---
title: "Wastewater Surveillance for Respiratory Viruses in a Remote Alaskan Community (2022–2024)"
id: "cdc-emerging-infectious-diseases-journal-0-wastewater-respiratory-virus-surveillance-in-remote-community-alaska-usa-2022"
canonical_url: "https://medichelpline.com/clinical-feed/cdc-emerging-infectious-diseases-journal-0-wastewater-respiratory-virus-surveillance-in-remote-community-alaska-usa-2022"
content_type: "clinical_feed_article"
specialty: "Infectious Disease"
source_name: "CDC Emerging Infectious Diseases Journal"
source_url: "https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article"
published_at: "2026-08-24T04:00:00.000Z"
evidence_level: "Agency Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Wastewater Surveillance for Respiratory Viruses in a Remote Alaskan Community (2022–2024)
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/cdc-emerging-infectious-diseases-journal-0-wastewater-respiratory-virus-surveillance-in-remote-community-alaska-usa-2022
- **Specialty:** [Infectious Disease](https://medichelpline.com/clinical-feed/infectious-disease.md)
- **Primary Source:** CDC Emerging Infectious Diseases Journal
- **Source URL:** [Original Journal Publication](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article)
- **Published At:** 2026-08-24T04:00:00.000Z
- **Evidence Rating:** Agency Feed
## Executive GIST (TL;DR)
- This study evaluated on-site **wastewater surveillance** (WS) for respiratory viruses in Bethel, a remote, predominantly Indigenous hub in southwest Alaska, from October 2022 through May 2024. - WS sampling used the Moore swab passive method at the community’s last lift station; samples were collected more than three times per week on average during high-activity periods and less frequently during low-activity periods. - Wastewater testing used a clinical real-time PCR platform (Cepheid GeneXpert Xpress with CoV-2/Flu/RSV cartridges) on unconcentrated 300 µL aliquots; YKHC did not perform a local validation of this laboratory method. - The study analyzed 318 wastewater samples and compared results to 7,392 clinical respiratory virus tests from the regional hospital laboratory. - Wastewater detections: **SARS-CoV-2** in 265/318 (83.3%) samples, **influenza A** in 128/318 (40.3%), **RSV** in 78/318 (24.5%), and **influenza B** in 29/318 (9.1%). - Correlations (Spearman ρ) between wastewater signals and clinical results were reported as: influenza B ρ = 0.85, influenza A ρ = 0.62, RSV ρ = 0.60, and SARS-CoV-2 ρ = 0.59. - The study highlights practical barriers in rural WS uptake (laboratory access, costs, staffing, decentralized systems) and shows that local, on-site testing can improve timeliness and be operationally feasible. - Sampling location captured roughly 90% of piped wastewater and about 50% of hauled sewage; the system context (piped vs truck-hauled customers) affects wastewater volume and signal interpretation. - A concentration step was evaluated but abandoned for surveillance because it added time and resources without clear improvement in detection for this implementation. - The authors conclude WS is feasible and provided corroborating data used to inform timing of seasonal respiratory immunization campaigns in the region.
