Pharmacy & Healthcare

Call it déjà flu

Influenza has been an unpleasant visitor in certain states and cities year after year. Walgreens knows where, but there’s more mystery around why.

Josh Gaby, Walgreens News
Everything’s bigger in Texas, or so the old saying goes.

So would that include the flu?
If you’re going by the Walgreens Flu Index – as local health officials and media have since we first introduced the report during the 2014-15 flu season – then, yes, there always seems to be a heaping helping of Texas when it comes to the states and markets where we’re seeing the most flu activity. Simply put, the index tracks the number of anti-viral flu prescriptions filled at Walgreens pharmacies, providing a window into where flu is showing up the most in the U.S. and Puerto Rico. Last flu season, our data pointed to Texas as the No. 3 state for flu activity overall, behind Mississippi and Oklahoma, with five Texas markets finishing among the top 10 (including the top four spots).
This season, for the week ending Jan. 25, Texas was the No. 3 state overall (behind Wyoming and New Mexico) and again had five of the top 10 markets, including El Paso (1), the Brownsville area (2) and Dallas-Fort Worth (4).
Going back several years, the results have been noticeably similar.
So why Texas? Why so much flu there?
Just as experts can’t say with confidence whether a given flu season will be mild or severe, or which strains of influenza will be circulating the most, the question of why certain parts of the country get hit harder than others – even year after year – can be something of a guessing game.

Roy Armstrong, Walgreens regional healthcare director for the Gulf Coast region, which includes Houston and all of coastal Texas, has a few possible explanations. One is that many communities in Texas, particularly near the Mexican border, have populations that culturally are not as receptive to getting vaccines – including the flu shot. There’s also a lot of transnational travel, which can lend itself to the spread of flu.

And there’s this: Texas might be a perennial hot spot because of, well … the heat.
“We’ve found it can be harder to convince someone in Houston, South Texas – really anywhere in Texas – to get a flu shot because it can be 100 degrees still in August and into September,” says Armstrong. “Even now, in January, it’s typically in the 70s.”
Frances Colon, a Walgreens pharmacy manager in Brownsville, Texas – part of the No. 2 market for flu, according to our latest index – can attest to this reluctance from customers. Hot weather often creates a false sense of security about the flu. “Every day, we’re telling customers, ‘You need to get your flu shot so you’re protected – it takes two weeks for the vaccine to create immunity in your body,’” she says. “And they’ll say, ‘No, I’ll get it later.’ Then, when the temperature goes down – here, that usually means 60, 65 degrees – that’s when a lot of our patients finally decide to come to the pharmacy, and by that time, a lot of people are already sick.”
Armstrong’s Gulf Coast region also includes nearly all of Mississippi, Louisiana and Alabama – all of which were in our top 10 states for flu activity last season. In those states, Armstrong suspects the flu problem may have more to do with overall health patterns. According to Walgreens tracking, all three states rank low for prescription adherence (that’s how well patients get their medications filled and take them on time), and Mississippi and Louisiana in particular have been cited by the CDC and other health organizations as two of the unhealthiest states when it comes to physical activity and people proactively taking care of their own health.
“Certainly, immunizations are going to fall under that umbrella,” says Armstrong. “And when you don’t have a high percentage of people getting flu shots in a certain area, you’re going to be more susceptible to flu outbreaks.”

Meanwhile, up in the Midwest …

Hundreds of miles north in Nebraska, they’re also dealing with curiously high rates of flu – as they did last season and the season before that. Nebraska was our No. 6 state for flu activity overall in 2018-19, with Lincoln and Hastings-Kearney comprising our No. 7 market. For the month of December 2019, Nebraska was far and away the state with the most flu medication dispensed on average per Walgreens pharmacy, and Lincoln and Hastings-Kearney were our No. 6 market as of Jan. 25, with Omaha also a hotbed.
There’s no Texas heat at play here. Nebraska isn’t a border state or travel hub. So what’s going on?
Like Armstrong in the Gulf Coast, Tracie Bowman, regional healthcare director for the Midwest region, can only speculate. But she has seen some interesting trends.

