Beryllium Policy

 

Purpose

Due to improvement in the diagnosis of beryllium related diseases and the       implementation of a Federal program to compensate individuals who have       developed beryllium diseases, it is necessary to review information pertaining to beryllium associated medical conditions and consider development of a BWC       policy for diagnosis.            This document is intended to provide an overview of the following:

·      Beryllium and its uses;

·      Medical conditions associated with beryllium exposure;

·      Diagnostic studies for beryllium associated medical conditions;

·      Recently implemented U. S. Department of Energy and Department of Labor programs; and

·      Diagnostic criteria and process to be used by BWC.

 

Resources

Jewell, Gregory, M.D., BWC Medical Advisor

Lockey, James, M.D., Occupational Medicine and Pulmonary Specialist, University of Cincinnati

See footnotes at end of document

 

Scope

This policy applies to all BWC claims requesting evaluation or allowance of beryllium associated conditions.

 

Customers

·      BWC Providers

·      Disability Evaluators Panel (DEP) Physicians

·      Injured workers (IW)

·      BWC Service Offices

·      Managed Care Organizations (MCOs)

·      Claims Policy

 

Policy Designees

Designees for review of the policy will be limited to representatives from the Medical Management, Legal, Medical, Rehabilitation, and Claims Policy Support Services and Field Operations including Tina Kielmeyer, Gregory Jewell, M.D., Pete Mihaly, Shirley Moleno, Karen Fitzsimmons, Kim Robinson or designate.

 

Medical Research

The following medical research has been completed and summarized by BWC Advisor       Gregory Jewell, M.D.

 

Beryllium and its uses

Beryllium is the second lightest metal and is naturally occurring in a variety of rocks and dusts.  For industrial use it is mined as beryl and extradite ores which are then refined.  It can be used as a metal, mixed with other metals to form alloys, or processed to salts and oxides for other industrial processes.  As a metal, it is frequently used in the aerospace and defense industries, nuclear reactors, and nuclear weapons components. Beryllium is typically used as a 2% alloy with other metals, particularly copper.  It adds properties of resistance to corrosion, wear, and fatigue; high electrical and thermal conductivity; strength; and hardness.  These metals may be used for a variety purposes including springs, switches, relays, and connectors in automobiles, computers, telecommunications equipment; high-strength, non-sparking tools; molds or casts to make metals, glass, and plastic items; sports equipment; and dental bridges.  The salts and oxide forms are used in nuclear reactors, glass manufactures, and catalyst for certain chemical reactions.  During the 1940’s, beryllium was used to manufacture fluorescent lamps, but this process has been discontinued. [i]

 

Medical Conditions Associated with Beryllium Exposure

The health effects of beryllium were noted in the 1940’s and 1950’s when adverse health effects were noted in workers using beryllium in the production of fluorescent lamps and in the communities where beryllium was refined such as Lorain, Ohio.   The use of beryllium in fluorescent lamp production ceased in 1950.  In other processes, efforts were made to reduce the concentration of beryllium in the air at the workplaces.  Simultaneously, there was an increased use of beryllium in other industries such as the nuclear, aerospace, and alloy metal industries. [ii]

 

The usual route of exposure for most individuals is inhalation.  While there may be systemic and cutaneous effects, the most common and most significant effects involve the respiratory system.  There are two primary conditions of the pulmonary system attributed to beryllium exposure – acute beryllium disease and chronic beryllium disease (CBD).  Studies have also shown a possible increased prevalence of lung cancer in workers exposed to beryllium.  This will be discussed below.  It should be noted that the older term berylliosis has been replaced by chronic beryllium disease.  Berylliosis implies an interstitial lung disease (e.g., asbestosis, silicosis, and coal workers’ pneumoconiosis) but the pathogenesis differs in that with berylliosis lymphocytes become sensitized to beryllium which can result in granulomatous interstitial inflammation and fibrosis in susceptible individuals.

