CHEST RADIOGRAPHY

B Reader Information for Medical Professionals

Do you live in a coal mining area and expect to classify chest radiographs for the Coal Workers' X-Ray Surveillance Program as mandated by the Federal Mine Safety and Health Act of 1977?
Have you been asked to classify chest radiographs of asbestos- exposed workers as governed by the U.S. Department of Labor regulations?
Are you involved in classifying chest radiographs for medical screening, surveillance, research, or compensation programs?

The B Reader Examination

B Reader approval is granted to physicians with a valid U.S. state medical license who demonstrate proficiency in the classification of chest radiographs for pneumoconioses using the International Labour Office (ILO) Classification System.

Proficiency is evaluated via the B Reader Examination, which was developed in response to the mandates of the Federal Mine Safety and Health Act. Since the examination was first administered in 1974, more than 1000 physicians have passed it. Currently, there are about 300 B Readers (Current B Reader List).

Examinations are offered monthly at NIOSH’s Appalachian Laboratory for Occupational Safety and Health located in Morgantown, West Virginia. A passing score results in approval as a B Reader. Each B Reader is required to be re-examined every four years. Most B Readers renew for an additional term.

Regulations mandate that all physicians who participate in the examination and/or classify chest radiographs under the Act must utilize the ILO System and Standard Films. These standard films are necessary when participating in the B Reader Examination or utilizing the NIOSH Self-Study Syllabus, and are an important resource at the American College of Radiology (ACR) Symposium on Radiology of the Pneumoconioses.

For more information:
Wagner GR, Attfield MD, Parker JE. Chest Radiography in Dust-Exposed Miners: Promise and Problems, Potential and Imperfections. OCCUPATIONAL MEDICINE: State of the Art Reviews. Philadelphia, Hanley & Belfus, Inc. 1993; 8(1):127-141.

For additional information, you may wish to refer to:
Wagner GR, Attfield MD, Kennedy RD, Parker JE. The NIOSH B Reader Certification Program--An Update Report. JOURNAL OF OCCUPATIONAL MEDICINE. 1992; 34:879-884.

2011 ILO Revisions

NIOSH currently uses the revised edition (2011) of the Guidelines for the Use of the ILO International Classification of Radiographs of Pneumoconioses. Potential B Reader candidates should keep the following in mind:

B Reader certifications under the previous ILO system will continue to be valid until their date of expiration.
NIOSH has revised both the B Reader certification and recertification examinations to make them consistent with the 2011 ILO revision.
A revised Roentogenographic Interpretation Form, consistent with the 2011 ILO revision, is available from NIOSH and is being used in all components of the CWXSP. You may download a copy of the form from this site by clicking on the link above.
NIOSH tests all B Reader candidates according to the 2011 revised ILO system. Upon the expiration of their certification, current B Readers will be required to recertify under the revised system.

You can visit the ILO web site to obtain a copy of the Guidelines for the use of the ILO International Classification of Radiographs of Pneumoconioses (Edition 2011).

During the transition from the 1980 to the 2011 edition of the ILO Classification, readers have asked about the use of different available sets of standard radiographs in classifying films under the current 2011 revision of the Classification.

Two issues have arisen:

1) The ILO now offers two distinct sets of the standard films: the "Complete Set" consisting of 22 radiographs, and the "Quad Set" consisting of 14 radiographs. Although the two sets are generally comparable, international trials have demonstrated some tendency for film classifications to vary, depending on the set of radiographs used. Thus, for the purposes of classifications under the NIOSH Coal Workers' X-ray Surveillance Program, use of the "Complete Set" is preferred. Readers should consult with the responsible parties regarding this issue when they perform classifications for other purposes, such as research studies, medical surveillance programs, or clinical or medical-legal evaluations.

2) In order to preserve continuity and consistency in the classifications, the images used in reproducing the 2011 version of the standard radiographs are identical to those used for the 1980 set of standard radiographs, aside from one image which demonstrates pleural abnormalities. The ILO did endeavor to improve image quality in the 2000 set by utilizing advanced computer image techniques. The NIOSH Coal Workers' X-ray Surveillance Program requires that readers submit classifications adhering to the 2011 Revised Edition of the Guidelines for the Use of the ILO International Classification of Radiographs of Pneumoconiosis. The sets of standard images used in the 2011 and 1980 Classifications are nearly identical, and thus it is the individual reader's choice which of these two sets of standard radiographs to use after that time. However, because the quality of the 2011 standard radiographs has been enhanced by the ILO, NIOSH recommends that readers consider using these current standard radiographs for classifying films for NIOSH programs and studies.

