Water, Sanitation, and Hygiene insecurity and infectious disease outbreaks among internally displaced populations in Gaza: Implications of conflict-driven displacement on public health

The Gaza Strip, a small but densely populated region, has long been a flashpoint of conflict and humanitarian crisis. The recent escalation in violence starting 7 October 2024 has led to an unprecedented wave of internal displacement. This conflict has displaced thousands of individuals who have sought refuge in makeshift shelters such as schools and tented facilities. The rapid and large-scale displacement has compounded existing humanitarian challenges, especially concerning Water, Sanitation, and Hygiene (WaSH) infrastructure.

Before the conflict escalated, access to WaSH services in Gaza was already precarious, with many households experiencing limited access to clean water and adequate sanitation facilities due to longstanding political and economic instability. The blockade imposed on Gaza has severely restricted the movement of goods and services, including essential WaSH supplies and maintenance resources (Abuzerr et al. 2020; AlKhaldi et al. 2021; Zaqout et al. 2024).

Since 7 October, the situation has deteriorated significantly, with displaced populations facing even greater challenges. The compromised WaSH conditions have intensified the risk of infectious disease outbreaks, posing a significant threat to the health and well-being of the displaced population. Studies indicate that the incidence of waterborne diseases, such as diarrhea and cholera, has surged among internally displaced persons (IDPs), exacerbated by the contamination of water sources and the breakdown of sanitation systems (Abuzerr et al. 2019; D'Mello-Guyett et al. 2024). The lack of hygiene supplies further contributes to the spread of diseases, while overcrowding in temporary shelters increases vulnerability to respiratory infections (ACRPS 2024; Hussein et al. 2024).

The importance of WaSH infrastructure in maintaining public health cannot be overstated. Proper access to clean water, adequate sanitation facilities, and effective hygiene practices is critical in preventing the spread of infectious diseases. Inadequate WaSH conditions are strongly associated with increased incidence rates of waterborne diseases such as diarrhea, cholera, and hepatitis A, as well as vector-borne diseases like malaria and dengue fever (WHO 2015). Studies have shown that in emergency settings, poor WaSH conditions contribute to higher rates of morbidity and mortality among displaced populations (UNICEF 2023).

Damage to infrastructure resulting from repeated military operations has compounded these challenges, creating a critical situation where basic needs are unmet and the risk of disease outbreaks is heightened (Abuzerr & Zinszer 2024; OCHA 2024). The failure of emergency relief efforts to fully address the scale of needs in Gaza underscores the severity of the humanitarian crisis and the urgent need for targeted interventions (Mahmoud & Abuzerr 2023; Shafi & Malik 2024).

The current humanitarian situation in Gaza highlights the need for a comprehensive understanding of how WaSH insecurity affects displaced populations. While previous research has documented the impact of WaSH conditions in conflict settings, there is a need for up-to-date, localized data that reflect the specific challenges faced by displaced individuals in Gaza (Abuzerr et al. 2020; Avelar Portillo et al. 2023; Alareqi et al. 2024).

Accordingly, this study aims to address this gap by providing a detailed analysis of disease incidence and the factors contributing to WaSH-related health risks among IDPs in Gaza. Understanding the interrelation between WaSH insecurity and infectious disease outbreaks is crucial for developing effective response strategies and interventions. The findings of this study are expected to contribute valuable insights into the specific needs of displaced populations in Gaza, inform humanitarian response efforts, and guide policy decisions aimed at improving WaSH conditions and health outcomes in similar conflict settings.

This study employed a mixed-methods approach to investigate the relationship between WaSH insecurity and the spread of infectious diseases among IDPs in the Gaza Strip. The research was conducted across the five governorates of Gaza-North Gaza, Gaza City, Deir al-Balah, Khan Younis, and Rafah-between 3 April and 6 August 2024. The study combined quantitative data collection and analysis with qualitative methods to provide a comprehensive understanding of the WaSH conditions and their health impacts in displaced communities residing in schools and tented shelters.