 

Acute Beryllium Disease

Acute beryllium disease is rarely seen today due to efforts to reduce airborne exposure to beryllium and its salts.  The condition is caused by the soluble beryllium salts and its severity is determined by the intensity of exposure.  Massive exposure can result in a chemical pneumonia within 72 hours that can follow a fulminant course while lower concentration may be insidious. 

 

The symptoms are dependent on the magnitude of exposure.  Usually there is irritation of the upper respiratory tract with nasal discharge, paroxysmal cough, burning sensation of chest, and shortness of breath.  There may be low grade fever, possibly central cyanosis, and widespread inspiratory crackles (rales).  The symptoms usually resolve and if they persist for more than 12 months, the disease is said to be chronic.

 

Arterial blood gas analysis demonstrates hypoxia and possibly hypercapnia as seen in pneumonia or pulmonary edema.  These findings completely resolve unless the disease process progresses.  The chest x-ray typically lags clinical symptoms by 1 to 3 weeks.  Characteristically there is a diffuse haziness followed by widespread, large, ill-defined opacities similar to pulmonary edema or bilateral pneumonia.  This usually returns to normal within a few months.

 

The diagnosis is made on the findings of an acute nasopharyngitis, tracheobronchitis, or pneumonitis developing one to three days following an inhalation.  Other features include low grade fever and weight loss.  The condition has no specific diagnostic findings to differentiate it from pneumonia from another cause.

 

Treatment consists of rest, steroids such as prednisone, and supplemental oxygen as needed.  Recovery occurs in most cases within one to six months, but fulminant cases have a 7 percent mortality rate.  It is believed by some experts that a proportion of individuals who have had acute beryllium disease may later develop chronic beryllium disease even without additional exposure.[iii]

 

Chronic Beryllium Disease (CBD)

CBD is a systemic disease primarily affecting the lungs as a result of sensitization of the individual to beryllium.  The disease may develop within a month or two of exposure or be delayed as long as 40 years following exposure.  Though controversial, it is estimated that perhaps 30% of individuals with acute beryllium disease may progress to progressive beryllium disease.  However, the two diseases are different in pathology and CBD appears to develop even in individuals with low levels of exposure.

 

While CBD may be asymptomatic, the most common symptom is the insidious development of shortness of breath particularly with exertion.  There also may be fatigue and cough which is usually non-productive and may be related to exertion or paroxysmal dyspnea. In advanced cases weight loss is common and associated with malaise, anorexia, and arthralgia.  The disease is usually limited to the lungs with interstitial, endobronchial, and thoracic lymph node involvement.  The physical findings of CBD include crackles (rales), and possibly central cyanosis in advanced cases. 

 

Pulmonary function tests are not specific and include obstruction or mixed obstruction and restriction.  Later in the disease, a restrictive pattern predominates.  Diffusing capacity is a sensitive indicator of early disease as is abnormal gas exchange during maximal exercise testing. The most sensitive indicator of CBD is worsening of gas exchange during maximum exercise testing.

 

Chest radiographs may range from being entirely normal to having small nodular opacities throughout the lung fields with perhaps higher distribution in the upper lobes.  They may advance with the formation of conglomerate masses as the disease progresses.  Mediastinal adenopathy similar to sarcoidosis is observed in approximately one third of cases.  One study of high resolution computed tomography (HRCT) demonstrated small ill-defined nodules, septal lines, areas of ground-glass attenuation, and adenopathy.  The HRCT scan is most likely more sensitive for detecting early lung parenchymal changes in comparison to the standard chest radiograph. 

 

The histopathology examination shows noncaseating granulomas with mononuclear cell infiltrates and varying degrees of interstitial pulmonary fibrosis.  This pathology is indistinguishable from sarcoidosis.  Demonstration of beryllium in the tissue does not prove beryllium caused the disease and its absence does not exclude the diagnosis since CBD is considered to be the result of a lymphocyte hypersensitivity mechanism. 

