Vitamin Deficiencies, Parasites & Trauma

1. Vitamin Deficiencies, Parasites & Trauma WORKING WITH REFUGEES IN PRIMARY CARE

2. Vitamin B12 Disorders* in Refugee Populations * Includes insufficiency and deficiency of Vitamin B12

3. 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

4. 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

5. 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)

6. 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

7. 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

8. 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

9. Other Common Vitamin Deficiencies • Vitamin B1(thiamine) • Betel nut • Pickled tea leaves • Vitamin D • Women & clothing • Children • Elderly

10. Parasitic Infections in Refugee Populations Ascaris & More…

11. 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

12. 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

13. Common Pathogenic Parasites & Host Organ Sites • Hookworm– small intestine (Anycyclostoma dudenale, Necator americanus) • Roundworm (nematode)– small intestine, lungs (Ascaris lumbricoides, Strongyloides stercorarius) • Echinococcusgranulosus – liver, lungs, kidney, spleen, nervous tissue, bone • Pinworm (Enterobius vermicularis) – intestine • Schistosoma spp. – mesenteric or vesical veins • Whipworm (Trichuris trichiura) – large intestine

14. 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

15. 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

16. 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)

17. 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

18. Working with Refugee Trauma Survivors .

19. 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

20. 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

21. Common methods of Torture . . • 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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!

29. 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

30. 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

31. Treatment of Trauma Survivors • Creating safe place & therapeutic relationship • Referral to Amber & support of follow-up • Physical exercise • Relaxation techniques • Encouragement of spirituality & religion • Recreating meaning in life • Employment & hobbies • Strengthening social connections • Minimizing maladaptive coping • Limiting exposure to trauma reminders (e.g. media)

32. 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

33. 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 trauma • Identify Mrs. M’s strengths, discuss self-coping strategies

34. 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

35. 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

36. 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

37. 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

38. 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 HealthCoordinator (505) 603-7021 • Brian Isakson, PhD; UNM SEH Clinic Psychologist (505) 272-5885 • KrystalHielo, 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

39. 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