Cumulative Sensitization and Disease in a Beryllium Oxide Ceramics Worker Cohort

Impact of Epidemic Intelligence Service Training in Occupational Respiratory Epidemiology

The Centers for Disease Control and Prevention's Epidemic Intelligence Service (EIS) is a fellowship in applied epidemiology for physicians, veterinarians, nurses, scientists, and other health professionals. Each EIS fellow is assigned to a position at a federal, state, or local site for 2 years of on-the-job training in outbreak investigation, epidemiologic research, surveillance system evaluation, and scientific communication. Although the original focus of the program on the control of infectious diseases remains salient, positions are available for training in other areas of public health, including occupational respiratory disease. In this Perspective, we describe the EIS program, highlight three positions (one federal and two state-based) that provide training in occupational respiratory epidemiology, and summarize trainees' experiences in these positions over a 30-year period. For early-career health professionals interested in understanding and preventing occupational respiratory hazards and diseases, EIS offers a unique career development opportunity.

A Cluster of Beryllium Sensitization Traced to the Presence of Beryllium in Concrete Dust

BACKGROUND

Chronic beryllium disease (CBD), a granulomatous disease with similarities to sarcoidosis, arises only in individuals exposed to beryllium. Inhaled beryllium can elicit a T-cell-dominated alveolitis leading nonnecrotizing granulomata. CBD can be distinguished from sarcoidosis by demonstrating beryllium sensitization in a lymphocyte proliferation test.

RESEARCH QUESTION

Beryllium exposure usually occurs in an occupational setting. Because of the diagnosis of CBD in a patient without evident beryllium exposure, we performed a beryllium-lymphocyte proliferation test (BeLPT) among his work colleagues.

STUDY DESIGN AND METHODS

This field study investigated a cohort of work colleagues without obvious beryllium exposure. Twenty-one of 30 individuals were assessed in our outpatient clinic for beryllium sensitization. Therefore, BeLPT was performed with freshly collected peripheral blood mononuclear cells. Data were extracted from clinical charts, including geographical data. Beryllium content in dust samples collected at the workplace was measured by graphite-furnace atomic absorption spectroscopy and was compared with samples from different areas of Germany.

RESULTS

For the initial patient, the diagnosis of sarcoidosis was reclassified as CBD based on two positive BeLPT results. Assessment of his workplace did not identify a source of beryllium. However, BeLPTs performed on his workmates demonstrated beryllium sensitization in 5 of 21 individuals, suggesting a local beryllium source. Concrete dust obtained from the building yard, the workplace of the index patient, contained high amounts of beryllium (1138 ± 162 μg/kg), whereas dust from other localities (control samples) showed much lower beryllium content (range, 147 ± 18-452 ± 206 μg/kg). Notably, the control dust collected from different places all over Germany exhibit different beryllium concentrations.

INTERPRETATION

We describe a cluster of beryllium-sensitized workers from an industry not related to beryllium caused by environmental exposure to beryllium-containing concrete dust, which exhibited markedly elevated beryllium content. Importantly, analyses of dust samples collected from different localities showed that they contain markedly different amounts of beryllium. Thus, besides workplace-related exposure, environmental factors also are capable of eliciting a beryllium sensitization.

Research to Practice Implications of High-Risk Genotypes for Beryllium Sensitization and Disease

OBJECTIVE

Beryllium workers may better understand their genetic susceptibility to chronic beryllium disease (CBD) expressed as population-based prevalence, rather than odds ratios from case-control studies.

METHODS

We calculated CBD prevalences from allele-specific DNA sequences of 853 workers for Human Leukocyte Antigen (HLA)-DPB1 genotypes and groups characterized by number of E69-containing alleles and by calculated surface electronegativity of HLA-DPB1.

RESULTS

Of 18 groups of at least 10 workers with specific genotypes, CBD prevalence was highest, 72.7%, for the HLA-DPB102:01:02/DPB117:01 genotype. Population-based grouped genotypes with two E69 alleles wherein one allele had -9 surface charge had a beryllium sensitization (BeS) of 52.6% and a CBD prevalence of 42.1%.