 

In recent years, the Beryllium lymphocyte proliferation test (BeLPT) has been developed.  This test quantitates the beryllium specific cellular immune response of cells from the plasma or cells obtained by bronchoalveolar lavage (BAL) by using the cell uptake of radiolabeled DNA precursors.  Over 90% of individual with CBD have a positive response.  Reportedly, a subset of individuals with CBD has a negative response to the blood BeLPT, but a positive response to the BAL BeLPT.  This test can also be negative in individuals with CBD due to inhibitory effect of alveolar macrophages or the effect of corticosteroid treatment.  Asymptomatic individuals without CBD who have had beryllium exposure can test BeLPT positive indicating they are beryllium sensitized.  These individuals may later develop CBD as represented by granulomatous inflammation and fibrosis within the lung parenchyma.

 

Many individuals with CBD have no or limited symptoms.  Corticosteroids are used to treat symptomatic individuals to try to alleviate symptoms and slow progression of the disease.  This can be supplemented with oxygen.  Lung transplantation may be considered when necessary. [iv]

 

Lung Cancer

Early studies have indicated a slight excess of lung cancer deaths in beryllium workers at production facilities.  This increase is statistically significant and IARC has classified beryllium as a Group I human carcinogen.  Diagnosis and treatment for any beryllium-related lung cancer would be identical to that provided for non-occupational cancer.

 

Diagnostic Studies for Beryllium Associated Medical Conditions

The primary diagnostic study specific to beryllium is the blood beryllium lymphocyte proliferation test (BeLPT).  This test is used to detect an individual’s sensitivity to beryllium and to support a diagnosis of CBD.  The test involves procedures which require a degree of expertise and experience.  In an attempt to standardize the procedure, the United States Department of Energy (DOE) has published procedures.[v] Five facilities have been authorized by DOE to provide BeLPT testing for DOE and its contractors.  These facilities include Cleveland Clinic, National Jewish Hospital, University of Pennsylvania Hospital, Specialty Laboratory, and Oak Ridge Institute for Science and Education (ORISE).  Information pertaining to these laboratories can be obtained at http://www.hanford.gov/pmm/icpt/icptagreements.html. 

 

The principle of the BeLPT is that T cells sensitive to a specific antigen will undergo a proliferation response when exposed to the antigen in-vitro.  If this occurs from T cells from an individual’s blood specimen, the individual is said to be sensitive or hypersensitive to the antigen.  Beryllium can be an antigen and is associated with a granulomatous hypersensitivity disorder in an estimated 2-5% of individuals exposed to beryllium. 

 

Large numbers of CD4+ T-lymphocytes accumulate in the lung in individuals with CBD.  These cells can be obtained by performing bronchoalveolar lavage (BAL).  The beryllium reactivity of the lymphocytes obtained by BAL in individuals with CBD is usually greater than the reactivity of lymphocytes obtained from peripheral blood.  The sensitivity and specificity of the peripheral blood BeLPT is not clearly defined.  This is explained by the fact that the populations of normal people (without CBD) have not had lung biopsy or BAL to diagnose or exclude CBD.  However, it is estimated that repeatedly positive BeLPTs (beryllium sensitive individuals) predict CBD will develop in approximately 44 to 50 percent (positive predictive value) of these individuals.

 

Federal Programs Related to Beryllium

DOE Chronic Beryllium Disease Prevention Program

 

The Department of Energy published its final rule of the Chronic Beryllium Disease Prevention Program (CBDPP) in December 1999.  The purpose of the program is to reduce the number of workers exposed to beryllium in DOE facilities, minimize the levels of exposure, and establish medical surveillance requirements for beryllium to ensure early detection of CBD.  This rule provides for volunteer medical surveillance program for beryllium-associated workers.  The baseline medical evaluation includes a medical and work history, respiratory questionnaire, physical examination, chest x-ray, spirometry, a blood BeLPT, and other tests deemed appropriate by the examining physicians.  Periodic medical evaluations must be provided to beryllium workers annually and beryllium-associated workers every three years.  These evaluations include a medical and work history, respiratory questionnaire, physical examination, blood BeLPT, and any other medical evaluations deemed appropriate by the examining physicians.  A chest radiograph must be provided every five years. This program requires the physician to notify the employer of any beryllium related conditions and recommendations.  This is also communicated to the employee for consideration of placing the employee in a different job.[vi]

