Vitamin Deficiencies, Parasites &
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 &
 Remember “traditional” causes of Vitamin B B12 disorders (e.g.
pernicious anemia)
 Deficiency has been documented in various resettled refugee
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
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
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
Vitamin B12 deficiency
Consider testing for H. pylori infection
and/or intestinal parasites
100 – 400 pg/mL
>400 pg/mL
Check serum methylmalonic acid
& homocysteine levels
No Vitamin B12 deficiency
Both/either level is elevated
Vitamin B12 deficiency
Both levels are normal
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, &
 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
 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
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
Common methods of Torture
 Beatings
 Torture or death of others
 Electric shocks
 Hanging by limbs
 Sexual humiliation/rape
 Burning
 Exposure to extreme conditions
 Submersion in water
 Threat with violence to loved
 Forced nakedness
(including loved ones)
Being forced to watch or
participate in torture/death of
Solitary confinement or overcrowded cells
Sleep deprivation
Undergoing random &
unpredictable interrogation
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
 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
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
 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 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)
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
 Mrs. M reluctant to see mental health professional
 Review common sx of trauma
 Identify 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
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
 Health Information Translations
 Rochester General Hospital Refugee Health Information
 MedlinePlus
 ClicOnHealth (includes information on diabetes & depression; can
search site by language or topic)
 Healthy Roads Media (multimedia info, including audio & visual
 CDC (screening guidelines, links)

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