beryllium disease increasing awareness protecting worker health n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Beryllium Disease: Increasing Awareness/Protecting Worker Health PowerPoint Presentation
Download Presentation
Beryllium Disease: Increasing Awareness/Protecting Worker Health

Loading in 2 Seconds...

play fullscreen
1 / 37

Beryllium Disease: Increasing Awareness/Protecting Worker Health - PowerPoint PPT Presentation


  • 149 Views
  • Uploaded on

Beryllium Disease: Increasing Awareness/Protecting Worker Health. L.B. Sandy Rock, MD, MPH Risk Communicator. Potential Causes of Occupational Lung Disease at the Hanford Site (in order of worker concern 2011). Beryllium Disease. Hazards Beryllium Asbestos Hexavalent Chromium

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Beryllium Disease: Increasing Awareness/Protecting Worker Health' - lotta


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
beryllium disease increasing awareness protecting worker health

Beryllium Disease:Increasing Awareness/Protecting Worker Health

L.B. Sandy Rock, MD, MPH

Risk Communicator

beryllium disease

Potential Causes of Occupational Lung Diseaseat the Hanford Site (in order of worker concern 2011)

Beryllium Disease
  • Hazards
    • Beryllium
    • Asbestos
    • Hexavalent Chromium
    • Silica (dust)?
    • Allergens
    • (Tobacco)
    • Fumes/exhaust
what is cbd

Beryllium Disease

What is CBD?
  • Beryllium
    • What and where (and why?)
  • Exposure
    • How and how much
  • Sensitization
    • BeLPT
  • Lung disease
    • “Systemic granulomatous disease”
    • Chronic lung disease---varying severity
  • Also…Class IA carcinogen
outcome objectives

Beryllium Disease

Outcome objectives:
  • After actively participating in this discussion, attendees will be able to
    • 1) describe the characteristics of chronic beryllium disease (and how it is diagnosed);
    • 2) explain how and where exposure to beryllium can occur (and the importance of occupational history);
    • 3) identify the uncertainties inherent in delineating environmental testing, exposure, diagnostic testing, treatment, and all levels of prevention (thus, why it is so challenging an occupational disease).
case study 1

Beryllium Disease

Case Study 1

A 52-year-old male former Health Physics Technician at Hanford worked in several areas now known to have been beryllium contaminated. Ten years ago he developed a mild to moderate pneumonitis after exposure to chemical vapors from a storage tank; chest x-ray revealed hilaradenopathy compatible with sarcoidosis and biopsy confirmed the diagnosis. He was treated with systemic corticosteroids initially, and, later, by inhalation. Because of work history and sarcoidosis diagnosis, beryllium sensitization blood test was performed and was negative for four consecutive years; on the fifth year, he had a positive test followed by a positive confirmatory test “just a few months after stopping inhaled cortisone.”

case study 2

Beryllium Disease

Case Study 2

A 50-year-old male power operator worked for many years in the 300 Area at Hanford, a known beryllium-contaminated area. He heard about the Voluntary Beryllium Program but was reluctant at first to join it. He had no health problems. At coworkers’ urging, he later entered the program and had a negative initial blood test for beryllium sensitization; one year later, he had positive tests. He is angry that his first test was negative since he “continued to work in possible beryllium contaminated buildings.”

pre post quiz

Beryllium Disease

Pre/Post Quiz

Both of the above patients were referred to a major medical center known for expertise in beryllium disease and both were diagnosed with CBD. Neither one has developed symptoms or required any treatment to date.

Questions:

  • Patients with a work history in all but which job category and presenting with a sarcoidosis-like syndrome should be tested for Beryllium Disease?
    • Nuclear
    • Sporting equipment
    • Ceramic
    • Fast Food
    • Electronic
  • What test distinguishes Chronic Beryllium Disease from sarcoidosis?
    • BeLPT
    • LeBPT
    • Lipotropin, blood
    • Speckled macrophage test
    • Transbronchial biopsy
  • Many workers express anxiety about being tested for CBD. Which of the following is the least of their concerns?
    • Job loss
    • Loss of insurability
    • Lack of compensation programs
    • Lack of specific treatment
    • Uncertainty in diagnosis
quiz cont d

Beryllium Disease

Quiz (cont’d)

4. What nationally-recognized center is considered the most knowledgeable about CBD?

  • Scripps Memorial Hospital
  • National Jewish MC, Denver
  • University of Virginia
  • Tulane University Medical Center
  • Mayo Clinic