CONCLUSIONS

The high CBD and BeS prevalences associated with -9-charged E69 alleles and two E69s suggest that workers may benefit from knowing their genetic susceptibility in deciding whether to avoid future beryllium exposure.

Beryllium and other metal-induced lung disease

PURPOSE OF REVIEW

Metals can cause disease of the upper and lower respiratory tract that mirror disease due to other causes, such as asthma, rhinosinusitis, acute bronchitis, chronic bronchitis, acute pneumonitis, bronchogenic carcinoma, and interstitial lung disease. This article will describe some uncommon and unique lung diseases that can be induced by metals.

RECENT FINDINGS

Our understanding of old occupational lung diseases, such as chronic beryllium disease, continues to increase. New exposures in the workplace, such as indium, have been identified as novel occupational hazards. New forms of exposure, such as titanium dioxide nanoparticles, create risk of lung disease that is not seen with larger particles.

SUMMARY

Knowledge of several unusual and/or unique occupational lung diseases should prompt questioning about a patient's occupational history, which may uncover an occupational, rather than an idiopathic, lung disease.

An official American Thoracic Society statement: diagnosis and management of beryllium sensitivity and chronic beryllium disease

RATIONALE

Beryllium continues to have a wide range of industrial applications. Exposure to beryllium can lead to sensitization (BeS) and chronic beryllium disease (CBD).

OBJECTIVES

The purpose of this statement is to increase awareness and knowledge about beryllium exposure, BeS, and CBD.

METHODS

Evidence was identified by a search of MEDLINE. The committee then summarized the evidence, drew conclusions, and described their approach to diagnosis and management.

MAIN RESULTS

The beryllium lymphocyte proliferation test is the cornerstone of both medical surveillance and the diagnosis of BeS and CBD. A confirmed abnormal beryllium lymphocyte proliferation test without evidence of lung disease is diagnostic of BeS. BeS with evidence of a granulomatous inflammatory response in the lung is diagnostic of CBD. The determinants of progression from BeS to CBD are uncertain, but higher exposures and the presence of a genetic variant in the HLA-DP β chain appear to increase the risk. Periodic evaluation of affected individuals can detect disease progression (from BeS to CBD, or from mild CBD to more severe CBD). Corticosteroid therapy is typically administered when a patient with CBD exhibits evidence of significant lung function abnormality or decline.

CONCLUSIONS

Medical surveillance in workplaces that use beryllium-containing materials can identify individuals with BeS and at-risk groups of workers, which can help prioritize efforts to reduce inhalational and dermal exposures.

Beryllium disease among construction trade workers at Department of Energy nuclear sites

BACKGROUND

A medical surveillance program was developed to identify current and former construction workers at significant risk for beryllium related disease from work at the DOE nuclear weapons facilities, and to improve surveillance among beryllium exposed workers.

METHODS

Medical examinations included a medical history and a beryllium blood lymphocyte proliferation test (BeLPT). Stratified and multivariate logistic regression analyses were used to explore the risk of disease by age, race, trade, and reported work in buildings where beryllium was used. After adjusting for covariates, the risk of BeS was significantly higher among boilermakers, roofers, and sheet metal workers, as suggested in the stratified analyses. Workers identified as sensitized to beryllium were interviewed to determine whether they had been subsequently diagnosed with chronic beryllium disease.

RESULTS

Between 1998 and December 31, 2010 13,810 workers received a BeLPT through the BTMed program; 189 (1.4%) were sensitized to beryllium, and 28 reported that they had had a compensation claim accepted for CBD.

