive

director from 2007–2008. Henderson was a participant in the 1993 NATS

Intern Program and later hosted the program in 1998. He was chair of

the coordinating committee for the 2008 NATS 50th National Conference

in Nashville, Tenn. Henderson has held teaching positions at Oklahoma

Baptist University, Austin Peay State University, and Georgia Southern

University. In these positions he has taught voice, foreign language

diction, opera, choral techniques, choral literature, song literature, and

directed choirs. He also served as music department chair at Austin Peay

and Georgia Southern. As baritone soloist, Henderson has appeared in

concert, opera, and oratorio across the country. A district winner and

regional nalist in the Metropolitan Opera auditions, Henderson was

winner of the 1995 National Federation of Music Clubs Artist Awards. He

also was a regional nalist in the NATSAA competition.

Dr. Thomas L. Carroll is a surgeon at Brigham and Women’s

Hospital (BWH) specializing in laryngology and Assistant Professor of

Otolaryngology at Harvard Medical School. Since 2014 he has served

as the director of the BWH Voice Program, which provides diagnoses

and innovative therapies for patients with voice, swallowing, and airway

disorders. Dr. Carroll’s interest in voice began as a boy chorister at St.

Thomas Choir School in New York and continued through a music degree

at Oberlin College. He received his MD from Wright State University

School of Medicine and completed his residency in otolaryngology at the

University of Colorado-Denver and Health Sciences Center. Dr. Carroll

completed a fellowship in laryngology and care of the professional voice at

the University of Pittsburgh Medical Center Voice Center. Clinical interests

include care of the professional voice, early glottic cancer with an empha-

sis on voice preservation, laryngopharyngeal reux, and related disorders

such as chronic cough, vocal cord paralysis/paresis, and ofce-based

laryngeal surgery, including vocal fold augmentation for both diagnostic

and therapeutic purposes and photoangiolytic (KTP) laser therapy.

Jeremy Samuel Faust, MD, MS, MA (@jeremyfaust) is an attending

physician in the Brigham and Women’s Hospital Department of Emergency

Medicine in the Health Policy Division and is an Instructor at Harvard

Medical School. He is medical editor-in-chief of ACEP Now and an associ-

ate editor of News & Perspectives for The Annals of Emergency Medicine.

His writing has appeared in The New York Times, Slate, The New York

Daily News, Mother Jones, Undark, and peer reviewed journals includ-

ing JAMA, Lancet Oncology, The Annals of Emergency Medicine, and

others. He has spoken internationally at the Royal College of Emergency

Medicine, Social Media and Critical Care (Australia, Germany, Ireland),

and domestically at the Counsel of Residency Directors of Emergency

Medicine (CORD); Harvard Medical School’s Writing, Publishing, and

Social Media for Healthcare Professionals; Resuscitation; and elsewhere.

He and Lauren Westafer, DO, MPH, are the cohosts of the award winning

FOAMcast, a popular emergency medicine podcast and inaugural recipient

of EMRA’s FOAMer of the Year award.

Dr. Christine Petersen’s scholarly work has focused on the recognition

and prevention of zoonotic diseases, primarily the epidemiology and

immunobiology of vector-borne and parasitic diseases, and now, SARS-

CoV-2. Dr. Petersen is the scientic program chair for the American

Society of Tropical Medicine and Hygiene. Her collaborative group works

in Brazil, India and Ethiopia via NIH/Fogarty International Center and NIAID-

funded studies focused on understanding tranmission and host immune

susceptibility for zoonoses. Dr. Petersen’s published and patented work

demonstrates the ability to target reservoir species for immunologic and

parasitologic control of infections to promote disease elimination. As

director of the Center for Emerging Infectious Diseases, Dr. Petersen

coordinates One Health activities focused on understanding, detecting

and preventing emerging zoonotic disease gloablly. Dr. Petersen is a

Professor at University of Iowa, College of Public Health, Department

of Epidemiology.