Pooled analysis of ten echocardiography-confirmed studies across Nepal — encompassing 209,815 participants and 5,440 cases — estimates an overall rheumatic heart disease (RHD) prevalence of 3.1% (95% CI 1.6–5.8%). The urban-rural split is stark: Kathmandu-based studies yield 1.1%, while non-Kathmandu regions show 7.2% — a six-fold disparity. Meta-regression further reveals a rising temporal trend over three decades (β = 0.092, p = 0.001) with no evidence of burden reduction.
RHD is caused by streptococcal throat infections triggering autoimmune damage to heart valves — a condition almost entirely eliminated in high-income countries through penicillin prophylaxis and improved sanitation. That rural Nepal still carries a 7.2% prevalence in 2025 reflects compounding failures: limited primary care reach, inadequate streptococcal treatment, and surgical inaccessibility for advanced valve disease. The rising temporal trend is particularly alarming and may reflect better case detection via echocardiography or genuine epidemiological worsening — the data cannot distinguish between the two.
Critical limitations temper interpretation. Heterogeneity is extreme (I² = 99.8%), the prediction interval spans 0.3–28.5%, and GRADE certainty is rated only low-to-moderate. Small-study bias cannot be excluded. As a preprint posted to medRxiv and not yet peer-reviewed, these estimates may shift substantially after independent scrutiny. Still, the directional signal — deep rural disadvantage, no secular improvement — is epidemiologically coherent and demands policy attention regardless of final precision estimates.