5. An evaluation for Chronic Beryllium Disease would include all of the following EXCEPT:

  • Chest x-ray (PA/Lat)
  • Bronchoscopy with lavage and biopsy
  • Node biopsy for beryllium particle spectroscopy
  • DLCO diffusion
  • Spirometry
beryllium

Beryllium Disease

Beryllium
  • Atomic number = 4
  • Atomic weight = 9
  • High tensile strength
  • High heat capacity
  • Excellent electrical conductivity
  • High stiffness (modulus of elasticity)

Beryllium is amazingly versatile as a metal alloy and is used in dental appliances, golf clubs, non-sparking tools, wheelchairs, automobiles, bicycle frames and electronics.

main industries

Beryllium Disease

Main industries

nuclear production/fabrication facilities

aerospace

aircraft manufacture and maintenance

computer

dental laboratories/ceramics

telecommunications

foundries and metal reclamation

industrial uses

Beryllium Disease

Industrial Uses

Gyroscopes, guidance systems, accelerometers

Reactor rods (controls fission reactions)

X-ray windows

Spark-free tools (strengthens copper)

Consumer products: Mountain bikes, golf clubs, baseball bats, electronics, ceramics, fishing rods, space shuttle/aviation, brakes

[Fluorescent lights]

what and

Beryllium Disease

What and…
  • Beryllium in the environment
    • Ash
      • Volcanic
        • Mt St Helens
      • Fly Ash
        • Coal-fired power plants
        • Incinerators
  • Beryl
    • Gemstone
      • Emerald, aquamarine, goshenite, and davidsonite
  • Beryllium particles (fine) and beryllium oxide
    • Likely sensitizers
    • Occur in refining and other processing of beryllium metal
how much

Beryllium Disease

… how much?
  • Do we know?
    • Probably THE most contentious issue
  • Genetics--HLA-DPB polymorphisms
    • “Glu69”
      • HLA-DPB1-Glu69 marker
        • glutamine residue at position 69 (Glu 69+) of the B1 chain of the HLA-DPB molecule
  • Permissible Exposure Level
    • A workplace determination
      • OSHA
      • ACGIH
      • DOE/CBDPP
numbers aka epidemiology

Beryllium Disease

Numbers (aka “epidemiology”)
  • CBD in the general population?
    • = Sarcoidosis + BeLPT positivity
  • CBD in workers
    • Industries
      • Nuclear weapons production among many others
      • Ceramics
    • DOE sites
      • Hanford
      • Rocky Flats
      • Others
  • History
    • First described 1933 Germany/discovered 1943 in U.S./ Fluorescent lamp manufacturing (more acute lung disease known since 1930’s)
at hanford

Beryllium Disease

…at Hanford…

from 11/97-1/11---

  • Sensitized: 113
  • CBD: 32
  • Workers tested: 5752 (through 10/1/10)
  • Workers in Be medical programs: 4476 (1/11/11)
    • Be-Worker—3257
    • Be-Program-Voluntary (formerly “Previous Worker”)—1219
newly diagnosed beryllium sensitized workers fy10
Beryllium Disease

16 newly diagnosed Beryllium Sensitized workers in FY10

  • 4 on initial screening for beryllium work clearance with no prior Hanford work history and with significant other DOE/DOD work history
    • Including previous employment in facilities such as Palo Verde, Shearon Harris, INL moving beryllium waste containers, non-Hanford radioactive waste disposal,
  • 2 with prior Hanford work history and potential significant non-Hanford DOE/DOD experience
    • Including previous employment in facilities such as INL from 1989-1993, US Navy
  • 10 with no reported non-Hanford (or any other) work experience
Newly Diagnosed Beryllium Sensitized Workers, FY10
insidious

Beryllium Disease

Insidious
  • Exposure
    • Dust---processing, grinding, etching
  • Sensitization
    • No stigma
  • CBD
    • Mild symptoms in most, at first
what happens

Beryllium Disease

What happens…
  • Exposure- Sensitization
    • Lung
    • Skin (significance?)
    • 2-15%?
  • Sensitization Granuloma formation in lungs (CBD)
    • 20-100%?
  • CBD diminished pulmonary function
    • Variable course: obstruction; restriction; ↓ gas transport (O2, CO2) (↓DLCO)
evaluation

Beryllium Disease

Evaluation
  • Laboratory Studies
    • Blood BeLPT
      • test of choice
        • beryllium sensitization
        • peripheral blood mononuclear cells exposed in vitro to beryllium salts at varying concentrations for variable time intervals
        • cell proliferation in the presence of beryllium indicates a positive test result.
        • performed only in selected specialized laboratories(Oak Ridge; U Penn; Nat’l Jewish, Denver; Cleveland Clinic)
evaluation cont d