CONCLUSIONS

These data on former construction workers gives us additional information about the predictive value of the blood BeLPT test for detection of CBD in populations with lower total lifetime exposures and more remote exposures than that experienced by current workers in beryllium machining operations. Through this surveillance program we have identified routes of exposures to beryllium and worked with DOE site personnel to identity and mitigate those exposures which still exist, as well as helping to focus attention on the risk for beryllium exposure among current demolition workers at these facilities.

Long-term efficacy of a program to prevent beryllium disease

BACKGROUND

In 2000, a manufacturer of beryllium materials and products introduced a comprehensive program to prevent beryllium sensitization and chronic beryllium disease (CBD). We assessed the program's efficacy in preventing sensitization 9 years after implementation.

METHODS

Current and former workers hired since program implementation completed questionnaires and provided blood samples for the beryllium lymphocyte proliferation test (BeLPT). Using these data, as well as company medical surveillance data, we estimated beryllium sensitization prevalence.

RESULTS

Cross-sectional prevalence of sensitization was 0.7% (2/298). Combining survey results with surveillance results, a total of seven were identified as sensitized (2.3%). Early Program workers were more likely to be sensitized than Late Program workers; one of the latter was newly identified. All sensitization was identified while participants were employed. One worker was diagnosed with CBD during employment.

CONCLUSIONS

The combination of increased respiratory and dermal protection, enclosure and improved ventilation of high-risk processes, dust migration control, improved housekeeping, and worker and management education showed utility in reducing sensitization in the program's first 9 years. The low rate (0.6%, 1/175) among Late Program workers suggests that continuing refinements have provided additional protection against sensitization compared to the program's early years.

Dissolution of beryllium in artificial lung alveolar macrophage phagolysosomal fluid

Dissolution of a lung burden of poorly soluble beryllium particles is hypothesized to be necessary for development of chronic beryllium lung disease (CBD) in humans. As such, particle dissolution rate must be sufficient to activate the lung immune response and dissolution lifetime sufficient to maintain chronic inflammation for months to years to support development of disease. The purpose of this research was to investigate the hypothesis that poorly soluble beryllium compounds release ions via dissolution in lung fluid. Dissolution kinetics of 17 poorly soluble particulate beryllium materials that span extraction through ceramics machining (ores, hydroxide, metal, copper-beryllium [CuBe] fume, oxides) and three CuBe alloy reference materials (chips, solid block) were measured over 31 d using artificial lung alveolar macrophage phagolysosomal fluid (pH 4.5). Differences in beryllium-containing particle physicochemical properties translated into differences in dissolution rates and lifetimes in artificial phagolysosomal fluid. Among all materials, dissolution rate constant values ranged from 10(-5) to 10(-10)gcm(-2)d(-1) and half-times ranged from tens to thousands of days. The presence of magnesium trisilicate in some beryllium oxide materials may have slowed dissolution rates. Materials associated with elevated prevalence of CBD had faster beryllium dissolution rates [10(-7)-10(-8)gcm(-2)d(-1)] than materials not associated with elevated prevalence (p<0.05).

Evaluation of a preventive program to reduce sensitization at a beryllium metal, oxide, and alloy production plant

OBJECTIVE

We evaluated a workplace preventive program's effectiveness, which emphasized skin and respiratory protection, workplace cleanliness, and beryllium migration control in lowering beryllium sensitization.

METHODS

We compared sensitization prevalence and incidence rates for workers hired before and after the program using available cross sectional and longitudinal surveillance data.

RESULTS

Sensitization prevalence was 8.9% for the Pre-Program Group and 2.1% for the Program Group. The sensitization incidence rate was 3.7/1000 person-months for the Pre-Program Group and 1.7/1000 person-months for the Program Group. After making adjustments for potential selection and information bias, sensitization prevalence for the Pre-Program Group was 3.8 times higher (95% CI = 1.5 to 9.3) than the Program Group. The sensitization incidence rate ratio comparing the Pre-Program Group to the Program Group was 1.6 (95% CI = 0.8 to 3.6).

CONCLUSIONS

This preventive program reduced the prevalence of but did not eliminate beryllium sensitization.