<P> By the end of the pandemic, the isolated island of Marajó, in Brazil's Amazon River Delta had not reported an outbreak . </P> <P> In a 2009 paper published in the journal Clinical Infectious Diseases, Karen Starko proposed that aspirin poisoning had contributed substantially to the fatalities . She based this on the reported symptoms in those dying from the flu, as reported in the post mortem reports still available, and also the timing of the big "death spike" in October 1918 which happened right after the Surgeon General of the United States Army, and the Journal of the American Medical Association both recommended very large doses of 8.0--31.2 g of aspirin per day . Starko also suggests that the wave of aspirin poisonings was due to a "perfect storm" of events: Bayer's patent on aspirin expired, so that many companies rushed in to make a profit and greatly increased the supply; this coincided with the flu pandemic; and the symptoms of aspirin poisoning were not known at the time . </P> <P> As an explanation for the universally high mortality rate, this hypothesis was questioned in a letter to the journal published in April 2010 by Andrew Noymer and Daisy Carreon of the University of California, Irvine, and Niall Johnson of the Australian Commission on Safety and Quality in Health Care . They questioned this universal applicability given the high mortality rate in countries such as India, where there was little or no access to aspirin at the time . They concluded that "the salicylate (aspirin) poisoning hypothesis (was) difficult to sustain as the primary explanation for the unusual virulence of the 1918--1919 influenza pandemic". </P> <P> But they overlooked that inexpensive aspirin had become available in India and other places after October 1918, when the Bayer patent expired . In responding, Starko pointed to anecdotal evidence of aspirin over-prescription in India and argued that even if aspirin over-prescription had not contributed to the high Indian mortality rate, it could still have been a major factor for other high rates in areas where other exacerbating factors present in India played less of a role . </P>

What percentage of the population died from the spanish flu