Letter to the Editor: Beryllium

I n their letter to the editor (J. Occup. Environ. Hyg. 2:D48– D50, 2005) entitled “Beryllium Workers’ Health Risks,” Newman and colleagues raise some worthy points with regard to the Henneberger estimates of the size of the berylliumexposed worker population. However, several of Newman’s comments regarding the “beryllium problem” and “true burden of beryllium-related disease” ignore important details critical to understanding modern day beryllium health risks. The majority of persons diagnosed today with chronic beryllium disease (CBD) do not have clinically evident disease. Before the late 1980s, workers were diagnosed with CBD only when they exhibited clinical(1) (observable) symptoms of CBD and changes in their chest X-ray or lung function test. In the late 1980s and early 1990s, the criteria for the diagnosis of CBD(2) were expanded to include workers without clinical symptoms or measurable impairment, so called having subclinical CBD. (3) These workers were diagnosed on the basis of abnormal beryllium blood lymphocyte proliferation tests (BeBLPT) for beryllium sensitization and the presence, upon lung biopsy, of granulomata. Newman and others have noted that granuloma formation can have many causes, including exposures to other metals such as aluminum, copper, titanium, and zirconium. (4) Workers with subclinical CBD have no symptoms and may or may not develop clinical CBD over time. (5) The natural history of subclinical CBD is not yet known, yet it is very evident from studies conducted by Brush Wellman Inc., the National Institute for Occupational Safety and Health (NIOSH), and others that the rate of subclinical CBD is much higher than the historical rate of clinical CBD. This research demonstrates that most persons do not progress to illness. Even the recent paper by Newman et al.,(6) which attempts to predict a possible conversion rate for beryllium sensitization to CBD in a small study population, identified only one person undergoing treatment in the cohort of 55 persons. Beryllium sensitization does not equate to berylliuminduced illness. The term “sensitization” as it relates to beryllium has in the last several years become strictly associated with the BeBLPT. The BeBLPT is an in vitro laboratory test to measure if a response occurs when a water-soluble beryllium compound is added to immune cells isolated from a blood sample. Another measure of sensitization, the beryllium skin patch test,(7) gives a picture of beryllium sensitization prevalence and incidence that is very different from that derived from studies of beryllium workers using the BeBLPT. Sensitization identified by either method is not a measure of a health effect, illness, or disability. Nor does the BeBLPT alone detect subclinical or clinical CBD or define who will or will not develop CBD. Workers exposed to any level of beryllium should not be included in the calculations of beryllium-exposed industries or considered for medical monitoring. Every person on the planet has exposure to beryllium via ingestion and inhalation of beryllium. Beryllium is in all soil and most rock. It is emitted to the air via erosion, volcanic action, the burning of coal, and as a naturally occurring constituent(8) in hundreds of products, where beryllium is not intentionally introduced, from ceiling tiles to cigarettes to sandpaper. Based on Dr. Newman’s definition, the entire worldwide work force can be included in his definition and, therefore, should be considered for medical monitoring using the BeBLPT. The broad use of the BeBLPT is unwarranted. First, the BeBLPT has been demonstrated to be highly variable and unreliable,(9) has no standardized test protocol among laboratories, does not lead to early treatment of beryllium disease, and creates needless fear and anxiety. Positive tests have been found in 1% to 2% of newly hired workers before occupational exposure is initiated. In addition, BeBLPT results can and do reverse. For example, in a survey at Brush Wellman’s primary beryllium production facility in Ohio, 18 persons who were confirmed BeBLPT positive (two positive tests) in the early 1990s and who continued to work in beryllium operations were retested in 1999. The retest found 10 of the 18 (55%) BeBLPT negative based on testing a blood sample at two different laboratories. (9) The BeBLPT test is similar to genetic testing in that the indiscriminate use of the BeBLPT may result in serious socioeconomic consequences for workers, including denial of insurance and discriminatory employment practices. Unlike genetic testing, however, there are no federal or state protections against potential discrimination over a positive beryllium blood test result. Second, the BeBLPT is not recommended as a biological indicator by the American Conference of Governmental Industrial Hygienists (ACGIH ©R ) Biological Exposures Indices Committee (BEI). (10) The Army, Navy, and Air Force have endorsed the use of the BeBLPT as part of their diagnostic protocols for persons experiencing clinical lung symptoms to discriminate possible beryllium-induced health effects from