{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,26]],"date-time":"2026-02-26T11:21:17Z","timestamp":1772104877673,"version":"3.50.1"},"reference-count":30,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,2,26]],"date-time":"2026-02-26T00:00:00Z","timestamp":1772064000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000026","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["1U01DA053903-01"],"award-info":[{"award-number":["1U01DA053903-01"]}],"id":[{"id":"10.13039\/100000026","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000001","name":"National Science Foundation","doi-asserted-by":"publisher","award":["2412446"],"award-info":[{"award-number":["2412446"]}],"id":[{"id":"10.13039\/100000001","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Viruses"],"abstract":"<jats:p>Wastewater testing for SARS-CoV-2 provided useful public health information during the COVID-19 pandemic yet was underutilized in rural communities. We addressed this gap by implementing wastewater surveillance and assessing its performance in 10 communities in Eastern Kentucky. We collected wastewater samples 1\u20132 times weekly at 10 wastewater treatment plants (WWTPs) from May 2021 until April 2023 and measured SARS-CoV-2 RNA concentrations using polymerase chain reaction testing. We calculated time-lagged correlations between wastewater concentrations and county-level reported COVID-19 cases by site. We developed a generalized linear model to estimate COVID-19 incidence from wastewater SARS-CoV-2 concentrations. The 10 participating WWTPs served 2430 to 35,575 customers, and 90% were in rural counties. We cumulatively analyzed 818 wastewater samples. Correlations between wastewater SARS-CoV-2 concentrations and COVID-19 cases were significant at seven of the WWTPs and were strongest during the Delta variant period. The incidence density model predicted more COVID-19 cases during the latter study period (May 2022\u2013April 2023) than were officially reported. Wastewater surveillance data in these rural communities corroborated clinical case data and may have more accurately described community disease levels later in the pandemic.<\/jats:p>","DOI":"10.3390\/v18030282","type":"journal-article","created":{"date-parts":[[2026,2,26]],"date-time":"2026-02-26T10:33:02Z","timestamp":1772101982000},"page":"282","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Wastewater Surveillance for SARS-CoV-2 in Rural Kentucky, 2021\u20132023"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7193-065X","authenticated-orcid":false,"given":"James W.","family":"Keck","sequence":"first","affiliation":[{"name":"Department of Family and Community Medicine, University of Kentucky, Lexington, KY 40506, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0503-3173","authenticated-orcid":false,"given":"Reuben","family":"Adatorwovor","sequence":"additional","affiliation":[{"name":"Department of Biostatistics, University of Kentucky, Lexington, KY 40506, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-7378-6466","authenticated-orcid":false,"given":"Ann","family":"Noble","sequence":"additional","affiliation":[{"name":"Department of Mechanical and Aerospace Engineering, University of Kentucky, Lexington, KY 40506, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Savannah","family":"Tucker","sequence":"additional","affiliation":[{"name":"Department of Mechanical and Aerospace Engineering, University of Kentucky, Lexington, KY 40506, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"William D.","family":"Strike","sequence":"additional","affiliation":[{"name":"Department of Biomedical Engineering, University of Kentucky, Lexington, KY 40506, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Soroosh","family":"Torabi","sequence":"additional","affiliation":[{"name":"Department of Mechanical and Aerospace Engineering, University of Kentucky, Lexington, KY 40506, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6448-3505","authenticated-orcid":false,"given":"Mohammad Dehghan","family":"Banadaki","sequence":"additional","affiliation":[{"name":"Department of Mechanical and Aerospace Engineering, University of Kentucky, Lexington, KY 40506, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Blazan","family":"Mijatovic","sequence":"additional","affiliation":[{"name":"Department of Mechanical and Aerospace Engineering, University of Kentucky, Lexington, KY 40506, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Steven K.","family":"Roggenkamp","sequence":"additional","affiliation":[{"name":"Institute for Biomedical Informatics, University of Kentucky, Lexington, KY 40506, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-5375-5492","authenticated-orcid":false,"given":"Donna L.","family":"McNeil","sequence":"additional","affiliation":[{"name":"Kentucky Water Research Institute, University of Kentucky, Lexington, KY 40506, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6762-5847","authenticated-orcid":false,"given":"Lindell