AMATRICE, Italy — Rescue crews using bulldozers and their bare hands raced to dig out survivors from a strong earthquake that reduced three central Italian towns to rubble Wednesday.
The death toll stood at 159, but the number of dead and missing was uncertain given the thousands of vacationers in the area for summer's final days.
Residents wakened before dawn by the temblor emerged from their crumbled homes to find what they described as apocalyptic scenes "like Dante's Inferno," with entire blocks of buildings turned into piles of sand and rock, thick dust choking the air and a putrid smell of gas.
"The town isn't here anymore," said Sergio Pirozzi, the mayor of the hardest-hit town, Amatrice. "I believe the toll will rise."
The magnitude 6.2 quake struck at 3:36 a.m. and was felt across a broad swath of central Italy, including Rome, where residents woke to a long swaying followed by aftershocks. The temblor shook the Lazio region and Umbria and Le Marche on the Adriatic coast, a highly seismic area that has witnessed major quakes in the past.
Dozens of people were pulled out alive by rescue teams and volunteers that poured in from around Italy.
"She's alive!" two women cheered as they ran up the street in Pescara del Tronto, one of the three hardest hit hamlets, after a 10-year-old girl was pulled from the rubble 17 hours after the quake struck.
And there were wails when bodies emerged.
"Unfortunately, 90 percent we pull out are dead, but some make it, that's why we are here," said Christian Bianchetti, a volunteer from Rieti who was working in devastated Amatrice. Flood lights were set up so the rescue could continue through the night.
Premier Matteo Renzi visited the zone Wednesday, greeted rescue teams and survivors, and pledged that "No family, no city, no hamlet will be left behind." Italy's civil protection agency reported the death toll had risen to 159 by late Wednesday; at least 368 others were injured.
Worst affected were the tiny towns of Amatrice and Accumoli near Rieti, some 60 miles northeast of Rome, and Pescara del Tronto further east. Italy's civil protection agency set up tent cities around each town to accommodate thousands of homeless.
Italy's health minister, Beatrice Lorenzin, visiting the devastated area, said many of the victims were children: The quake zone is a popular spot for residents of Roman with second homes, and the population swells in August when most Italians take their summer holiday before school resumes.
The medieval center of Amatrice was devastated, with the hardest-hit half of the city cut off by rescue crews digging by hand to get to trapped residents.
The birthplace of the famed spaghetti all'amatriciana bacon and tomato sauce, the city was full for this weekend's planned festival honoring its native dish. Some 70 guests filled its top Hotel Roma, famed for its amatriciana. Five bodies were pulled from the rubble before the operation was suspended when conditions became too dangerous.
Amatrice is made up of 69 hamlets. Teams from around Italy were working to reach with sniffer dogs, earth movers and other heavy equipment. More than 200 aftershocks jolted the region throughout the day, some as strong as magnitude 5.1.
"The whole ceiling fell but did not hit me," marveled resident Maria Gianni. "I just managed to put a pillow on my head and I wasn't hit, luckily, just slightly injured my leg."
Agostino Severo, a Rome resident visiting Illica, said workers eventually arrived after an hour or so. "We came out to the piazza, and it looked like Dante's Inferno," he said. "People crying for help, help."
President Barack Obama, speaking by telephone to Italian President Sergio Mattarella, said the U.S. sent its thoughts and prayers to the quake victims and saluted the "quick action" by first responders, White House spokesman Josh Earnest said.
Pope Francis skipped his traditional catechism for his Wednesday general audience and instead invited the thousands of pilgrims in St. Peter's Square to recite the rosary with him.
"I don't know what to say. We are living this immense tragedy," said a tearful Rev. Savino D'Amelio, a parish priest in Amatrice. "We are only hoping there will be the least number of victims possible and that we all have the courage to move on."