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Risk of COVID-19 at Choir Practice

May 12, 2020 5:21 pm

MMWR reports that after attending a 2.5 hr choir practice with one COVID+ symptomatic person, 87% of the choir developed COVID 19; 3 were hospitalized, and two died. 

Choir practice was attended by 61 persons, including a symptomatic index patient, 32 confirmed and 20 probable secondary COVID-19 cases occurred (attack rate = 53.3% to 86.7%); three patients were hospitalized, and two died. Transmission was likely facilitated by close proximity (within 6 feet) during practice and augmented by the act of singing.

The potential for superspreader events underscores the importance of physical distancing, including avoiding gathering in large groups, to control spread of COVID-19. Enhancing community awareness can encourage symptomatic persons and contacts of ill persons to isolate or self-quarantine to prevent ongoing transmission.

On March 17, 2020, a member of a Skagit County, Washington, choir informed Skagit County Public Health (SCPH) that several members of the 122-member choir had become ill. Three persons, two from Skagit County and one from another area, had test results positive for SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Another 25 persons had compatible symptoms. SCPH obtained the choir’s member list and began an investigation on March 18.

Among 61 persons who attended a March 10 choir practice at which one person was known to be symptomatic, 53 cases were identified, including 33 confirmed and 20 probable cases (secondary attack rates of 53.3% among confirmed cases and 86.7% among all cases). Three of the 53 persons who became ill were hospitalized (5.7%), and two died (3.7%). The 2.5-hour singing practice provided several opportunities for droplet and fomite transmission, including members sitting close to one another, sharing snacks, and stacking chairs at the end of the practice.

The act of singing, itself, might have contributed to transmission through emission of aerosols, which is affected by loudness of vocalization (1). Certain persons, known as superemitters, who release more aerosol particles during speech than do their peers, might have contributed to this and previously reported COVID-19 superspreading events (2–5). These data demonstrate the high transmissibility of SARS-CoV-2 and the possibility of superemitters contributing to broad transmission in certain unique activities and circumstances. It is recommended that persons avoid face-to-face contact with others, not gather in groups, avoid crowded places, maintain physical distancing of at least 6 feet to reduce transmission, and wear cloth face coverings in public settings where other social distancing measures are difficult to maintain.



All 122 members were interviewed by telephone either during initial investigation of the cluster (March 18–20; 115 members) or a follow-up interview (April 7–10; 117); most persons participated in both interviews. Interviews focused on attendance at practices on March 3 and March 10, as well as attendance at any other events with members during March, other potential exposures, and symptoms of COVID-19. SCPH used Council of State and Territorial Epidemiologists case definitions to classify confirmed and probable cases of COVID-19 (6). Persons who did not have symptoms at the initial interview were instructed to quarantine for 14 days from the last practice they had attended. The odds of becoming ill after attending each practice were computed to ascertain the likelihood of a point-source exposure event.

No choir member reported having had symptoms at the March 3 practice. One person at the March 10 practice had cold-like symptoms beginning March 7. This person, who had also attended the March 3 practice, had a positive laboratory result for SARS-CoV-2 by reverse transcription–polymerase chain reaction (RT-PCR) testing.

In total, 78 members attended the March 3 practice, and 61 attended the March 10 practice. Overall, 51 (65.4%) of the March 3 practice attendees became ill; all but one of these persons also attended the March 10 practice. Among 60 attendees at the March 10 practice (excluding the patient who became ill March 7, who also attended), 52 (86.7%) choir members subsequently became ill. Some members exclusively attended one practice; among 21 members who only attended March 3, one became ill and was not tested (4.8%), and among three members who only attended March 10, two became ill (66.7%), with one COVID-19 case being laboratory-confirmed.

Because illness onset for 49 (92.5%) patients began during March 11–15 (Figure), a point-source exposure event seemed likely. The median interval from the March 3 practice to symptom onset was 10 days (range = 4–19 days), and from the March 10 practice to symptom onset was 3 days (range = 1–12 days). The odds of becoming ill after the March 3 practice were 17.0 times higher for practice attendees than for those who did not attend (95% confidence interval [CI] = 5.5–52.8), and after the March 10 practice, the odds were 125.7 times greater (95% CI = 31.7–498.9).



Among the 61 choir members who attended the March 10 practice, the median age was 69 years (range = 31–83 years); 84% were women. Median age of those who became ill was 69 years, and 85% of cases occurred in women. Excluding the laboratory-confirmed index patient, 52 (86.7%) of 60 attendees became ill; 32 (61.5%) of these cases were confirmed by RT-PCR testing and 20 (38.5%) persons were considered to have probable infections. These figures correspond to secondary attack rates of 53.3% and 86.7% among confirmed and all cases, respectively. Attendees developed symptoms 1 to 12 days after the practice (median = 3 days). The first SARS-CoV-2 test was performed on March 13. The last person was tested on March 26.

Three of the 53 patients were hospitalized (5.7%), including two who died (3.8%). The mean interval from illness onset to hospitalization was 12 days. The intervals from onset to death were 14 and 15 days for the two patients who died.

SCPH collected information about patient signs and symptoms from patient interviews and hospital records (Table 2). Among persons with confirmed infections, the most common signs and symptoms reported at illness onset and at any time during the course of illness were cough (54.5% and 90.9%, respectively), fever (45.5%, 75.8%), myalgia (27.3%, 75.0%), and headache (21.2%, 60.6%). Several patients later developed gastrointestinal symptoms, including diarrhea (18.8%), nausea (9.4%), and abdominal cramps or pain (6.3%). One person experienced only loss of smell and taste. The most severe complications reported were viral pneumonia (18.2%) and severe hypoxemic respiratory failure (9.1%).

Among the recognized risk factors for severe illness, the most common was age, with 75.5% of patients aged ≥65 years. Most patients (67.9%) did not report any underlying medical conditions, 9.4% had one underlying medical condition, and 22.6% had two or more underlying medical conditions. All three hospitalized patients had two or more underlying medical conditions.


The author has no conflicts of interest to disclose related to this subject

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