WORKING WITH REFUGEES IN PRIMARY CARE

Vitamin Deficiencies, Parasites & Trauma

Vitamin B12 Disorders* in Refugee Populations

* Includes insufficiency and deficiency of Vitamin B12

Vitamin B12 Background & Etiology

Vitamin B12 (cobalamin) important in DNA synthesis & neurologic function Essential co-factor in two enzymatic reactions involving

methylmalonic acid & homocysteine

Obtained naturally only from animal food sources (AFS)

Deficiency a common problem in most of the world, due to limited or no AFS

Vitamin B12 Background & Etiology, cont.

Other major risk factor for deficiency in refugees : H. pylori infection (up to 90% in some populations)

Other parasitic infections (Giardia lamblia & tapeworm infestation) also increase risk by causing chronic diarrhea & malabsorption

Remember “traditional” causes of Vitamin B B12 disorders (e.g. pernicious anemia)

Deficiency has been documented in various resettled refugee groups MMWR March 25, 2011: 64% prevalence in Bhutanese

refugees in U.S. 2008-2011

Clinical Manifestations of Vitamin B12 Disorders

Insufficiency/deficiency: various hematologic & neuropsychiatric disorders Megaloblastic anemia, pancytopenia Paresthesias, peripheral neuropathy, demyelination

disorders Irritability, personality change, mild memory

impairment, dementia, depression, psychosis Possible increased risk of MI/stroke (increased

homocysteine levels)

Diagnosis of Vitamin B12 Disorders

Evaluate serum Vitamin B12 and folic acid levels

Consider evaluation of methylmalonic acid & homocysteine levels

Consider testing for H. pylori & other parasitic infections

Evaluation of Suspected Vitamin B12 disorder

Measure serum vitamin B12 & folic acid levels↓

Folic acid normal (if low, treat with folic acid and recheck vitamin B12 and folic acid levels)

↓Serum B12 level

↓ <100 pg/mL 100 – 400 pg/mL >400 pg/mL ↓ ↓ ↓

Vitamin B12 deficiency Check serum methylmalonic acid No Vitamin B12 deficiency

& homocysteine levels ↓ ↓

Consider testing for H. pylori infection and/or intestinal parasites ↓

______________________↓ ↓

Both/either level is elevated Both levels are normal ↓ ↓

Vitamin B12 deficiency No Vitamin B12 deficiency

Treatment of Vitamin B12 disorders

Oral Vitamin B12 (cyanocobalmin) 1,000 mcg to 2,000 mcg PO x 1-2 weeks, then 1,000 mcg/day for life (depending on etiology/re-testing results)

Oral treatment is as effective, less expensive, & easier to administer as traditional IM injections, even in patients with pernicious anemia or ileal disease Cochrane Review 2005 Two RCTs included; total of 108 participants; 93

followed-up from 90 days to four months

Other Common Vitamin Deficiencies

Vitamin B1 (thiamine) Betel nut Pickled tea leaves

Vitamin D Women & clothing Children Elderly

Parasitic Infections in Refugee Populations

Ascaris & More…

Parasitic Infections: Background

Worldwide prevalence of parasitic infections: > 1 billion people are Ascaris carriers 12% of world population infected with Entamoeba

histolytica At least 500 million carry Trichuris 200-300 million infected with 1+ Schistosoma species In U.S. ~65 million people with intestinal parasites

Background, cont.

Most common pathogenic parasites in refugees are Trichuris (whipworm), Giardia, Entamoeba histolytica, Schistosoma spp., hookworm, & Ascaris

Lice & scabies are the two most common arthropod parasites found in refugee populations

Common Pathogenic Parasites & Host Organ Sites

Hookworm– small intestine (Anycyclostoma dudenale, Necator americanus)

Roundworm (nematode)– small intestine, lungs (Ascaris lumbricoides, Strongyloides stercorarius)

Echinococcus granulosus – liver, lungs, kidney, spleen, nervous

tissue, bone

Pinworm (Enterobius vermicularis) – intestine Schistosoma spp. – mesenteric or vesical veins Whipworm (Trichuris trichiura) – large intestine

Consequences of Parasitic Infections

May include anemia due to blood loss and iron deficiency, vitamin deficiencies, malnutrition, growth retardation, invasive disease, and death

Significant morbidity & mortality from obstruction of intestines, bile ducts, lymph channels, and brain/other organ capillaries

Screening for Parasitic Infections

CDC recommends all resettled refugees be screened

At this time, refugees in NM are not specifically screened for parasitic infections

Refugees ≥ 2 years of age are treated empirically with Albendazole 400 mg Po x 1 at their initial SEH Public Health screening visit May not eradicate Strongyloides Doesn’t treat Schistosoma

Screening, cont.