E.","family":"Ormsbee","sequence":"additional","affiliation":[{"name":"Department of Civil Engineering, University of Kentucky, Lexington, KY 40506, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Scott M.","family":"Berry","sequence":"additional","affiliation":[{"name":"Department of Mechanical and Aerospace Engineering, University of Kentucky, Lexington, KY 40506, USA"},{"name":"Department of Biomedical Engineering, University of Kentucky, Lexington, KY 40506, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"511","DOI":"10.1021\/acs.estlett.0c00357","article-title":"Presence of SARS-Coronavirus-2 RNA in Sewage and Correlation with Reported COVID-19 Prevalence in the Early Stage of the Epidemic in The Netherlands","volume":"7","author":"Medema","year":"2020","journal-title":"Environ. Sci. Technol. Lett."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"138764","DOI":"10.1016\/j.scitotenv.2020.138764","article-title":"First Confirmed Detection of SARS-CoV-2 in Untreated Wastewater in Australia: A Proof of Concept for the Wastewater Surveillance of COVID-19 in the Community","volume":"728","author":"Ahmed","year":"2020","journal-title":"Sci. Total Environ."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2000776","DOI":"10.2807\/1560-7917.ES.2020.25.50.2000776","article-title":"Evaluation of Lockdown Effect on SARS-CoV-2 Dynamics through Viral Genome Quantification in Waste Water, Greater Paris, France, 5 March to 23 April 2020","volume":"25","author":"Wurtzer","year":"2020","journal-title":"Eurosurveillance"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1242","DOI":"10.15585\/mmwr.mm7036a2","article-title":"Using Wastewater Surveillance Data to Support the COVID-19 Response\u2014United States, 2020\u20132021","volume":"70","author":"Kirby","year":"2021","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"171566","DOI":"10.1016\/j.scitotenv.2024.171566","article-title":"The National Wastewater Surveillance System (NWSS): From Inception to Widespread Coverage, 2020\u20132022, United States","volume":"924","author":"Adams","year":"2024","journal-title":"Sci. Total Environ."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"100348","DOI":"10.1016\/j.coesh.2022.100348","article-title":"The Need of an Environmental Justice Approach for Wastewater Based Epidemiology for Rural and Disadvantaged Communities: A Review in California","volume":"27","author":"Medina","year":"2022","journal-title":"Curr. Opin. Environ. Sci. Health"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"149618","DOI":"10.1016\/j.scitotenv.2021.149618","article-title":"COVID-19 Wastewater Surveillance in Rural Communities: Comparison of Lagoon and Pumping Station Samples","volume":"801","author":"Towhid","year":"2021","journal-title":"Sci. Total Environ."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"E416","DOI":"10.5942\/jawwa.2016.108.0093","article-title":"The Human Capital Resource Challenge: Recognizing and Overcoming Small Utility Workforce Obstacles","volume":"108","author":"Switzer","year":"2016","journal-title":"J. AWWA"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"6","DOI":"10.2105\/AJPH.2022.307141","article-title":"Wastewater Surveillance\u2014\u201cMessy\u201d Science with Public Health Potential","volume":"113","author":"Keck","year":"2023","journal-title":"Am. J. Public Health"},{"key":"ref_10","unstructured":"Keshaviah, A., Karmali, R., Vohra, D., Huffman, T., Hu, X., and Diamond, M. (2022). The Role of Wastewater Data in Pandemic Management, Mathematica."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"121095","DOI":"10.1016\/j.watres.2023.121095","article-title":"Making Waves: The Benefits and Challenges of Responsibly Implementing Wastewater-Based Surveillance for Rural Communities","volume":"250","author":"Cohen","year":"2024","journal-title":"Water Res."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1984","DOI":"10.1021\/acsestwater.2c00044","article-title":"Development and Validation of a Simplified Method for Analysis of SARS-CoV-2 RNA in University Dormitories","volume":"2","author":"Strike","year":"2022","journal-title":"ACS EST Water"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1654","DOI":"10.3201\/eid2608.201246","article-title":"US CDC Real-Time Reverse Transcription PCR Panel for Detection of Severe Acute Respiratory Syndrome Coronavirus 2","volume":"26","author":"Lu","year":"2020","journal-title":"Emerg. Infect. Dis."},{"key":"ref_14","unstructured":"(2025, January 09). The New York Times Coronavirus (COVID-19) Data in the United States (Archived). Available online: https:\/\/github.com\/nytimes\/covid-19-data."