Data were collected through structured face-to-face interviews using a pre-tested questionnaire. The questionnaire captured data on demographics, household WaSH conditions (water source, sanitation facilities, hygiene practices), and the incidence of infectious diseases, including diarrhea, acute respiratory infections (ARIs), skin infections, and other WaSH-related illnesses. Data collection was conducted by trained field workers under the supervision of the research team.

The sample size for the quantitative component of this study was determined based on the estimated prevalence of WaSH-related infectious diseases among IDPs in the Gaza Strip. The calculation aimed to ensure adequate power to detect statistically significant associations between WaSH conditions and the incidence of infectious diseases.

This calculation yielded a minimum sample size of approximately 288 households per governorate. To account for potential non-responses and incomplete data, the sample size was increased by 10%, resulting in a final sample size of approximately 317 households per governorate. Given the five governorates, the total sample size was 1,585 households. For ease of sampling, this was rounded to 1,500 households, with 300 households selected from each governorate.

Quantitative data were analyzed using SPSS (Version 24.0). Descriptive statistics, including frequencies, mean scores, and standard deviations, were used to summarize the demographic characteristics and WaSH conditions of the study population. The association between WaSH conditions and the incidence of infectious diseases was assessed using chi-square tests for categorical variables and logistic regression models to control for potential confounders. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to quantify the strength of associations. Values of p < 0.05 were considered statistically significant.

For the qualitative component, purposive sampling was used to select key informants and focus group participants. Key informants included health care providers, community leaders, and representatives from humanitarian organizations involved in WaSH services. Additionally, 15 focus group discussions (FGDs) were conducted with displaced persons in schools and tented shelters, with three FGDs held in each governorate. Each FGD consisted of 8–10 participants, ensuring a diverse representation of gender, age, and socioeconomic status.

Qualitative data were collected through semi-structured interviews with key informants and FGDs with displaced persons. The interview and FGD guides were developed based on the study objectives and included questions on the perceived adequacy of WaSH services, challenges faced by displaced persons in accessing clean water and sanitation, and the impact of these conditions on health and well-being. All interviews and FGDs were audio-recorded with participants' consent and transcribed verbatim.

Thematic analysis was employed to analyze qualitative data using NVivo (Version 12). Transcripts were coded inductively to identify emerging themes related to WaSH insecurity and its health impacts. The research team independently coded a subset of transcripts to ensure consistency and reliability of the coding process. Discrepancies were resolved through discussion. The final themes were synthesized to provide a nuanced understanding of the WaSH-related challenges faced by displaced populations and their implications for public health.

Informed consent was obtained from all participants prior to data collection. Participants were assured of the confidentiality of their responses and the voluntary nature of their participation. The study adhered to the principles of the Declaration of Helsinki, ensuring respect for the rights and dignity of all participants.

A total of 1,500 households were surveyed across the five Gaza Strip governorates. Each governorate contributed 300 households to the study sample. The majority of households were headed by individuals with either primary or secondary education, and over two-thirds of the heads of households were unemployed. The average household size was 5.9 members. Slightly more than half of the participants were female, and most households were located in schools (58.3%) rather than tented shelters (41.7%) (Table 1).

Most households relied on tanker trucks as their primary water source (55.0%), with only 21.0% accessing piped water. A significant proportion of households (65.0%) had access to less than 20 L of water per person per day. Shared latrines were the most common sanitation facility (61.7%), with a notable percentage of households (17.3%) practicing open defecation. While 57.0% of households reported having handwashing facilities, only 21.7% always had soap available (Table 2).

ARIs were the most prevalent, affecting 49.3% of the study population. Diarrhea was the second most common illness, with an incidence rate of 24.9%. Other notable conditions included skin rashes (3.7%), scabies (2.5%), and acute viral hepatitis (5.6%) (Table 3).

