The first record of the outbreak in Hong Kong appeared on 13 July 1968. By the end of July 1968, extensive outbreaks were reported in Vietnam and Singapore. Despite the fatality of the 1957 Asian Flu in China, little improvement had been made regarding the handling of such epidemics. The Times newspaper was actually the first source to sound alarm regarding this new possible pandemic. By September 1968, the flu reached India, the Philippines, northern Australia and Europe. That same month, the virus entered California from returning Vietnam War troops but did not become widespread in the United States until December 1968. It would reach Japan, Africa and South America by 1969. The outbreak in Hong Kong, where density is about 500 people per acre, reached maximum intensity in two weeks, lasting six months in total from July to December 1968, however worldwide deaths from this virus peaked much later, in December 1968 and January 1969. By that time, public health warnings and virus descriptions were issued in the scientific and medical journals. In comparison to other pandemics, the Hong Kong flu yielded a low death rate, with a case-fatality ratio below 0.5% making it a category 2 disease on the Pandemic Severity Index. The pandemic infected an estimated 500,000 Hong Kong residents, 15% of the population. In the United States, approximately 33,800 people died, including conjoined twins Daisy and Violet Hilton in January 1969.