The early detection of infectious diseases within a community is a critical public health function, and an important element of health security. School settings can quickly amplify the rate of disease transmission, making early disease detection and monitoring particularly critical in order to prevent and mitigate community outbreaks. School-based syndromic surveillance has been shown to mirror the local community and ED disease surveillance data [14, 16, 18], as well as play a role in informing school closure decisions [13, 17, 19]. Therefore, school-based syndromic surveillance data can play an important role in community early detection programs and school disaster plans. In addition, school-based syndromic surveillance data has been used during past events to inform and develop risk communication messages for the public regarding status of an outbreak in the community [21]. In order to have this data available to enhance health security, schools must take an active role in both collecting and reporting syndromic surveillance data. The Missouri K-12 schools in this study demonstrated that school nurses can play a vital role in assisting with the collection and reporting of syndromic surveillance indicators, particularly since almost all (90 %) of the school nurses surveyed indicated that they were already collecting at least one syndromic surveillance indicator. Though almost all of the schools are collecting at least one syndromic surveillance indicator, only half of the nurses report this data to their local public health department. Fewer than a quarter of the schools report absenteeism data to public health, though almost three-quarters collect this data. The most plausible explanation for this is that schools collect absenteeism data for tracking truancy and obtaining state funding based on student enrollment rather than for the intention of using absenteeism as a syndromic surveillance indicator. It is also possible that school nurses do not have an incentive to report this data or understand the importance of syndromic surveillance data to community resilience. Regardless of the reason(s) why, it is worrisome that this valuable set of data is not routinely reported.

The lack of reporting for absenteeism is particularly concerning since research indicates that communicable disease transmission is common in school settings [12, 13, 16, 17] and that an increase in student absenteeism could be a precursor to, or signal a community-wide outbreak. In addition, children are often disproportionally affected during biological events [17], so it is appropriate to use absenteeism data to inform school closure decisions [17, 20]. For example, during the 2009 H1N1 influenza A pandemic, many schools across the country closed, citing absenteeism as their primary rationale along with high levels of illness [17]. Many of these schools had already invested substantial resources into their response and preparedness efforts for the H1N1 influenza A pandemic, yet the absenteeism data still prompted many school closures [17]. Therefore, it is especially important that schools routinely report their absenteeism data due to the potential impact it may have on school closure and other policy decisions in future communicable disease outbreaks. Challenges with utilizing school absenteeism data include its application to localized outbreaks, optimization of school closures, development and widespread acceptance of a single integrated system [12, 17, 20], so it important to recognize that school absenteeism alone should not inform school closure decisions.

This study found that public health official engagement with schools, or even the perception of their interest in collaboration, is associated with higher collection and reporting of school-based syndromic surveillance data. In this study, nurses’ perception of public health officials’ interest in school-based syndromic surveillance data was associated with higher collection of influenza-like and gastrointestinal illness indicators. Of course, data collection is only the first step in syndromic surveillance; reporting this data is vital to its use. A critical finding from this study is that school nurses who believed public health officials were interested in school-based data were 12.7, 10 and 9.2 times more likely to report influenza-like illness, gastrointestinal illness and absenteeism data, respectively, compared to nurses who did not share this belief. In addition, school nurses who reported that the health department had approached them about collecting syndromic surveillance data were 3.1 and 4.6 times more likely to report influenza-like and gastrointestinal illness data, respectively, compared to nurses who had not been approached by public health officials. The transition from the collection to reporting of syndromic surveillance indicators is clearly augmented when health departments express interest in the information by approaching the school.

An easy intervention to address this is for public health officials to engage school nurses and administrators in a dialogue about the role schools play in community health security. For instance, public health officials could point out that the Centers for Disease Control and Prevention (CDC) recommend in their pandemic planning checklist for K-12 schools [23] that schools consider engaging in community-wide syndromic surveillance programs. Findings from this study indicate that public health officials could increase their access to school-based syndromic surveillance data by simply letting the nurse or school administrators know that they are interested in this data. Given that so many schools are already collecting at least some types of syndromic surveillance data, it would not be a tremendous burden for the school nurse or administrator to simply report this data to local public health. Enhancing the partnership between schools and public health would also have other benefits for community health security and resilience by increasing coordination across the agencies, a gap that has been identified in multiple past studies [22, 24].

Other important predictors for the collection of syndromic surveillance indicators included nurses’ knowledge of how to collect and analyze syndromic surveillance data, and the perception that school administrators supported syndromic surveillance data collection. It is also notable that if a school nurse has served as a member of their school’s disaster planning committee, the reporting of influenza-like illness data increased. These factors are all actionable items that could greatly influence the level of collection and reporting of syndromic surveillance data by schools. Educational programs related to the collection and, more importantly, analysis of school-based syndromic surveillance data could be developed to aid nurses in gaining this knowledge. Half of the school nurses in this study self-identified as knowing how to collect syndromic surveillance data for their school, but less than a third indicated that they know how to analyze the data. Reporting of syndromic surveillance data to the health department is important, but internal review and analysis of the data would strengthen school resilience and increase the likelihood of early identification of an event; it could also be used to help inform school closure decisions during future biological events [17, 19]. If school-based syndromic surveillance educational programs were developed, it would be critical that they be offered face-to-face, such as a presentation at a national conference, as research has indicated that school nurses overwhelmingly prefer this format [25].

Another potential intervention to increase collection and reporting of school-based syndromic surveillance data would be to develop an educational program or biological event disaster exercise targeted at school administrators. Administrators determine the disaster planning priorities for their school, which could include syndromic surveillance participation. As of July, 2015, no existing studies could be found that describe school administrators’ attitudes, beliefs or priorities related to school biological event preparedness. Two studies have examined school administrators’ attitudes towards and involvement in school emergency management planning, but neither one specifically assessed biological events [26, 27]. One study measured school administrators’ perceptions of their school’s readiness for “all-hazards”, but biological events were not included in the disasters assessed [27]. The second study found that school administrators recognize their responsibility for school or district emergency management plans, either directly if they are on the planning committee or indirectly if they delegate that responsibility to others [26]. The Umoh [26] study assessed perceptions about administrators’ preparedness for terrorist threats, but biological events were not explicitly addressed; the study focused on bomb and active shooter threats. Based on the limited research found regarding school administrators and biological events, it is assumed that neither a needs assessment nor an intervention has been attempted to address these critically influential individuals. Future studies should assess school administrators’ knowledge and/or beliefs regarding the importance of school preparedness for bioterrorism, pandemics or outbreaks of emerging pathogens and the role that schools play in community resilience against these events. This could improve school participation in community syndromic surveillance programs, as findings from this study indicate that it is critical to gain school administrators’ support for the collection and analysis of school-based syndromic surveillance data.

Limitations of this study include the possibility of some self-selection bias by the subjects due to the study design. Also it is important to recognize that the study data was only collected in Missouri, and only from nurses belonging to the Missouri Association for School Nurses (MASN), which could limit some of the generalizability, particularly since not all school nurses in the state belong to MASN. Strengths of this study include the fact that the demographics of the nurse participants in this study are nearly identical to those of school nurses nationwide [28]. Additionally, school participation in the collection and reporting of syndromic surveillance data, and school nurses’ attitudes regarding syndromic surveillance have not been previously assessed. Future studies could further elucidate the factors influencing the implementation of syndromic surveillance programs in schools including both gathering as well as reporting of collected data.