Households with access to less than 20 L of water per person per day had 2.58 times the odds of reporting diarrhea compared to those with more than 50 L. Additionally, the use of shared latrines was associated with a 1.75 times higher likelihood of experiencing ARIs. The absence of handwashing facilities was linked to a 2.10 times higher likelihood of skin rashes, while lack of soap availability significantly increased the odds of scabies (OR = 3.45). These findings highlight the critical role of WaSH conditions in the health outcomes of displaced populations (Table 4).

The qualitative component of this study explored the lived experiences, perceptions, and coping strategies of IDPs in the Gaza Strip in relation to WaSH insecurity. In-depth interviews and FGDs were conducted with participants from each of the five Gaza Strip governorates. Thematic analysis was used to identify and interpret key themes emerging from the data.

Participants across all governorates expressed profound concerns about the inadequacy of WaSH facilities in displacement settings, emphasizing the severe impact on their daily lives. Many participants reported feelings of frustration and helplessness due to the lack of access to clean water, proper sanitation, and basic hygiene facilities.

• – Lack of access to clean water: Water scarcity was the most frequently mentioned issue. Participants described the water they received from tanker trucks as being of poor quality, often leading to skin irritations, gastrointestinal issues, and a pervasive sense of fear about the potential for disease outbreaks. A participant from Khan Younis shared, ‘We are forced to drink water that smells and tastes bad. We know it's not safe, but we have no other choice.’

• – Inadequate sanitation facilities: The sharing of latrines among multiple families was highlighted as a significant problem, particularly in maintaining privacy and hygiene. A mother of three from Gaza City stated, ‘The toilets are dirty, and it's difficult to keep them clean because so many people use them. My children are getting sick because of this.’

• – Limited hygiene resources: The lack of soap and other basic hygiene materials exacerbated concerns about personal and public health. Participants reported rationing soap and water, which led to insufficient handwashing and increased anxiety about disease transmission. A displaced woman from Rafah noted, ‘We can't even wash our hands properly. This makes us feel vulnerable, like we're just waiting to get sick.’

Participants consistently linked WaSH insecurity to various health issues, corroborating the quantitative findings. The qualitative data provided deeper insights into how these health problems manifested and affected the daily lives of displaced individuals.

• – Physical health deterioration: Diarrhea, skin infections, and respiratory illnesses were the most commonly reported health issues. Participants described these conditions as recurring problems, often leading to chronic health issues due to the inability to access adequate healthcare services in the displacement settings. A young father from Deir al-Balah mentioned, ‘My children are constantly sick. They get diarrhea, then skin rashes, then coughing. It never stops.’

• – Psychological distress: The constant fear of disease, coupled with the harsh living conditions, contributed to significant psychological stress among participants. Many reported feelings of anxiety, depression, and a sense of hopelessness. A participant from North Gaza described, ‘We are living in fear. Fear of getting sick, fear of not being able to care for our families, fear of what will happen next. It's exhausting.’

Despite the challenges, participants demonstrated resilience and adaptability in coping with the WaSH crisis. Several coping strategies emerged, highlighting the resourcefulness of displaced communities in the face of adversity.

• – Community solidarity: Sharing resources and supporting each other was a common coping strategy. Participants described how communities came together to share water, soap, and other essentials, often prioritizing those most in need, such as children and the elderly. A participant from Rafah noted, ‘We try to help each other as much as we can. If one family has extra soap, they share it. It's the only way we can survive.’

• – Adaptive practices: Participants also reported adapting their daily routines to manage the scarcity of resources. For example, some families reduced the frequency of bathing and washing clothes to conserve water, while others used makeshift latrines or disposed of waste in safer areas to prevent contamination. A mother from Gaza City shared, ‘We have to be creative. We use old clothes as rags to clean ourselves and our children. It's not ideal, but we do what we can.’

