Talks involving the United States, Egypt, Israel and Qatar on a Gaza truce have ended without a breakthrough as calls grow for Israel to hold back on a planned assault on the southern end of the enclave, crammed with over a million displaced people.

The city of Rafah, whose pre-war population was about 300,000, teems with homeless people living in tent camps and makeshift shelters who fled there from Israeli bombardments in areas of Gaza farther north during more than four months of war.

Israel says it wants to flush out Hamas militants from hideouts in Rafah and free Israeli hostages being held there. Its military is making plans to evacuate Palestinian civilians. But no plan has been forthcoming and aid agencies say the displaced have nowhere else to go in the shattered territory.

With Palestinians in Rafah “starting death in the face,” United Nations aid chief Martin Griffiths said an Israeli ground invasion there would make humanitarian relief nearly impossible.

“Military operations in Rafah could lead to a slaughter in Gaza. They could also leave an already fragile humanitarian operation at death’s door,” Griffiths said in a statement.

Israeli tanks shelled the eastern sector of Rafah overnight on Tuesday, causing waves of panic, residents said.

They said displaced people – dozens so far – had begun to leave Rafah after Israeli shelling and air strikes in recent days.

Rafah neighbours Egypt, but Cairo has made clear it will not allow a refugee exodus over the border.

Gaza health officials announced 133 new Palestinian deaths in the past 24 hours, bringing the total to 28,473 killed and 68,146 wounded since October 7, when 1,200 people were killed in a Hamas rampage across the border into Israel, triggering the war.

Many other people are believed to be buried under rubble of destroyed buildings across the densely populated Gaza Strip, much of which is in ruins. Supplies of food, water and other essentials are running out and diseases are spreading.

About half of Gaza’s 2.3 million people are now squeezed into Rafah.

In Cairo, Egyptian President Abdel Fattah al-Sisi conducted talks with CIA Director William Burns and Qatari Prime Minister Sheikh Mohammed bin Abdulrahman bin Jassim Al-Thani aimed at agreeing a Gaza truce, protecting civilians and delivering more aid into the enclave, Egypt’s state information service said.

In a statement on its website, it cited a “keenness to continue consultation and coordination” on the key issues, indicating that no breakthrough was made.

The Egyptian statement made no mention of Israel. The Israeli delegation left Cairo for home, a Reuters reporter said. The Israeli prime minister’s office did not immediately respond to a request for comment.

Israel has vowed to fight on, for many months if necessary, until it eradicates Hamas.

A Palestinian official said earlier the sides were seeking a formula acceptable to Hamas, which insists that Israel commit to ending its war and pulling its forces from Gaza.

A Hamas official said Hamas had told the participants it does not trust Israel not to renew the war if the Israeli hostages being held by Palestinian militants are released.

The hostages were seized in Hamas’ raid into southern Israel on October 7. Securing their return is a priority for Prime Minister Benjamin Netanyahu’s government as well as wiping out Hamas, which governs the small coastal territory.

US President Joe Biden on Monday said Washington was working on a hostage deal to bring “immediate and sustained” calm to Gaza for at least six weeks.

Biden has urged Israel to refrain from a Rafah offensive without a viable plan to protect civilians.

In the latest bloodshed, Israel’s military said its forces had killed dozens of Palestinian fighters in clashes in southern and central Gaza over the past 24 hours.

Gaza health officials said an Israeli strike on a house in Nusseirat refugee camp in central Gaza killed 16 Palestinians overnight. They said another air strike on a car in Gaza City later on Tuesday killed six people including children.

Israeli sniper fire killed three Palestinians and injured 10 others on Tuesday at the Nasser Medical Complex in Khan Younis, the Palestinian health ministry said in a statement.