This section below summarizes the identified scientific evidence and jurisdictional guidance on pre-operative COVID-19 testing and vaccination. 

The following limitations should be noted:

• Evidence on pre-operative guidelines for fully vaccinated individuals is of low quality and only a small number of peer-reviewed publications are available. 

Scientific Evidence

Research on Pre-Operative and Surgical COVID-19 Testing

• Five identified single studies evaluated institutional pre-operative and surgical COVID-19 testing strategies across the United States (US), Italy, South Korea, and India.
  • Testing Methods: Reverse transcriptase-polymerase chain reaction (RT-PCR) testing of nasopharyngeal swabs was the most commonly evaluated pre-operative testing method. In particular, a study (January 2020) comparing accuracy of COVID-19 screening protocols for elective surgery reported that two different screening protocols for SARS-CoV-2 infection were effective for pre-operative screening surgery candidates: 1) pharyngeal swab alone; or 2) a combination of symptom evaluation, generic blood tests, and computed tomography (CT) of the chest.
  • Timing of Tests: Required timeframes for obtaining tests before surgery in 10 US health care institutions varied from one to five days before surgery. Following a positive test result, nine sites required postponement of surgery for at least 10 days.
  • Health Outcomes: A study (January 2021) on the association between pre-operative SARS-CoV-2 testing and post-operative pulmonary complications reported that swab testing was beneficial before major surgery, and in areas with a high 14-day SARS-CoV-2 case notification rate, but not in low-risk areas. To prevent one pulmonary complication, the number of patients needed to be swab-tested prior to major or minor surgery was 18 and 48, respectively, in high-risk areas, and 73 and 387 in low-risk areas.
  • Costs: A study (April 2021) on pre-operative screening strategies in a South Korean hospital reported that a total of 10,645 pre-operative RT-PCR tests were performed during the study period, costing the hospital approximately CAD $900,000. This was compared to the expected loss of CAD $15,000,000 that would have occurred had the operating rooms been closed for two weeks due to the nosocomial spread of COVID-19.

Research on Pre-Operative and Surgical COVID-19 Testing

• COVID-19 Vaccine and Mortality Prevention: A modelling study (March 2021) based on data from almost 60,000 patients internationally reported that fewer people need to be vaccinated to prevent one death in surgical patients compared with the general population; the study estimated that globally, prioritizing all surgical patients for pre-operative vaccination ahead of the general population is projected to prevent an additional 58,687 COVID-19-related deaths in one year.

International Scan

Screening Hospitalized and At-Home Pre-Operative Patients

• Reports from the United Kingdom, Italy, Germany, and Italy state that early in the pandemic, COVID-19 testing was used to conduct pre-operative screening of asymptomatic and pre-symptomatic surgical patients. For example, pre-operative COVID-19 testing was used at the University Hospital (Wuerzburg, Germany) to screen and transfer patients to spaces that were separated into SARS-CoV2 or non-SARS-CoV-2 areas (e.g., operation room).
  • Testing Method: The most common test used was the nasopharyngeal swab for PCR testing; antibody screening was also used to screen surgical patients in the United Kingdom.
  • Timing of Tests: The timings of pre-operative screenings varied from 12 hours to five days prior to surgery, and two to five days prior to hospital admission (at-home patients). Guidance (June 2021) from the United Kingdom reports that self-administered pharyngeal swab tests must be taken exactly three days before the day of the patient’s procedure(s).

COVID-19 Vaccination and Elective Surgery

• A review (May 2021) on COVID-19 vaccination and elective surgery reported that expert consensus from international professional societies generally recommend vaccinating patients against SARS-CoV-2 before elective surgery, as this may reduce the risk of COVID-19 complications and transmission of the virus during procedures.
• Most guidance documents on COVID-19 vaccination from Australia and England recommend pre-operative vaccination, though differ about suggested timings. One exception is the Royal College of Surgeons of England, which recommends that emergency surgery take place irrespective of COVID-19 immunization status.
  • Timing for Pre-Operative Vaccination: Recommendations on the timing for pre-operative COVID-19 vaccination is variable, ranging from a few days to weeks due to the unknown vaccine immunogenicity. No information was provided on whether partial or full vaccination is required/recommended before surgery. Recommendations on time of vaccination before surgery by specialty groups varied as follows:
    • General Surgery: A few days to one week; one week, and serveral weeks;
    • Kidney Transplant: Three to four weeks;
    • Plastic or Cosmetic Surgery: At least one week; and
    • Immunology: One week.

Canadian Scan

Screening Pre-Operative Patients

• A modelling study (June 2021) on the impacts of conducting surgery without pre-operative testing in Canada (excluding Quebec) reported that, at the time of writing, no province has a mandate to routinely test elective surgical patients for COVID-19 pre-operatively.
• British Columbia and Saskatchewan recommend pre-operative COVID-19 testing under specific circumstances, while Alberta does not recommend testing. In particular:
  • An Alberta Health Services (AHS) guidance document (June 2021) on infection prevention and control does not recommend routine pre-operative COVID-19 testing at this time since the burden of the virus in the nasopharynx may be below the detection threshold at the time of the swab, and there may be false reassurance from a negative test result. As an alternative, the AHS uses the followingpoint-of-care assessment tools: AHS Acute Care COVID-19 Expanded Testing Algorithm; and/or Form #21615 Communicable Disease (Respiratory) Initial Screening; and/or Form #21666 Ambulatory Care Communicable Disease (Respiratory) Screening.
• A Saskatchewan Health Authority guidance document (April 2021) reported that point-of-care (POC) PCR testing was in place effective March 17, 2021. POC-PCR tests are used for patients, including those vaccinated, who have screened negative and are asymptomatic, presenting for all-day surgeries, same-day surgeries, and inpatient procedures.

Ontario Scan

• An Ontario Health guidance document (June 2020) recommends that pre-surgical (non-emergent) and pre-procedural COVID-19 testing should be conducted as close as possible to the date of the surgery or procedure, given local testing capacity.

The COVID-19 Evidence Synthesis Network is comprised of groups specializing in evidence synthesis and knowledge translation. The group has committed to provide their expertise to provide high-quality, relevant, and timely synthesized research evidence about COVID-19 to inform decision makers as the pandemic continues. The following members of the Network provided information for this Evidence Synthesis Briefing Note:

• Evidence Synthesis Unit, Research Analysis and Evaluation Branch, Ontario Ministry of Health; and
• Ontario Health (Cancer Care Ontario). (June 22, 2021). Email Communications.