Implementing a national acute rheumatic fever case-finding program and registry in Nepal: protocol for a multi-site...

Rheumatic heart disease (RHD) is a leading cause of preventable cardiovascular morbidity and mortality among children and young adults in low- and lower-middle-income countries. Acute rheumatic fever (ARF), the immunologic precursor to RHD, is frequently missed in endemic settings, resulting in delayed treatment and progressive valvular disease. Nepal bears a high burden of RHD but lacks a coordinated system for early ARF identification, standardized echocardiographic evaluation, and longitudinal follow-up.

This protocol describes implementation of a standardized ARF case-finding program and integrated clinical and echocardiographic registry across 11 district and referral hospitals in Nepal. The program is delivered through the PRIMA Network in partnership with the Kathmandu Institute of Child Health (KIOCH), embedded within existing PEN-Plus chronic disease infrastructure at district-level facilities. Case-finding is integrated into routine care using the 2015 modified Jones criteria, standardized echocardiography protocols, centralized training, and REDCap registry-based follow-up. Implementation outcomes are evaluated using Proctor's taxonomy, focusing on acceptability, feasibility, and adoption of the program within routine care, rather than on clinical detection rates or RHD outcomes. Contextual determinants are examined using the Consolidated Framework for Implementation Research (CFIR). Care-process indicators including diagnostic patterns and follow-up completion are summarized descriptively over the first 12 months of program delivery.

This protocol describes a pragmatic approach to embedding ARF case-finding within routine district-level care in Nepal. Findings will inform future evaluations of program performance, scale-up, and sustainability, and may serve as a replicable model for strengthening ARF detection in other RHD-endemic low-resource settings.