• – Seeking external support: While internal coping mechanisms were crucial, participants also expressed a strong need for external support, particularly from humanitarian organizations. Many called for increased access to clean water, improved sanitation facilities, and the provision of hygiene supplies. A displaced man from Khan Younis expressed, ‘We need help. We can't do this on our own. The organizations need to step up and provide us with the basics to survive.’

Participants provided insights into potential solutions and recommendations to address the WaSH crisis in the displacement settings. These suggestions were often grounded in their lived experiences and reflected a deep understanding of the complexities of their situation.

• – Improving WaSH infrastructure: The most common recommendation was the improvement of WaSH infrastructure, including the provision of clean water, the construction of more latrines, and the regular supply of hygiene materials. Participants emphasized that these improvements were essential for preventing disease and improving overall well-being. A participant from Deir al-Balah suggested, ‘We need more toilets, and they need to be cleaned regularly. We also need a reliable source of clean water. Without these, nothing will change.’

• – Strengthening health education: Participants also highlighted the importance of health education, particularly in teaching families about safe hygiene practices and the importance of sanitation. Several participants noted that while resources were limited, better education could help them use what they had more effectively. A young mother from North Gaza stated, ‘We need to be taught how to stay safe with the little we have. Even small tips can make a big difference.’

• – Increased humanitarian aid: Finally, there was a strong call for increased humanitarian aid, both in terms of quantity and quality. Participants stressed that ongoing support was crucial for their survival and urged international organizations to prioritize their needs. A participant from Rafah concluded, ‘We are grateful for the help we've received, but it's not enough. We need more, and we need it now. Our lives depend on it.’

The Gaza Strip's current humanitarian crisis, marked by large-scale internal displacement due to recent escalations in conflict, has significantly exacerbated WaSH issues. This study's findings reveal alarming rates of infectious diseases among displaced populations, underscoring the critical need for comprehensive WaSH interventions to address the heightened health risks.

The data from this study indicate a troubling prevalence of infectious diseases linked to inadequate WaSH conditions. ARIs (49.3%) and diarrhea (24.9%) are the most common ailments among the displaced population, reflecting severe compromises in water and sanitation infrastructure. These findings are consistent with previous research demonstrating that poor WaSH conditions are a major driver of disease outbreaks in humanitarian emergencies (D'Mello-Guyett et al. 2018; Hammer et al. 2018; UNICEF 2022; WHO 2022).

Inadequate WaSH infrastructure has been shown to contribute significantly to the spread of waterborne diseases such as diarrhea and hepatitis, which are prevalent in conflict settings due to the contamination of water sources and the breakdown of sanitation systems (Abuzerr et al. 2019; D'Mello-Guyett et al. 2024; Taha et al. 2024). Similarly, respiratory infections are exacerbated by overcrowding and inadequate shelter conditions, which are prevalent in temporary accommodations like schools and tents (ACRPS 2024; Hussein et al. 2024).

The qualitative data from this study provide a deeper understanding of the lived experiences of displaced individuals. Participants reported severe challenges related to WaSH, including insufficient access to clean water, inadequate sanitation facilities, and limited hygiene supplies. These issues not only contribute to the spread of diseases but also exacerbate psychological distress and diminish the overall quality of life (OCHA 2024).

Community coping strategies, while valuable, have proven insufficient to fully address the systemic deficiencies in WaSH infrastructure. Displaced individuals have developed adaptive practices to manage the scarcity of resources, but these measures cannot replace the need for effective, large-scale interventions (Krishnan 2016; Yasmin et al. 2023). The findings highlight a critical gap between emergency relief efforts and the actual needs of the displaced population, which calls for more robust and sustained humanitarian responses.

Addressing the WaSH needs of displaced populations requires a multifaceted approach. Immediate measures should include the provision of adequate sanitation facilities, clean water supplies, and hygiene products in shelters. Emergency relief efforts must be scaled up to address the immediate health risks associated with poor WaSH conditions (UNICEF 2023). This includes ensuring that water sources are safe and that sanitation facilities are functional and accessible to all displaced individuals.