Beryllium Disease

Evaluation, cont’d
  • Imaging Studies
    • Chest x-ray:
      • normal in about half of the patients with documented chronic beryllium disease (CBD)
      • hilaradenopathy and/or increased interstitial markings.
    • High-resolution CT (HRCT) scan, chest
      • more sensitive
      • ground glass opacification (see the image next slide), parenchymal nodules, or septal lines
      • negative in 25% of patients with documented CBD.
slide21

Beryllium Disease

A high-resolution CT scan of the chest showing the typical ground glass appearance in a patient with chronic beryllium disease, or berylliosis.

evaluation cont d1

Beryllium Disease

Evaluation, cont’d
  • Other Tests
    • Pulmonary function tests include the following:
      • Spirometry
      • Lung volumes
      • Diffusing capacity of lung for carbon monoxide (DLCO)
    • Arterial blood gases
    • Cardiopulmonary exercise
  • With disease progression, spirometry may show evidence of obstruction, restriction, or both. (In an early study in 40 patients with advanced CBD, an obstructive pattern was observed in 39% of patients, a restrictive pattern in 20%, and a low DLCO in 36%.)
  • The DLCO declines over the course of the disease. The most sensitive test is abnormalities in gas exchange during exercise.
  • Laser microprobe mass spectrographic (LAMMS) analysis can be used to detect beryllium in histologic sections from lung biopsy specimens. This test is not necessary for the diagnosis and is not widely available.
evaluation1

Beryllium Disease

Evaluation
  • Procedures
    • Flexible fiberopticbronchoscopy with BAL and transbronchial biopsies (TBBX)
      • to confirm a suspected diagnosis of CBD.
        • Patients with CBD usually have BAL lymphocytosis (>20% lymphocytes).
        • The BeLPT test also can be performed on BAL cells.
        • A minimum of 6 high-quality biopsies should be obtained to optimize the yield. If TBBX results are negative but suspicion high, consider repeat bronchoscopy.
    • Open lung biopsy may need to be performed if repeat bronchoscopy findings still are negative.
  • Histologic Findings
    • The hallmark of CBD is the presence of nonnecrotizing granulomas on lung biopsy (see the image below). These granulomas are histopathologically indistinguishable from sarcoid granulomas
how is it treated

Beryllium Disease

How is it treated?
  • Sensitization
    • Prevent further exposure
    • Evaluate and re-evaluate
      • Referrals
        • National Jewish Medical Center (NJH;Denver)
  • Chronic Beryllium Disease
    • A type of chronic lung disease
    • Specialist evaluation & directed care
    • No controlled studies for CBD therapy are available. Based on the pathogenesis of the disease (immune-mediated) and due to the similarities with sarcoidosis, CBD is treated with corticosteroids. When corticosteroid therapy fails or in patients who develop significant adverse effects, methotrexate (MTX) may be considered
  • Maintain good general health!
how is it prevented

Beryllium Disease

How is it prevented?
  • The usual
    • Administrative Controls
    • Engineering Controls
    • PPE
    • Training/Work practices
    • Pre-planning/Hazard Awareness
  • The unusual
    • Sampling/monitoring (specifically for Be; controversy over “safe” levels)
    • CBDPP
      • enhances worker protection by detailing guidance and standards for monitoring, prevention of exposure, medical surveillance, and work practices
cbdpp

Beryllium Disease

CBDPP

Chronic Beryllium Disease Prevention Program

10 CFR 850 (DOE program rule)

AMH, DOE, Site contractors committee

Site-wide

necessary research

Beryllium Disease

Necessary research

Quantifying levels of sensitization and chronic beryllium disease in various work settings and worker populations

Understanding airborne beryllium exposure and the characteristics associated with risk of disease among exposed workers (as well as risk of aggravating disease)

Understanding how different routes of exposure contribute to disease risk

Understanding the genetic risk factors associated with disease

slide30

Beryllium Disease

BHSC

The Beryllium Health and Safety Committee (BHSC) is committed to preventing beryllium sensitization and chronic Beryllium Disease (CBD) and other adverse health effects that can be cased by workplace exposure to beryllium.