For one thing, early in the flu season, Nebraska seems to be “almost a step behind” in the flu strains affecting the population, says Bowman. Last flu season, while the H3N2 strain was hitting much of the country, Nebraska was seeing more H1N1. This season, while many areas of the country have seen high levels of Influenza B, Nebraska has only recently seen an increase in B after experiencing more H1N1 and Influenza A over the first few months. The four flu strains included in the quadrivalent flu vaccine don’t usually change significantly from year to year, says Bowman, but if Nebraskans have been circulating strains that the current vaccine isn’t quite as effective against, that could help explain the higher flu activity.
She thinks it might also be a matter of optics. If Walgreens pharmacies in Nebraska’s main population centers are dispensing high amounts of anti-flu medication on average, it might not mean Nebraska has more flu, per se, than neighboring states. Rather, it could mean there’s actually stronger patient access to health care – unlike in larger metropolitan areas or extremely rural areas of the U.S. Think of it this way: If more people can get in to see a doctor within the 48-hour window where Tamiflu is effective against flu symptoms, then more Tamiflu prescriptions will be written, which means Walgreens will fill more of them, which means activity on the flu index will be higher.
Another wrinkle, notes Debbie Hartle, a specialty pharmacy manager who recently managed the pharmacy at a busy Omaha Walgreens, is that some doctors who know an area has especially high flu activity (especially doctors accessed through telemedicine services) might prescribe Tamiflu based on what they believe to be flu without a positive flu test, to get the patient on medicine faster. For the same reason, doctors also sometimes write prescriptions proactively for entire families when one family member has the flu, accounting for more dispensing of medication. “We were moving a lot of the liquid anti-viral medication, which is mostly for children,” says Hartle. (Like many states, Nebraska does not permit pharmacists to vaccinate children younger than a certain age – in this case 7 – which might also have an effect on the state’s overall immunization levels.)
In any case, there’s no disputing that flu activity in Nebraska is nonetheless a real and persistent concern – and might well be again next year, regardless of the exact cause.
“Living in this part of the country, I don’t think I’ve ever had a time when so many people I’ve come into contact with have had influenza,” says Bowman. “A friend who’s a primary care physician told me he’s never tested so many people positive for flu in the last 10 years. Besides the numbers Walgreens is reporting, people are seeing it and feeling it for themselves.”

Pharmacist Danh Nguyen discusses the importance of the flu vaccine with
a customer in Papillion, Neb., a suburb of Omaha.

What we're doing about it
In Texas, Nebraska and other flu “hot zones,” the exact causes of regular yearly outbreaks may not be easy to pin down, but Walgreens response as a health care company is unmistakable. Here are some examples of the role we play in helping to protect the public:

  • Urging immunizations.

This includes both public awareness campaigns and in-store conversations. “Many folks who shop our stores don’t make it back to the pharmacy to fill prescriptions, so we rely heavily on the front of the store to promote the flu shot,” says Armstrong. “We’re seeing opportunities to do a better job of that, just making customers aware of the flu threat.”

  • Special attention to at-risk patients, including seniors.

“We’ll see that a patient may be diabetic or have another condition where their immune system is already a little bit weaker, and we’ll let them know we want to make sure we’re protecting them before the flu season hits fully,” says Colon. With a patient’s permission, Colon’s team will reach out to the doctor to check the patient’s immunizations records – not just for flu, but also pneumonia, shingles and other types of vaccines.

  • Flu voucher program.

Every year, an allotment of vouchers for no-cost flu vaccines is sent to each Walgreens regional office. These are divided among the areas and districts in that region and then given to patients who are uninsured or underinsured – often at community health events and flu clinics staffed by Walgreens pharmacists.

  • Making sure anti-flu medication is in stock where and when it’s needed.

It starts with the important work of the Walgreens supply chain to make sure pharmacies have plenty of inventory and can get even more of it quickly. “And we also proactively balance our supply across stores,” says Bowman. “If a store is closed for the night and they have lots in stock, but the 24-hour store down the street doesn’t, that doesn’t make sense.”

  • Dispelling myths.

"Many people think when they get a cold, that’s the flu, and we have to explain the difference,” says Colon. “We also have many patients who believe they will get the flu from a flu shot, which is not possible because the vaccine contains inactivated virus. There’s a lot of education by our pharmacy teams day in and day out.”


The intent of the Walgreens Flu Index is to get information about recent flu activity to the public with help from local health organizations and the media – all in the name of better awareness and community protection. And when that news coverage happens, there’s usually a noticeable (and immediate) effect in our stores. Debbie Hartle, the specialty pharmacy manager in Omaha, has been interviewed recently by the local newspaper and a TV news station, both of which cited information from the Walgreens Flu Index.

“In Omaha, whenever that type of news story comes out, there’s usually a rush of people coming to get a flu shot afterward,” says Hartle. “Around the holidays, we had a lot of people coming in saying, ‘Oops, I’m going to be around my family, and I heard on the news that there’s a high amount of flu in the area – I’d better get my vaccine.’”
What about the Gulf Coast in Texas? How is the news coverage there?
“Not enough,” admits Roy Armstrong, the regional healthcare director. “I think there’s an opportunity to do more, because it does have such an impact on driving awareness. If you say there’s a flu outbreak, people get alarmed: ‘Let me go get protected before it hits my house.’”

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