 

According to a subsequent DOE document, if the blood BeLPT is positive, a second specimen is tested to confirm the first positive result.  If the employee again tests positive, the employee may be offered a bronchoalveolar lavage, lung biopsy, and/or CT scan to assist in the diagnosis of CBD.  This article states that 25% of individuals who initially test positive do not test positive on a second test.  Two positive tests are required to indicate that the individual is sensitized to beryllium.[vii]Therefore, DOE is using the blood BeLPT for screening of beryllium workers and beryllium associated workers, but requiring two positive BeLPT results to confirm beryllium sensitivity.

 

Energy Employees Occupational Illness Compensation Program Act of 2000

This legislation by Congress established a program to provide benefits to employees or former employees of the Federal government or contractors if the employee had developed radiation-induced cancers, beryllium diseases, or silicosis while working in the nuclear weapons industry for DOE.  This act provides for medical benefits and a lump sum payment of $150,000 to eligible individuals.

 

The act described beryllium sensitivity as:

“Beryllium sensitivity as established by an abnormal beryllium lymphocyte proliferation test performed on either blood or lavage cells.”

 

According to the act, the term “established chronic beryllium disease” means chronic beryllium disease as established by the following criteria.

1) For diagnoses on or after January 1, 1993, beryllium sensitivity (as established in accordance with paragraph (8) (A), together with lung pathology consistent with chronic beryllium disease, including: 

(a) lung biopsy showing granulomas or a lymphocytic process consistent with chronic beryllium disease.

(b) computerized axial tomography scan showing changes consistent with chronic beryllium disease; or

(c)  pulmonary function or exercise testing showing pulmonary deficits consistent with chronic beryllium disease.

 

(2) For diagnoses of chronic beryllium disease prior to  January 1, 1993, the following criteria are required :

(a) occupational or environmental history or epidemiologic evidence of beryllium exposure; and

(b) three of the following criteria:

·      Characteristic chest radiographic (or computed tomography (CT)) abnormalities.

·      Restrictive or obstructive lung physiologic testing or diffusing lung capacity defect.

·      Lung pathology consistent with chronic beryllium disease.

·      Clinical course consistent with a chronic respiratory disorder.

·      Immunologic tests showing beryllium sensitivity (skin patch test or beryllium blood test preferred.)”

 

These definitions rely on (diagnoses after January 1, 1993) or are supported by (diagnoses before January 1, 1993) a positive BeLPT.  These definitions do not provide further description as to the types of findings that should be present on chest x-ray, HRCT scan, pulmonary function testing, or pathology.

 

Diagnostic Criteria and Claim Determination by BWC

Currently the Ohio Revised Code describes berylliosis in ORC 4123.68 (V) as follows:

 

“Berylliosis: Berylliosis means a disease of the lungs caused by breathing beryllium in the form of dust or fumes, producing characteristic changes in the lungs and demonstrated by x-ray examination, by biopsy, or by autopsy.”

 

Later ORC states “the administrator of workers’ compensation shall refer the claim to a qualified medical specialist for examination and recommendation with regard to the diagnosis, and other medical questions associated with the claim.  An employee shall submit to such examinations, including clinical and x-ray examinations, as the administrator requires.”

 

This description was written prior to the development of the BeLPT and the medical knowledge of beryllium sensitivity.

 

BWC Implementation of Revised Diagnostic Criteria.

