Famine has spread to two regions of war-torn Sudan, including a major city in Darfur where paramilitary fighters have been rampaging, a global hunger monitoring group said Monday, as the war has created the world’s largest humanitarian disaster.

The Integrated Food Security Phase Classification, the leading international authority on hunger crises, said famine has been detected in el-Fasher in Darfur and Kadugli town in South Kordofan province. Twenty other areas in Darfur and Kordofan, where fighting has intensified in recent months, are also at risk of famine, according to the IPC.

El-Fasher had been under siege by the paramilitary Rapid Support Forces for 18 months, cutting off much food and other supplies to tens of thousands of people. Last week, RSF fighters seized el-Fasher, reportedly unleashing attacks that killed hundreds, though the scope of violence is unclear as communications are poor.

Kadugli town also has been under RSF siege for months with tens of thousands of people trapped, as the paramilitary group tries to seize more territory from its rival, the Sudanese military.

‘Extremely high levels of malnutrition’

The war has torn Sudan apart since April 2023. More than 40,000 people have been killed, according to U.N. figures, but aid groups say the true number could be many times higher. The fighting has driven more than 14 million people from their homes and fueled disease outbreaks.

The latest IPC report said el-Fasher and Kadugli have experienced “a total collapse of livelihoods, starvation, extremely high levels of malnutrition and death.”

Famine is determined in areas where deaths from malnutrition-related causes reach at least two people, or four children under 5, per 10,000; at least one in five people or households severely lack food and face starvation; and at least 30% of children under 5 suffer from acute malnutrition based on a weight-to-height measurement — or 15% based on upper-arm circumference.

The IPC has confirmed famine only a few times, most recently in northern Gaza earlier this year amid Israel’s campaign against Hamas. It also confirmed famine in Somalia in 2011 and South Sudan in 2017 and 2020.

The IPC previously declared famine in five locations in Sudan. There were sprawling refugee camps near el-Fasher that emptied as RSF troops advanced, with most people fleeing into el-Fasher or nearby towns. The other locations were in parts of South and West Kordofan provinces that have since also fallen into RSF hands.

The new report said about 375,000 people had been pushed into famine in Darfur and Kordofan as of September, and another 6.3 million people across Sudan face extreme levels of hunger.