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Karen M. Starko, Reply to Noymer et al, Clinical Infectious Diseases, Volume 50, Issue 8, 15 April 2010, Pages 1203–1204, https://doi.org/10.1086/651473
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To the Editor—I understand the concern of Noymer et al [1] regarding the worldwide validity of the hypothesis that aspirin contributed to 1918 pandemic mortality [2]. However, worldwide use, as well as clinical, pathology, and physiology evidence of lung toxicity, indicate that aspirin may have played some role in mortality around the world.
I agree that aspirin is not the only risk factor for 1918 influenza mortality [2], yet the country “dose-response” test suggested fails to inform when competing risk factors are present. Potential competing factors, such as viral pathogenicity, bacterial colonization, immune response, smoking, preexisting conditions, and treatment, vary by locale; therefore, the role (etiologic fraction) of each factor is likely to vary by locale as well.
The possibility remains that the effect of aspirin on worldwide 1918 influenza mortality, if proven, may not have been trivial. Aspirin was widely used. In 1905, a British court struck down Bayer's British patent and opened the aspirin market in the entire British Empire. In 1918, US manufacturers produced 172 million tablets [3]. During the pandemic, the Indian Surgeon General recommended gargling with diluted potassium permanganate and aspirin [4, p 89], and in Delhi, an eminent Indian surgeon “insisted that smart young doctors in Bombay were recklessly misusing it—on the basis, he said, that it weakened the heart (old canard) and actually brought on pneumonia as a consequence” [5, p 137]. In New Zealand, 1 Maori village, impressed by aspirin, honored the local health superintendent who had provided it; a baby there was named "Aspirin" [5, p 138]. In New South Wales, Aspro was at the top of the list of fixed price wartime commodities [5, p 138]. Unfortunately, a precise reckoning of the amount of aspirin produced, distributed, and used in various countries remains elusive. Yet, importantly, even if the etiologic fraction is small, in a country with a large population, the number of deaths attributable to aspirin could be substantial.