Based on information from the Department of Energy and Department of Labor, most of the locations in Ohio that may have workers with beryllium sensitivity or CBD are located in Southern Ohio (Piketon Gaseous Diffusion Facility) or facilities operated by Brush Wellman near Cleveland and Sandusky.  It is possible that other vendors or contractors to these facilities may have employees who develop these conditions.  Regardless, these claims most likely will not be widespread and there will probably be limited interest in examiners to learn about the conditions.   Only examiners who may evaluate these individuals routinely will be familiar with process of obtaining blood and sending for the BeLPT.  It is probably not reasonable to require or allow examiners to perform bronchoalveolar lavage or lung biopsy since these are independent medical evaluations and invasive procedures are typically not performed.  HRCT scan is probably also not beneficial unless requested by the examiner when absolutely necessary due to logistics and costs. Therefore, it is reasonable for BWC to request the injured worker and/or employer to provide the results of testing performed as part of the Department of Energy program and to revise the criteria for beryllium related diagnoses to the following:

 

Chronic Beryllium Disease   ICD-9 503

 

1.    History of employment with employer with likelihood of exposure to beryllium dust, salt,  oxide, or vapors.; and

2.    Two positive BeLPT tests consistent with sensitivity to beryllium.  Tests may be conducted on the same blood specimen by two different approved laboratory facilities, specimens obtained at different times and analyzed by the same or two different laboratory facilities, or a positive blood BeLPT and positive BeLPT using cells obtained by bronchoalveolar lavage.  Only laboratory facilities approved by the Department of Energy will be accepted; and

3.    Lung biopsy or autopsy showing noncaseating granulomas with mononuclear cell infiltrates; or if pathological tissue can not be obtained, then

4.    High resolution computed tomography (HRCT) demonstrating small ill-defined nodules, septal lines, areas of ground-glass attenuation, or adenopathy which are consistent with CBD; or

5.    Three of the following:

·      Chest radiographs showing small nodular opacities throughout the lung fields with perhaps higher distribution in the upper lobes (or hilar lymphadenopathy);

·      Abnormal diffusion capacity (DLCO);

·      Spirometry showing obstructive; restrictive; or mixed pattern;

·      Clinical course consistent with a chronic respiratory disorder (>12 months with periodic treatment consistent with CBD.)

 

Beryllium Sensitivity 985.3 (Toxic Effect of other metals – Beryllium and its Compounds)

 

Beryllium sensitivity does not require any medical treatment and the employer or Department of Labor will provide medical surveillance as federally required.  Since there is an abnormal laboratory test (BeLPT), it could be argued that there is objective evidence of a medical condition and there should be a claim and claim allowance.     No medical or indemnity costs should be incurred for this condition since it requires no treatment except monitoring, is not impairing, and causes no disability.  To parallel the Federal programs, the following diagnostic criteria are offered:

 

1.    History of employment with employer with likelihood of exposure to beryllium dust, salt, oxide, or vapors; and

 

2.    Two positive BeLPT tests (either blood, BAL, or combination) consistent with sensitivity to beryllium.  Tests may be conducted on the same blood specimen by two different approved laboratory facilities, specimens obtained at different times and analyzed by the same or two different laboratory facilities, or a positive blood BeLPT and positive BeLPT using cells obtained by bronchoalveolar lavage.  Only laboratory facilities approved by the Department of Energy will be accepted.

 

This would include the following:

 

1.    Results of two BeLPTs performed at DOE approved laboratories;

2.    Results of any BeLPTs performed  using cells obtained by bronchoalveolar lavage;

 

If the individual is sensitized, the following studies may need to be reviewed to insure there are no findings consistent with chronic beryllium disease (CBD):

 

1.    Results of any HRCT scans performed as part of medical evaluations preferably interpreted by chest radiologist;

2.    Results of any pathology testing  performed  as part of medical evaluations.

3.    In disputed cases, request the HRCT scans and any tissue analysis available which can be sent for independent review.

 

Using the above criteria, the diagnosis of beryllium sensitivity can be made by  a  qualified  BWC physician file review.  It also may be possible in uncontested cases of CBD to determine the diagnosis based on the results of the above diagnostic studies.   If there is not adequate evidence based on this information, an IME can be performed by a few select pulmonary or occupational physicians familiar with this condition.  The IME would consist of:

 

1.    History and work history

2.    Physical Examination

3.    Review of medical records provided

4.    CXR if needed

5.    Spirometry if needed

6.    Diffusion capacity if needed

7.    In equivocal cases or when needed for additional evidence, HRCT may be considered appropriate to confirm changes consistent with CBD but not beryllium sensitivity.