Long-term strategies should focus on rebuilding and enhancing WaSH infrastructure to improve resilience against future crises. Investments in durable water and sanitation systems are crucial for ensuring that they can withstand both conflict and natural disasters (Johannessen et al. 2013; Roach & Al-Saidi 2021). Collaborative efforts between humanitarian organizations, local authorities, and international agencies are essential to implement these strategies effectively and to ensure that interventions are both practical and sustainable.

The findings of this study underscore the urgent need for targeted interventions to mitigate the adverse effects of inadequate WaSH conditions on displaced populations in Gaza. Immediate efforts should focus on enhancing water supply, particularly for households receiving less than 20 L per person per day, through the establishment of emergency water distribution points and temporary water tanks in displacement camps. Improving sanitation facilities is also critical, as shared latrines are linked to increased rates of ARIs; thus, constructing additional private latrines and ensuring regular maintenance and hygiene promotion are essential. Promoting hand hygiene by installing handwashing stations in high-traffic areas and implementing hygiene education campaigns will be vital for preventing skin rashes associated with the absence of handwashing facilities. Furthermore, addressing the lack of soap, which significantly impacts scabies prevalence, should involve distributing soap as part of hygiene kits to displaced families alongside educational initiatives highlighting its importance for preventing skin infections. Finally, integrating health services with WaSH interventions is crucial, providing medical care for common WaSH-related illnesses like diarrhea and skin rashes, while also offering mental health support to alleviate the overall health burden on displaced populations. By directing aid toward these priority interventions, stakeholders can effectively address the most pressing WaSH-related health risks, ultimately reducing disease transmission and alleviating the stress experienced by displaced individuals in conflict settings.

This study, while providing valuable insights into the impact of WaSH insecurity on health among displaced populations in Gaza, has several limitations. The cross-sectional design captures data at a single point in time, limiting the ability to establish causal relationships between WaSH conditions and health outcomes. Self-reported data, while useful, may be subject to recall bias or inaccuracies due to the high-stress environment of displacement camps. The study's sample of 1,500 displaced individuals, though substantial, may not fully represent all displaced persons, particularly those in other types of shelters or outside the reach of humanitarian efforts. The qualitative data collected were also limited by logistical constraints, potentially affecting the depth and breadth of insights into the diverse experiences of displaced individuals. Additionally, external factors such as the security situation and fluctuations in humanitarian aid may have influenced the results. The lack of baseline data prior to the conflict further hampers the ability to assess the extent of deterioration in WaSH conditions and health outcomes. Data collection challenges, including limited access to some areas, may have introduced biases and affected the comprehensiveness of the data. Addressing these limitations in future research through longitudinal studies, expanded qualitative components, and improved data collection methods will enhance the understanding of WaSH-related challenges and inform more effective humanitarian interventions.

This study highlights the critical link between WaSH insecurity and health outcomes among displaced populations in Gaza. The high incidence rates of infectious diseases observed in this study call for urgent and comprehensive action to improve WaSH conditions. By addressing both immediate needs and long-term infrastructure deficits, humanitarian efforts can better mitigate health risks and enhance the overall well-being of displaced individuals. Continued research and targeted interventions are essential for effectively addressing the complex challenges posed by WaSH insecurity in conflict-affected settings.

We extend our heartfelt gratitude to all individuals and organizations who contributed to the completion of this study. Our sincere thanks go to the displaced individuals in Gaza who participated in the survey and shared their invaluable experiences, providing critical insights into the impact of WaSH insecurity on their health. We are deeply appreciative of the support and collaboration from the local health authorities and humanitarian organizations, whose efforts in facilitating data collection and providing logistical support were indispensable. We also acknowledge the contributions of our research team and field staff, whose dedication and hard work ensured the successful implementation of the study. Their resilience and professionalism in challenging conditions were crucial to the project's success.

No funding was received.

Data cannot be made publicly available; readers should contact the corresponding author for details.

The authors declare no conflict of interest.