Since November last year, upwards of 250,000 Chechens - about one third of the republic's population - are thought to have been uprooted by the conflict.

The majority of refugees have headed for the Russian republic of Ingushetia, which has seen its own population almost double as a result of the war.

A similar number have crossed Chechnya's eastern border into the republic of Dagestan, joining around 7,000 Chechens displaced by fighting between Islamic rebels and Russian forces in the middle of 1999.

Click here for a map of Chechen refugee movements

Now with the onset of the fierce Russian winter, bringing temperatures well below zero, conditions for those fleeing the war are becoming increasingly harsh.

Spread of disease

The sprawling tent cities and railway carriages used to house the refugees provide at best only minimal levels of sanitation, and then only for the few.

As more and more arrivals flood in, hygiene levels have plummeted and with a chronic shortage of medicines and medical facilities, health officials say there is a growing risk of epidemics.

At the Sputnik refugee camp in Ingushetia, doctors say that up to 90% of the 7,000 registered refugees living there are infected with either lice of scabies.

Tuberculosis is also proving to be a growing problem, as are the flu and respiratory diseases - all of which are finding a fertile breeding ground in the camps' cramped conditions.

"The people are living in huge numbers in the tents," Said Visurov, a doctor from Grozny working for the charity Medecins du Monde, told reporters. "If one of them gets the flu, then as a rule everyone in the tent gets ill. When they call the doctor to one sick person, you then have to examine just about everyone."

Security threat

However the main problem facing aid agencies is security. Most international groups left the North Caucasus region after the first Chechen war in 1994-96 when foreigners became the targets for a series of kidnappings.

The few expatriates who are working in the region - the UNHCR has eight and that is considered a large number - require a heavily-armed escort.

"This is the biggest outflow of refugees we have seen in a long time" the UNHCR's Kris Janowski told BBC News Online.

"Because of the intense fighting, twice as many people are leaving as are returning."

Pressure to return

Officials say these areas are now safe to return to, but many refugees say they are still too scared to return, even if that means staying in worsening conditions of the camps.

Refugee officials say that recent attacks in northern Chechnya have demonstrated that it the area is still dangerous.

Some of the fiercest fighting has been in and around the Chechen capital, Grozny. But few, if any, of the current wave of refugees are thought to have come from the city itself.

There, the remaining 20,000 or-so civilian inhabitants are reported to be living "like rats", sheltering in the cellars of bombed-out buildings without adequate supplies of food and water or electricity.

Those left in the city are either too old, too sick or simply too scared to leave. The bodies of the dead are left where they fell because few are willing to venture into the open to bury them.

For the ones who have managed to escape the thought of returning remains a far off possibility.

"I have no hope of going home anymore," said one refugee, "they say Grozny has become a dead city. I guess we'll become permanent refugees."

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