 

This procedure makes use of results gathered by the employer and DOE and limits additional expense.  Also, by using a smaller panel of physicians, greater consistency in the program may be achieved.

 

BWC Procedure

Chronic Beryllium Disease (CBD)

·      BWC CST requests the results of testing performed as part of the Department of Energy program from the injured worker, the employer or IW representative.

·      The CST schedules a file review with available documentation by a DEP physician qualified to do beryllium file reviews.

·      The BWC diagnostic criteria for CBD include:

1.    History of employment with employer with likelihood of exposure to beryllium dust, salt,  oxide, or vapors.; and

2.    Two positive BeLPT tests consistent with sensitivity to beryllium.  Tests may be conducted on the same blood specimen by two different approved laboratory facilities, specimens obtained at different times and analyzed by the same or two different laboratory facilities, or a positive blood BeLPT and positive BeLPT using cells obtained by bronchoalveolar lavage.  Only laboratory facilities approved by the Department of Energy will be accepted; and

3.    Lung biopsy or autopsy showing noncaseating granulomas with mononuclear cell infiltrates; or if pathological tissue can not be obtained, then

4.    High resolution computed tomography (HRCT) demonstrating small ill-defined nodules, septal lines, areas of ground-glass attenuation, or adenopathy which are consistent with CBD; or

5.    Three of the following:

a.  Chest radiographs showing small nodular opacities  throughout the lung fields with perhaps higher  distribution in the upper lobes (or hilar  lymphadenopathy);

b. Abnormal diffusion capacity (DLCO);

c. Spirometry showing obstructive; restrictive; or mixed pattern;

d. Clinical course consistent with a chronic respiratory disorder (>12 months with periodic treatment consistent with CBD.)

·      The CST schedules an independent medical examination by a DEP pulmonary or occupational physician qualified to do beryllium exams if the CBD is contested by the employer or employee, if there is uncertainty from the file review, or if there is an order by the Industrial Commission to perform the exam.

 

Due to the complex nature of CBD and the limited number of cases that will be reviewed by BWC, contact BWC Medical Advisor, or Field Operations for assistance as  needed.

 

Beryllium Sensitivity

·      All monitoring for beryllium sensitivity should be reimbursed by the US Department of Energy via the Department of Labor Energy Employee Occupational Illness Compensation Program Act.  BWC should not have any responsibility for bill payments for beryllium sensitivity since this condition requires no treatment except monitoring, is not impairing, and causes no disability.

·      The diagnosis of beryllium sensitivity can be made  by a qualified  DEP physician file reviewer using the criteria for the diagnosis of beryllium sensitivity as documented in Section VII of this policy:

1.    History of employment with employer with likelihood of exposure to beryllium dust, salt, oxide, or vapors; and

2.    Two positive BeLPT tests (either blood, BAL, or combination) consistent with sensitivity to beryllium.  Tests may be conducted on the same blood specimen by two different approved laboratory facilities, specimens obtained at different times and analyzed by the same or two different laboratory facilities, or a positive blood BeLPT and positive BeLPT using cells obtained by bronchoalveolar lavage.  Only laboratory facilities approved by the Department of Energy will be accepted.

 

If the individual is sensitized, the following studies may need to be reviewed to insure there are no findings consistent with chronic beryllium disease (CBD):

 

1.    Results of any HRCT scans performed as part of medical evaluations preferably interpreted by chest radiologist;

2.    Results of any pathology testing performed  as part of medical evaluations.

 

·      The CST schedules an independent medical examination by a DEP pulmonary or occupational physician qualified to do beryllium exams if the CBD is contested by the employer or employee, if there is uncertainty from the file review, or if there is an order by the Industrial Commission to perform the exam.

 

Due to the complex nature of CBD and the limited number of cases that will be reviewed by BWC, contact BWC Medical Advisor, or Field Operations for assistance as needed.