Evaluate for eosinophilia with CBC w/ diff done at Public Health initial screening eosinophilia defined as >400 cells/μL May or may not be present with parasitic infection;

consider absolute eosinophil count

Stool studies (O&P; 2 samples collected >24 hrs apart)

Strongyloides serology (all refugees)

Schistosoma serology (sub-Saharan Africans)

Treatment & Follow-up

Treat pathogenic parasitic infections See CDC for recommendations & dosing

Re-check total eosinophil count in 3-6 months Persistent eosinophilia or symptoms requires

further dx evaluation

Working with Refugee Trauma Survivors

.

The Refugee Experience

Important to remember definition of “refugee”

Most refugees are forced from their homes due to war or threat of violence and usually flee their home country to save their lives and the lives of their family

Experience of Torture

5-35% of world’s refugees & asylees are estimated to have been tortured

Percentage of torture survivors in particular cultural groups is even higher (e.g. 2004 study: 44% of 1134 Ethiopian & Somali refugees in U.S.)

Torture is a global public health problem; it’s use has reached epidemic proportions worldwide

.. ..

Beatings Electric shocks Hanging by limbs Sexual humiliation/rape Burning Exposure to extreme

conditions Submersion in water Threat with violence to

loved ones Forced nakedness

Torture or death of others (including loved ones)

Being forced to watch or participate in torture/death of others

Solitary confinement or over-crowded cells

Sleep deprivation Undergoing random &

unpredictable interrogation

Common methods of Torture

Identifying Trauma &/or Torture Survivors

Have high index of suspicion of trauma/torture in refugee patients, but don’t assume that every refugee has trauma/torture experience

Most refugees don’t conceptualize trauma symptoms in terms of Western mental health concepts

Many are reluctant to access mental health services even when referred

Identifying Trauma &/or Torture Survivors

As health providers, we have a critical role in identifying and helping trauma survivors

Early intervention in treating trauma symptoms is important in preventing future disability & prolonged suffering

Refugees who are/may be trauma survivors need to be assessed for PTSD, MDD, and substance abuse

Identifying Trauma &/or Torture Survivors

Common features of trauma/torture survivors include: Status as a refugee/immigrant/asylee, history of civil war Reluctance to divulge pre-resettlement experiences Patient or family member politically active in home country Family member who has been tortured or killed History of imprisonment Any physical scarring Somatic symptoms with no known physical cause Psychiatric sx of trauma: depression, insomnia, nightmares,

irritability, difficulty concentrating, avoidance, anxiety with medical exams, appetite disturbance, suicidal thoughts

Trauma, Stress & Somatic Symptoms

Frequent complaints of unexplained pain & physical sx

Sx may be directly related to prior experience of starvation, malnutrition, infectious diseases, head injury, physical assault, or other untreated illnesses

Need full exam to r/0 physical illness, but many such somatic sx have emotional origin in trauma

Somatic sx often more culturally appropriate way of seeking help

Stigma of Mental Health Conditions

Mental health problems may be attributed to wide variety of causes (e.g. offending ancestor spirits, soul loss, witchcraft, voodoo, social circumstances, “thinking too much”)

“Mental illness” usually refers to persistent, psychotic states – being “crazy”

Being “crazy” is a significant social stigma in most cultures and may bring shame upon entire family/clan

Starting the Healing Process

PCP as catalyst for helping refugees understand & heal from trauma, and provide necessary general health education & care

Refer any refugee patient with known or suspected trauma/torture history to Amber Gray, NM State Refugee Mental Health Coordinator

Increasing Treatment Compliance

Not trauma/torture survivor specific!

Many refugees have never taken Western medications, or have but just for short periods (i.e. antibiotics)

Often lack understanding of why medications may need to be taken daily (vs. prn) and/or for extended periods of time – patient education essential!

Increasing Treatment Compliance, cont.

Exploring the patient’s understanding of their illness can help in comprehending why they miss appointments and/or don’t take medications as directed

Developing mutual understanding of the patient’s AND our rationales for treatment essential for ongoing compliance & strengthening therapeutic relationships

Increasing Treatment Compliance, cont.