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"206","DOI":"10.15585\/mmwr.mm7106a4","article-title":"Genomic Surveillance for SARS-CoV-2 Variants: Predominance of the Delta (B.1.617.2) and Omicron (B.1.1.529) Variants\u2014United States, June 2021\u2013January 2022","volume":"71","author":"Lambrou","year":"2022","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"651","DOI":"10.15585\/mmwr.mm7224a2","article-title":"Genomic Surveillance for SARS-CoV-2 Variants: Circulation of Omicron Lineages\u2014United States, January 2022\u2013May 2023","volume":"72","author":"Ma","year":"2023","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"489","DOI":"10.15585\/mmwr.mm7113e1","article-title":"Use of At-Home COVID-19 Tests\u2014United States, August 23, 2021\u2013March 12, 2022","volume":"71","author":"Rader","year":"2022","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1005","DOI":"10.15585\/mmwr.mm7132a1","article-title":"COVID-19 Self-Test Data: Challenges and Opportunities\u2014United States, October 31, 2021\u2013June 11, 2022","volume":"71","author":"Ritchey","year":"2022","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_19","unstructured":"Surgo Ventures (2026, February 20). COVID-19 Community Vulnerability Index (CCVI) Methodology. Available online: https:\/\/surgoventures.org\/resource-library\/report-vulnerable-communities-and-covid-19."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"118824","DOI":"10.1016\/j.watres.2022.118824","article-title":"Identification and Quantification of Bioactive Compounds Suppressing SARS-CoV-2 Signals in Wastewater-Based Epidemiology Surveillance","volume":"221","author":"Bayati","year":"2022","journal-title":"Water Res."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"173609","DOI":"10.1016\/j.scitotenv.2024.173609","article-title":"The Different Adsorption-Degradation Behaviors of SARS-CoV-2 by Bioactive Chemicals in Wastewater: The Suppression Kinetics and Their Implications for Wastewater-Based Epidemiology","volume":"938","author":"Bayati","year":"2024","journal-title":"Sci. Total Environ."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Xiang, L., Keck, J.W., Gallimore, J., Sakhaei, A., Loh, E., and Berry, S.M. (2025). Wastewater Infrastructure as a Public Health Tool: Agent-Based Modeling of Surveillance Strategies in a COVID-19 Context. Systems, 13.","DOI":"10.3390\/systems13121093"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"156535","DOI":"10.1016\/j.scitotenv.2022.156535","article-title":"Population Level SARS-CoV-2 Fecal Shedding Rates Determined via Wastewater-Based Epidemiology","volume":"838","author":"Prasek","year":"2022","journal-title":"Sci. Total Environ."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"159165","DOI":"10.1016\/j.scitotenv.2022.159165","article-title":"Variant-Specific SARS-CoV-2 Shedding Rates in Wastewater","volume":"857","author":"Prasek","year":"2023","journal-title":"Sci. Total Environ."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"197","DOI":"10.2166\/wh.2023.279","article-title":"Effectiveness of Environmental Surveillance of SARS-CoV-2 as an Early-Warning System: Update of a Systematic Review during the Second Year of the Pandemic","volume":"22","author":"Pires","year":"2024","journal-title":"J. Water Health"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"162953","DOI":"10.1016\/j.scitotenv.2023.162953","article-title":"Recent Progress on Wastewater-Based Epidemiology for COVID-19 Surveillance: A Systematic Review of Analytical Procedures and Epidemiological Modeling","volume":"878","author":"Ciannella","year":"2023","journal-title":"Sci. Total Environ."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"100326","DOI":"10.1016\/j.envadv.2022.100326","article-title":"Monitoring of COVID-19 in Wastewater across the Eastern Upper Peninsula of Michigan","volume":"11","author":"Jarvie","year":"2023","journal-title":"Environ. Adv."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"165013","DOI":"10.1016\/j.scitotenv.2023.165013","article-title":"SARS-CoV-2 Wastewater Monitoring in Rural and Small Metropolitan Communities in Central Michigan","volume":"894","author":"Conway","year":"2023","journal-title":"Sci. Total Environ."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"e02207-21","DOI":"10.1128\/spectrum.02207-21","article-title":"Wastewater-Based SARS-CoV-2 Surveillance in Northern New England","volume":"10","author":"Toledo","year":"2022","journal-title":"Microbiol. Spectr."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e01740-21","DOI":"10.1128\/aem.01740-21","article-title":"A Sensitive and Rapid Wastewater Test for SARS-COV-2 and Its Use for the Early Detection of a Cluster of Cases in a Remote Community","volume":"88","author":"Daigle","year":"2022","journal-title":"Appl. Environ. Microbiol."}],"container-title":["Viruses"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1999-4915\/18\/3\/282\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,26]],"date-time":"2026-02-26T10:38:32Z","timestamp":1772102312000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1999-4915\/18\/3\/282"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,26]]},"references-count":30,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["v18030282"],"URL":"https:\/\/doi.org\/10.3390\/v18030282","relation":{},"ISSN":["1999-4915"],"issn-type":[{"value":"1999-4915","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,26]]}}}