Pre-Examination Preparation

NIOSH strongly recommends pre-test preparation for examination participants to assure familiarity with the ILO Classification System and associated Roentgenographic Interpretation Form. Pre-test preparation is extremely important because anyone who fails the initial examination must wait ninety days before re-testing. The examination is difficult: only about half of the examinees pass.

The NIOSH Self Study Syllabus is offered in several formats from NIOSH and/or by attendance at the American College of Radiology (ACR) Symposium on Radiology of the Pneumoconioses.

The American College of Radiology (ACR) Symposium on Radiology of the Pneumoconioses is usually held every 2-3 years. Please contact the ACR for further details (800) 227-5463.

Digital Radiography

The world is in process of transition from film screen radiology to the use of digital imaging. In many places, the transition is virtually complete. Being aware of this trend, the National Institute for Occupational Safety and Health (NIOSH) has been pursuing means to facilitate and standardize the evaluation of chest images, with the object of enhancing the accuracy and precision of determinations and making modern digital imaging technologies accessible and practical for use in classification.

In March 2008, NIOSH hosted a workshop on Application of the ILO International Classification of Radiographs of Pneumoconioses to Digital Chest Radiographic Images (DHHS (NIOSH) Publication No. 2008-139). NIOSH has also conducted research to assess the equivalency of traditional radiography and digital radiography in pneumoconiosis classification.

Based upon the results of relevant completed and ongoing research, as well as consultation with experts in the field, NIOSH has concluded that digital radiography provides essentially equivalent classifications to those derived from film screen technology and is working to develop recommendations for digital radiographic imaging in the recognition and classification of pneumoconiosis.

Meanwhile, to comply with current regulatory requirements under 42CFR Part 37, B Readers must continue to use standard film-screen radiographs when classifying chest radiographs for the Coal Workers' X-Ray Surveillance Program until the new digital regulations are in place.

In addition, the guidelines for use of the ILO International Classification of Radiographs of Pneumoconioses prescribe side-by-side viewing of subject and standard radiographs, and state that the standard films take precedence in defining profusion categories. Thus, until provisions for use of digital images have been specified, readers using the ILO Classification for all purposes should continue to use traditional film screen radiographs and standards.

For more information:
Franzblau A, Kazerooni EA, Sen A, Goodsitt MM, Lee SY, Rosenman KD, Lockey JE, Meyer CA, Gillespie BW, Petsonk EL, Wang ML. Comparison of Digital Radiographs with Film Radiographs for the Classification of Pneumoconiosis. Acad Radiol 2009; 16:669-677.

AS Laney, EL Petsonk, AL Wolfe, MD Attfield: Comparison of storage phosphor computed radiography with conventional film-screen radiography in the recognition of pneumoconiosis. European Respiratory Journal. 2010. 36(1): p. 1-6

Sen A, Lee S-Y, Gillespie BW, Kazerooni EA, Goodsitt MM, Rosenman KD, Lockey JE, Meyer CA, Petsonk EL, Wang ML, Franzblau A. Comparison of Reliability of Classification for Pneumoconiosis of Film and Digital Radiographs: A Modeling Approach. Acad Radiol 2010; 17:511–519.

Roentgenographic Interpretation Form

Roentgenographic Interpretation Form
En español
(OMB 0920-0020) (CDC/NIOSH 2.8) (December 2009)
This form must be completed by the A or B Reader that interprets a chest radiograph for NIOSH as part of the Coal Workers' X-ray Surveillance Program. Mail to the address on the form. Do NOT send this form electronically to NIOSH. Print/Copy as a double-sided form.

More Information

For more information about the NIOSH B Reader process, write or telephone--

National Institute for Occupational Safety and Health
Coal Workers' Health Surveillance Program
1095 Willowdale Road - M/S LB205
Morgantown, WV 26505
(888)480-4042