Many patients discontinue meds when they feel better, if they have not noticed any effects/improvement within several days, or when side effects occur

Essential to review reasons for medication, dosing instructions, potential side effects, and length of treatment via an interpreter

Helpful to review all the above at every follow-up visit

Treatment of Trauma Survivors

Creating safe place & therapeutic relationshipReferral to Amber & support of follow-up Physical exerciseRelaxation techniquesEncouragement of spirituality & religionRecreating meaning in lifeEmployment & hobbiesStrengthening social connectionsMinimizing maladaptive copingLimiting exposure to trauma reminders (e.g.

media)

Case Study

Mrs. M – 42 yo married female from Somalia c/o HA, body pain, indigestion, palpitations Extensive w/u – no medical explanation for sx Medications provide little relief Patient & provider frustrated Missing appts despite urgent requests to be seen Provider apprehensive about upcoming visits & tries to

schedule appts as far out as possible

Case Study, cont.

Questions about Mrs. M’s experiences in Somalia & as a refugee

Mrs. M reluctant to see mental health professional

Review common sx of traumaIdentify Mrs. M’s strengths, discuss self-coping

strategies

Case Study, cont.

Mrs. M then shares that she is “trying to forget & build a new life,” she feels that she is “going crazy”

PCP reassures Mrs. M that she is not going crazy & that her sx are natural human reaction to the terrible events she has lived through

Mrs. M visibly relieved & agrees to schedule a follow-up visit

Case Study, cont.

Mrs. M continues to have difficulties making appts; she reports when in distress she calls for same-day appt, but by time her appt comes, she usually feels better & doesn’t want to take un-paid time off from work

After a few months, Mrs. M’s insomnia & nightmares worsen, she is missing more time from work, and functioning poorly when there. She describes frequent irritability and is easy to anger

Case Study, cont.

Mrs. M agrees to meet with mental health specialist

Mrs. M is prescribed combination treatment w/ psychotherapy & a SSRI; initially her sx improve, but then she discontinues the SSRI due to HA & nausea

Mr. M remembers about potential medication side effects & calls the clinic; Mr. & Mrs. M discuss this with PCP. Her dose is changed & importance of daily dosing is reiterated

Case Study, cont.

Frequent contact with her mental health specialists, case worker, & PCP help her to improve her ability to keep appts

Mrs. M continues her therapy sessions & with time is even able to tolerate a therapeutic dose of her medication

Mrs. M’s sx progressively improve, as does her work & family life. She is also able to gain insight into the relationship between stressors & her physical complaints, pain & panicky feelings, thus allowing her to manage her chronic sx & experience fewer crises

New Mexico Refugee Health Providers & Other Contacts

Marshall Jensen, Director of Catholic Charities Refugee Resettlement Program (505) 724-4670  Linda Hellyer, RN; SEH Public Health Nurse Manager (505) 841-8928  Maryanne Chavez, RN; SEH Public Health Nurse (505) 841-8928  Mary Abeyta, RN; SEH Public Health Nurse (505) 841-8928  Amber Gray, LPCC; State Refugee Mental Health Coordinator (505) 603-

7021  Brian Isakson, PhD; UNM SEH Clinic Psychologist (505) 272-5885  Krystal Hielo, UNM SEH Clinic Medical Assistant (505) 272-5885 Antia Sanchez, RN, MSN; UNM SEH Clinic Unit Director (505) 272-5885 Mary Johnson, CNP UNM SEH Clinic Nurse Practitioner (505) 272-5885 Maryalyse Adams Mercado, MD; Attending Physician FCCH; UNM SEH Clinic Volunteer Attending Physician & Refugee Health Liaison (608) 628-

4660

Refugee Health Online Resources

Refugee Health Information Network www.rhin.org  Health Information Translations www.healthinfotranslations.org Rochester General Hospital Refugee Health Information www.rochestergeneral.org/rochester-general-hospital/centers-and-

services/medical-services/refugee-healthcare  MedlinePlus

www.nlm.nih.gov/medlineplus/languages/all_healthtopics.html  ClicOnHealth (includes information on diabetes & depression;

can search site by language or topic) www.cliconhealth.org/HealthResources

 Healthy Roads Media (multimedia info, including audio & visual www.healthyroadsmedia.org 

CDC (screening guidelines, links) www.cdc.gov/immigrantrefugeehealth