The Mission of the BHSC will be accomplished by:

Promoting the safe use of beryllium

Obtaining a better understanding of exposure risks

Improving exposure monitoring

Fostering improved controls

Accumulating and disseminating information concerning beryllium process best work practices, as well as, data from the health studies concerning the hazards associated with beryllium

Training / mentoring of beryllium health professionals

Identifying and promoting research that has the potential to enhance or improve our worker safety programs

b a g

Beryllium Disease

B.A.G.
  • Beryllium Awareness Group
  • Affected workers
  • Open and closed meetings, monthly
    • Open: 1st Wed/mo @ HAMMER Rm 31, 1:30-4:30 PM
    • Closed: 3rd Wed

--------

---Be Registry--The DOE Beryllium-Associated Worker Registry is a complex-wide internal program to help DOE conduct and improve its [CBDPP]. 10 CFR 850.39 specifies beryllium recordkeeping and reporting requirements for both DOE federal and contractor employees. [It] contains data on DOE contractor and federal workers, the jobs they performed, their beryllium exposure monitoring results, results from screening tests for chronic beryllium diseases, and the results from subsequent medical diagnostic procedures.

outcome objectives1

Beryllium Disease

Outcome objectives:
  • After actively participating in this discussion, attendees will be able to
    • 1) describe the characteristics of chronic beryllium disease (and how it is diagnosed);
    • 2) explain how and where exposure to beryllium can occur (and the importance of occupational history);
    • 3) identify the uncertainties inherent in delineating environmental testing, exposure, diagnostic testing, treatment, and all levels of prevention (thus, why it is so challenging an occupational disease).
pre post quiz1

Beryllium Disease

Pre/Post Quiz

Both of the above patients were referred to a major medical center known for expertise in beryllium disease and both were diagnosed with CBD. Neither one has developed symptoms or required any treatment to date.

Questions:

  • Patients with a work history in all but which job category and presenting with a sarcoidosis-like syndrome should be tested for Beryllium Disease?
    • Nuclear
    • Sporting equipment
    • Ceramic
    • Fast Food
    • Electronic
  • What test distinguishes Chronic Beryllium Disease from sarcoidosis?
    • BeLPT
    • LeBPT
    • Lipotropin, blood
    • Speckled macrophage test
    • Transbronchial biopsy
  • Many workers express anxiety about being tested for CBD. Which of the following is the least of their concerns?
    • Job loss
    • Loss of insurability
    • Lack of compensation programs
    • Lack of specific treatment
    • Uncertainty in diagnosis
quiz cont d1

Beryllium Disease

Quiz (cont’d)

4. What nationally-recognized center is considered the most knowledgeable about CBD?

  • Scripps Memorial Hospital
  • National Jewish MC, Denver
  • University of Virginia
  • Tulane University Medical Center
  • Mayo Clinic

5. An evaluation for Chronic Beryllium Disease would include all of the following EXCEPT:

  • Chest x-ray (PA/Lat)
  • Bronchoscopy with lavage and biopsy
  • Node biopsy for beryllium particle spectroscopy
  • DLCO diffusion
  • Spirometry
beryllium corrective action plan becap

Beryllium Disease

Beryllium Corrective Action Plan (BeCAP)
  • A result of concerns brought to DOE through the Hanford Advisory Board (HAB)
    • HAB influenced by various parties
      • BAG
      • Activists
      • Elected government officials
    • Driven by perception that workers were becoming BeS
  • DOE HQ sent team from Health, Safety and Security office
    • Numerous interviews and records review (non-medical)
    • Evaluation took place for two weeks March 2010
    • Report released to public June 2010
  • Corrective Action Plan (BeCAP) developed and approved
    • “Final” agreed-upon Corrective Action Plan August 30, 2010 and accepted by DOE on 9/22/2010
  • All Hanford contractors responsible for meeting deadlines to complete assigned “opportunities for improvement” over the coming months.
summary

Beryllium Disease

Summary

Beryllium exposure can cause a granulomatous lung disease in workers who develop a lymphocyte-mediated sensitizationto the metal. Workers in diverse industries are at risk because beryllium's properties are critical to nuclear, aerospace, telecommunications, electronic, metal alloy, biomedical, and semiconductor industries. The occupational air concentration standard's failure to protect beryllium workers is driving many scientific and occupational health advances. These developments include study of bioavailability of different physicochemical forms of beryllium, medical surveillance to show effectiveness of skin protection in preventing sensitization in high-risk processes, gene-environment interaction, transgenic mice for use in experimental research, and risk-based management of industrial exposures in the absence of effective exposure-response information. Beryllium sensitization and disease prevention are paradigms for much broader public health action in both occupational and general population settings.

practice commitments

Beryllium Disease

Practice Commitments

I will make the following changes in my practice:

  • Include comprehensive work history in patient charts
  • Consider BeLPT in patients with sarcoidosis, particularly those with relevant work history
  • ****** (TBD by attendees)