Aerosol-generating behaviours in speech pathology clinical practice: A systematic literature review

Antonia Margarita Chacon; Duy Duong Nguyen; Patricia McCabe; Catherine Madill

doi:10.1371/journal.pone.0250308

Peer Review History

Original SubmissionDecember 8, 2020
25 Mar 2021 Decision Letter - Marie Jetté, Editor PONE-D-20-37986 Aerosol-generating behaviours in speech pathology clinical practice: a systematic literature review PLOS ONE Dear Dr. Chacon, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please address Reviewer 2's critique and include data published outside of the speech-language pathology literature including research generated by physicists, engineers, and other healthcare professionals. Please submit your revised manuscript by May 09 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Marie Jetté Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Additional Editor Comments (if provided): Please address Reviewer 2's critiques and include data generated by physicists, engineers, and other healthcare practitioners. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This review is timely and highlights the unique expertise of speech-language pathologists in respiratory-related activities during a respiratory virus pandemic. I believe the authors have done a notable job in describing their methods carefully and also using caution with interpreting their findings. I particularly appreciate the proposed distinction between aerosol-generating procedures vs. behaviors (and further by vegetative, ADLs, and performance). In addition, an advantage of this review is that the authors also highlighted how other professionals and scientists will find this information useful going forward during the era of COVID-19. Reviewer #2: Although this manuscript follows a strong methodological protocol and is well written, it relies on two fundamental misconception, which limit is scientific relevance: 1. The CDC defines AGPs as those medical procedures that are “more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing." Naming these physiological phenomena as aerosol generating behaviors within the context of SLP practice is not sound, as it implies that there is something unique about SLP practice making these phenomena riskier than in other healthcare settings or in the community. 2. Focusing on the body of evidence on aerosol generation in relation to speech pathology ignores the high quality data produced by physicists, engineers, other healthcare practitioners on aerosol generation during speech, singing and coughing. It is not clear to me why the authors decided to exclude this data and only focus on the speech pathology literature, as it ignores the multidisciplinary efforts towards better understanding of aerosol generation going much beyond the speech literature. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0250308.r001
Revision 1
30 Mar 2021 Author Response REVIEWER 1 RESPONSE: Thank you for your comment. REVIEWER 2 RESPONSE: Thank you for your comment and careful evaluation of our paper. 1. Thank you also for providing the CDC definition of AGPs. While the CDC’s definition focuses upon those procedures eliciting higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking or breathing, given that these activities do generate infectious respiratory aerosols and are routinely performed in our clinical practice, we wished to examine these specific behaviours more closely from a Speech Pathology perspective. The CDC definition appears to exclude these behaviours being considered as AGPs despite these activities occurring routinely in SLP practice and daily life. Therefore, in introducing the concept of AGBs, we wished to further elucidate the risk posed by performing these behaviours in the context of healthcare practice and societal interactions. You have mentioned that we imply that there is something unique about SLP practice which makes these phenomena riskier than in other contexts. We agree that there are components of our practice which are in fact unique to other contexts in which the behaviours of breathing, speaking, singing, coughing, loud voicing and sustained phonation are produced. In SLP assessment and therapy sessions, the clinician and patient typically sit in an enclosed space for an hour, purposefully producing these tasks which are likely to generate high levels of aerosols in close proximity. There are no other contexts of which we are aware where this range of behaviours with aerosol-generating potential are elicited purposefully and routinely across interactions. While we cannot state conclusively that the tasks performed in SLP clinical contexts make the practice of speech pathology riskier, we think it is reasonable to assume there is some degree of higher risk owing to the length of time of SLP assessment and treatment sessions, and specific, often repeated cueing of these behaviours that occurs in these sessions. As reviewer 1 has acknowledged in their comment ‘an advantage of this review is that the authors also highlighted how other professionals and scientists will find this information useful going forward during the era of COVID-19’, we have not limited the application of our findings to a SLP context but rather, aimed to extrapolate our conclusions to broader settings, healthcare and otherwise. 2. We absolutely agree that solely exploring a speech pathology context would not enable us to draw well- informed conclusions regarding the aerosol generating potential across the six explored behaviours. We apologise if it was unclear from our paper that we did in fact explore these behaviours across a range of fields beyond speech pathology. If we bring the reviewer’s kind attention to our search strategy (supplementary material S2), page 1 (‘Speech Pathology Clinical Tasks’)- the terms used to explore aerosol generation in SLP would not have excluded non-SLP literature. The terms searched include such terms as ‘breath* OR cough* OR speech…’, which were then coupled with other terms (‘coronavirus’, ‘aerosols’ and ‘transmission risk’) across our database searches, which certainly did yield papers from the fields of engineering, other healthcare settings, etc. as has been recommended. We also acknowledge an additional area requiring clarification is that our exclusion criteria specified in pages 8-9 of the manuscript detailed that one of our exclusion criteria was papers ‘not relevant to speech pathology voice, resonance or motor speech clinical practice’. We understand how this may have been misconstrued to suggest we excluded papers that weren’t written specifically for speech pathology, but in fact meant to indicate that any articles not exploring the tasks of interest (speech, breathing, singing, sustained phonation, loud voicing and prolonged phonation) were excluded, i.e. no exclusion occurred if articles were not specifically related to the SLP field. We have therefore amended the inclusion criteria (pages 8-9) to clarify that papers not exploring the behaviours of interest were excluded; not exclusion of papers beyond the field of SLP. As further evidence of this, we’d like to kindly refer the reviewer to a further supplementary materials document uploaded with our submission (S3), to examine the titles, outcome measures and findings of included studies. In reviewing this list, we hope it becomes clear that there is a limited number that were specific to speech pathology (only Giovanni et al., 2020 and two ‘clinical guidelines’ documents), with the remainder being conducted across broader multidisciplinary settings. Finally, upon initial submission of our paper, we were requested by PLOS One to modify the title of our review from ‘Aerosol-generating behaviours in voice and speech: A systematic literature review’ to a title that was more ‘specific, descriptive, concise, and comprehensible to readers outside the field (for example by specifying that the systematic review focuses on AGPs in speech pathology clinical practice)’. As such, we framed our paper title to focus moreso upon speech pathology following this request by the editorial board, despite our intention that our paper explore and be applied to contexts beyond the field of SLP. Attachments Attachment Submitted filename: Response to Reviewers.pdf* https://doi.org/10.1371/journal.pone.0250308.r002
5 Apr 2021 Decision Letter - Marie Jetté, Editor Aerosol-generating behaviours in speech pathology clinical practice: a systematic literature review PONE-D-20-37986R1 Dear Dr. Chacon, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Marie Jetté Academic Editor PLOS ONE Additional Editor Comments (optional): Thank you for responding to the reviewers' suggestions. Reviewers' comments: https://doi.org/10.1371/journal.pone.0250308.r003
Formally Accepted
16 Apr 2021 Acceptance Letter - Marie Jetté, Editor PONE-D-20-37986R1 Aerosol-generating behaviours in speech pathology clinical practice: a systematic literature review Dear Dr. Chacon: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Marie Jetté Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0250308.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .