The Stone/Gill SID treatment protocol for COVID-19

This updated version of the Stone/Gill SID treatment protocol is the result of correspondence during the Summer of 2024 between Eleftherios Gkioulekas and Jacqueline Stone. The resulting document resolves some ambiguities of the original version and includes the description of the intensified protocol used during the Delta variant. The finalized document has also been included in our data and materials document, which is available on Figshare. The PDF file is attached below

Sid Protocol

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Zimbabwe rollout of Silver and Ivermectin Protocol.

In early 2020, with a looming pandemic, it became obvious in Zimbabwe that the country’s healthcare system was inadequate to deal with the upcoming infections.

With a shortage of general healthcare facilities, including ICU beds and a poor general population, it was imperative that any solution needed to be low-cost, but highly effective. When Covid-19 infections began to escalate, it became clear that positive patients would have to be treated predominantly at home, as there were an inadequate number of ICU and hospital beds. Doctors were forced to come up with innovative methods of treating the pandemic.

The positive support received from the Zimbabwean government provided doctors with the freedom to try different treatment regimens, leading to an interesting protocol which is currently being used successfully today. This protocol allows doctors to treat patients who present with oxygen saturations even lower than 80% at home, rather than admitting them and burdening the healthcare system. As a consequence of successful treatment protocols, the Covid-19 mortality rate in Zimbabwe was lower than that seen in first world countries.

A Harare physician, Dr Jackie Stone, was making colloidal silver for her family and decided to use it on a patient with Covid-19, leading to exceptional results. As I was using Ivermectin at the time for my own family, we realised, through discussion, that the mode of action of the two treatments was such that they complemented each other and this prompted us to collaborate in putting a protocol together which included the use of both agents and Doxycycline.

This approach was validated in Zimbabwe through collaboration with Professor Thomas Borody who predicted that Ivermectin, Doxycycline and Zinc would be the optimal antiviral combination for COVID 19.

The outcome was better than expected. Patients, including those with oxygen saturations of below 80%, treated according to the combination protocol, would recover within 24 hours and did not require hospitalisation. The treatment was very cost-effective and patients could be treated at home.

Treatment at home was eventually extended to nursing patients at home, if they required oxygen. This protocol was associated with a mortality rate much lower than that experienced in more advanced, first world countries. The treatment was found to be reliable enough to send a patient home, if their condition showed signs of noticeable improvement and their oxygen saturation levels were rising. Even with initial saturation levels of well below 80%, patients were confidently sent home on this treatment. Any patient sent home with compromised oxygen saturation levels would be supervised by nursing staff. A small number of patients with severe disease were admitted to state hospitals, not always resulting in the best outcome, as these patients had invariably already reached a critical point of no return.

From August 2020, to the end of November 2020, there were only two deaths reported in a practice seeing an average of 20 patients a day and using the combined Silver/Ivermectin protocol. Both patients had unfortunately arrived too late, with saturation levels of below 50%.

With this positive outcome and the knowledge that the treatment was working successfully, the combination protocol is being extended to the rest of the country, with the support of the Zimbabwean government and some sponsors who are bringing in large amounts of Ivermectin and silver, to assist with the rollout of this protocol.

The SID Protocol. Dr Jackie Stone and Dr Martin Gill

SID stands for Silver, Ivermectin and Doxycycline

An “A-B-C-D-E-F” approach to treating Covid-19-positive patients with the SID protocol:

Initial assessment to determine if admission to the unit is needed (A,B,C,D,E)

A = ASSESSMENT (A-B-C-D-E)

A: Ambulant - If on a stretcher or too exhausted to walk they should be admitted to the unit, and not discharged until improving.

B: Breathing - If tachypnoeic with a respiratory rate over 22 per minute or worsening / slow respiratory rate due to exhaustion, (often associated with hypoxia with an O2 saturation below 70% )( watch the exhausted patient carefully).

C: Consciousness/confusion - Confusion or decreased or loss of consciousness is a bad prognostic factor. Keep in for observation under ICU level nursing care if possible, rather than home nursing.

D: Duration - If the patient has been symptomatic for longer than 10 days and is displaying the above-mentioned symptoms and/or has an elevated pulse rate, then the prognosis may be poor. This patient must remain in the unit for aggressive care including continuous nebulisation IV steroids and antibiotics, and subcutaneous enoxaparin if available.

E: Elevated pulse rate

Patients fulfilling any of the above criteria were flagged, as they were generally distressed, confused and often significantly hypoxic (Sp02<80%) and needed immediate and continuous care.

They were immediately put on continuous nebulisation using oxygen, cannulated, anticoagulated and bloods were taken for prognostic as well as treatment reasons.

The following protocol was then followed:

Start patient on Ivermectin 0.6 mg/kg stat dose. Be prepared to titrate to effect up to 1-2mg/kg if saturations do not come up. Maintain on 0.3- 0.6mg per kg for up to 10 days. Rather err of the side of giving too much, than too little given the safety margins and therapeutic index of this drug. Warn the patient there is a 20% chance of visual side effects. Continue until symptom free for 48 hours.

Continuous nano particulate silver nebulisations - continue until saturations are above 90% then reduce to at least 3 times a day.

Doxycycline 200mg stat then 100 mg bd for a minimum of 5 days. 10 days of treatment was given in Delta. If patient unable to tolerate oral meds, IV Ceftriaxone 1-2g was given daily.

Zinc Sulphate 20-40 mg tds p.o.

Prednisone 1mg/kg or Dexamethasone 8 mg iv stat, followed by Prednisolone 40-80mg od for 5- 10 days if CRP over 20 or if saturation less than 80%

Aspirin 300 mg daily

Clexane (enoxaparin) 80mg subcutaneously od transitioning to rivaroxaban 20mg od if the D Dimer is raised. Continue rivaroxaban for at least 30 days and longer if D Dimer has not come down.

Midazolam, ONLY if confused and pulling out lines/pulling off oxygen. Rarely more than 1 dose is needed.

Monitor O2

If the patient responds to treatment, continue as indicated below. If the patient doesn’t respond, counsel family.

Arrange referral to nearest hospital with ventilatory support as a last resort.

If not available, provide palliative support at home. (This was only needed in patients presenting with less than 50% saturation)

Patients not requiring admission to the unit:

A- Assessment: Sats >80%, not tachypnoeic, tachycardic or confused.

B = BREATHING B = BLOODS

Breathing

All sick patients were given an initial nanoparticulate silver nebulization 5-8 ml. Patients with a respiratory rate of over 22 to 25 per minute are flagged.

Respiratory distress is of concern: patients who are short of breath, grunting, or showing signs of shortness of breath and in particular tiredness, are flagged as high risk. Patients with saturations of <80% are commenced on oxygen.

Bloods

Bloods were drawn before silver nebulisation treatment was commenced. Blood was planned to be stored for cytokines and viral load studies for a clinical trial, which did not occur because of regulatory issues.

Nurses were instructed to draw yellow, purple and blue topped tubes. Initial bloods on all patients were: Full Blood Count, LDH, lymphocyte ratio, CRP and D-Dimer.

In the case of patients who had the funds, those who were diabetic, or dehydrated, a U&E and HbA1c were done, as clinically indicated.

Patients who presented with chest pain received a CKMB blood test.

C = CANNULATION – bloods to be drawn, meds to be given

In terms of OBSERVATIONS, pulse and saturations are important:

If the pulse rate was >120, or if the saturations were <80%, patients were considered high risk and were likely to need more time in the unit and to need home nursing and home oxygen, when they left.

Cannulation

Cannulation was the route by which bloods were taken. This often took place simultaneously with the other ABC’s.

Patients who were hypoxic, febrile and systemically unwell were given Ceftriaxone 1g, intravenously and Dexamethazone 8mg, or Hydrocortisone 100 - 200mg, as a stat dose, as clinically indicated.

D = DRUGS

D = DIABETES D = DOCTOR

Drugs

The first drug administered is Ivermectin at a minimum dose of 0.2mg/kg. During Delta the starting dose was 0.6mg/kg.

Diabetes

A glucose reading was taken for diabetic patients, if it had not been done already. Patients with uncontrolled diabetes were referred to a diabetic GP for an intravenous insulin infusion and diabetes management. This care was provided by a dedicated doctor, as part of this protocol, as bringing diabetes under strict control had been shown to improve survival rates in diabetic patients. Should the patient elect to have their treating doctor offer the patient this support, it was their choice.

Doctor

The above protocol was initiated by trained and experienced nurses in a very underresourced setting . At this stage, the doctor needed to have been called and the full blood count and LDH were usually available. From this point, the patient was provided with individualised treatment by the doctor.

If the patient was hypoxic and the CRP >20, treatment included Prednisone 40mg - 80mg daily. In cases where the D-Dimer was raised, subcutaneous Enoxaparin, at a dose of 80mg – 100mg (8000 – 10 000u) was administered, followed by Riveroxiban/Xarelto at a dose of 20mg per day, for 30 days.

If neutrophils were raised and the patient remained cannulated, a dose of Ceftriaxone at a dose of 1g daily was given, until oral treatment was considered adequate. When the switch was made to oral treatment, Doxycycline was used at a dose of 100mg BD for 10 days. The alternative was Azithromycin 500mg bd then 500mg od for 5 day. Both Doxy and Azithro can be used if coinfection with mycoplasma cannot be excluded.

If the patient presented with mild disease and was positive for Covid on PCR, or antigen testing, a clinical diagnosis was made on the basis of symptoms such as: (a) Hypoxia; (b) Raised LDH; (c) Low lymphocytes; (d) Raised monocytes; (e) Raised D-Dimer; (f) Suggestive radiology.

Ivermectin was given at a dose of 0.1mg to 0.2mg per kilogram, on days zero, four and eight in 2020. By December 2020 this increased to 12mg once daily in December for 5-7 days and as we realised that higher doses led to more rapid recovery with no safety concerns, the dose progressively increased to 0.4-0.6mg/kg once daily for 5-7 days by July 2021, as knowledge regarding the need for and safety of higher doses became available, and was given for up to 48 hours after resolution of symptoms. This was used in conjunction with nanoparticulate silver nebulization 5-8 ml three times daily for 5-7 days (or for 48 hours post symptoms resolution), doxycycline 100mg twice daily for 10 days and Zinc 20mg three times a day for 10 days.

Vitamin D was given to all patients at 5000 – 10 000 IU per day as well, and Vitamin C was dosed at 1g three times a day, if available.

If any of the following were present:

(a)    The Lymphocyte to LDH ratio was over 210;

(b)    The D-Dimer was raised;

(c)     The CRP was raised;

(d)    The patient was in stage 3 of the disease as per the FLCCC/Dr. McCullough’s definitions.

they were given all of the following:

Ivermectin. This was dosed at 0.2 to 0.3mg per kilogram daily, for 5 days during the beta wave and 0.4- 0.6mg/kg for 10 days during the delta wave

Silver nebulisation 5-8ml at least three times a day up to continuously if needed, if sats dropped below 90%

Doxycycline 100mg twice daily for 10 days Zinc 20mg twice daily for 10 days

E = EXIT FROM THE UNIT

Exiting the unit needed to be well planned, as when the patient entered, they had 6 hours in the unit, which was a relay station between the patient and home nursing, or hospital. Should a patient’s condition be assessed as severe, and the patient was deemed unlikely to survive, palliative home nursing was required, with a palliative care protocol as per the University of Cape Town. This happened once.

Most patients were started on a treatment protocol, and the exit strategy was normally home on Ivermectin treatment, nebulisation with Nano Silver, as well as oral Doxycycline and Zinc.

Home nursing and home oxygen could be added to this treatment

Patients who were going to require intubation and ventilation and who were deteriorating, were transferred to hospital, with the knowledge that Ivermectin and Nano Silver nebulisation treatments will be discontinued. This only occurred when we ran out of oxygen. This almost always led to the death of these patients.

Consequently, only palliative patients were transferred to hospital, or the patient was kept for just over 24 hours, during which time 2 doses of Ivermectin and continual Silver nebulisations were given.

In cases where additional respiratory support was required, patients were put on high flow oxygen with PEEP via an OxERA mask.

F = FAMILY

Patients’ families were assessed for prophylaxis. Ivermectin at 0.1mg to 0.2mg per kilogram was used as a single dose for this purpose, as well as a single Silver nebulisation, which was repeated when they returned to see the family the next day and when they went home with their relative. In delta 0.2-0.4mg/kg was given od for 5 days as prevention