Meta-analysis aggregates information across related studies to provide more reliable statistical inference and has been a vital tool for assessing the safety and efficacy of many high profile pharmaceutical products. A key challenge in conducting a meta-analysis is that the number of related studies is typically small. Applying classical methods that are asymptotic in the number of studies can compromise the validity of inference, particularly when heterogeneity across studies is present. Moreover, serious adverse events are often rare and can result in one or more studies with no events in at least one study arm. While it is common to use arbitrary continuity corrections or remove zero-event studies to stabilize or define effect estimates in such settings, these practices can invalidate subsequent inference. To address these significant practical issues, we introduce an exact inference method for comparing event rates in two treatment arms under a random effects framework, which we coin "XRRmeta". In contrast to existing methods, the coverage of the confidence interval from XRRmeta is guaranteed to be at or above the nominal level (up to Monte Carlo error) when the event rates, number of studies, and/or the within-study sample sizes are small. XRRmeta is also justified in its treatment of zero-event studies through a conditional inference argument. Importantly, our extensive numerical studies indicate that XRRmeta does not yield overly conservative inference. We apply our proposed method to reanalyze the occurrence of major adverse cardiovascular events among type II diabetics treated with rosiglitazone and in a more recent example examining the utility of face masks in preventing person-to-person transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 2019 (COVID-19).

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