## Clinical Analysis & Structured Key Points
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[EID Journal](https://wwwnc.cdc.gov/eid/) 2. [Volume 32](https://wwwnc.cdc.gov/eid/early-release) 3. [Early Release](https://wwwnc.cdc.gov/eid/early-release#issue-1344) 4. [Main Article](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article) * [Facebook](https://www.facebook.com/sharer/sharer.php?u=%2Feid%2Farticle%2F32%2F9%2F26-0709_article "Share to Facebook") * [Twitter](http://twitter.com/share?url=%2Feid%2Farticle%2F32%2F9%2F26-0709_article&text= "Share to Twitter") * [LinkedIn](https://www.linkedin.com/shareArticle?url=%2Feid%2Farticle%2F32%2F9%2F26-0709_article&title= "Share to LinkedIn") * [Syndicate](https://tools.cdc.gov/medialibrary/index.aspx#/sharecontent//eid/article/32/9/26-0709_article "Embed this Page") [ Emerging Infectious Disease journal ISSN: 1080-6059 ](https://wwwnc.cdc.gov/eid/) _Disclaimer: Early release articles are not considered as final versions. Any changes will be reflected in the online version in the month the article is officially released._ ##### Volume 32, Supplement –Summer 2026 SUPPLEMENT ISSUE ##### _Other_ ### Wastewater Respiratory Virus Surveillance in Remote Community, Alaska, USA, 2022–2024 On This Page [Methods](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article) * * * [Results](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article) * * * [Discussion](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article) * * * [Cite This Article](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article) Figures [Figure 1](https://wwwnc.cdc.gov/eid/article/32/13/26-0709-f1) * * * [Figure 2](https://wwwnc.cdc.gov/eid/article/32/13/26-0709-f2) * * * [Figure 3](https://wwwnc.cdc.gov/eid/article/32/13/26-0709-f3) Tables [Table](https://wwwnc.cdc.gov/eid/article/32/13/26-0709-t1) Downloads [Appendix ](https://wwwnc.cdc.gov/eid/article/32/13/26-0709-app1.pdf) * * * [RIS [TXT - 2 KB] ](https://wwwnc.cdc.gov/eid/article/32/13/26-0709.ris) Article Metrics [Metric Details](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article) Related Articles [The Enduring Influence of Nancy J. Cox (1948–2026)](https://wwwnc.cdc.gov/eid/article/32/10/26-0830_article) * * * [Wastewater Surveillance, World Athletics Championship](https://wwwnc.cdc.gov/eid/article/32/13/26-0537_article) * * * [Influenza A(H3N2) Subclade K in Wastewater](https://wwwnc.cdc.gov/eid/article/32/13/26-0431_article) * * * [More articles on Influenza](https://wwwnc.cdc.gov/eid/spotlight/influenza) Brian Lefferts[![Comments to Author](https://wwwnc.cdc.gov/eid/content/images/icon/email.gif)](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#comment) , Alyssa Leary, Dana Bruden, Ian Blake, Christine Richman, Sarah Sixberry, Michael Vicente, Jennifer Pak, Ellen Hodges, and James W. Keck Author affiliation: Yukon-Kuskokwim Health Corporation, Bethel, Alaska, USA (B. Lefferts, A. Leary, C. Richman, S. Sixberry, M. Vicente, J. Pak, E. Hodges); Centers for Disease Control and Prevention, Anchorage, Alaska, USA (D. Bruden, I. Blake, J.W. Keck); Alaska Native Tribal Health Consortium, Anchorage (J.W. Keck) [Cite This Article](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article "Show Article Citations") Open modal [Citation for Media](https://wwwnc.cdc.gov/eid/press) ### Abstract Wastewater surveillance (WS) is underused in rural communities. We evaluated WS performance in the remote, subarctic, mostly Indigenous, community of Bethel, Alaska, USA, during October 2022–May 2024. Wastewater was collected >3 times weekly and underwent on-site PCR testing for SARS-CoV-2, respiratory syncytial virus (RSV), and influenza A and B viruses. We compared WS virus detection with local clinical data by using results from 318 wastewater samples and 7,392 clinical tests. We detected SARS-CoV-2 in 265 (83.3%) wastewater samples, influenza A virus in 128 (40.3%), RSV in 78 (24.5%), and influenza B virus in 29 (9.1%). Wastewater signals correlated with clinical results for influenza B virus (Spearman ρ = 0.85), influenza A virus (ρ = 0.62), RSV (ρ = 0.60), and SARS-CoV-2 (ρ = 0.59), providing corroborating data that informed the timing of seasonal respiratory virus immunization campaigns. Our findings show that WS is feasible and useful for disease surveillance in rural Alaska. Wastewater surveillance (WS) expanded substantially during the COVID-19 pandemic ([_1_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r1 "1")). Testing wastewater for the SARS-CoV-2 virus has several advantages over traditional case-based disease surveillance, including its efficiency in monitoring community disease trends, independence from healthcare-seeking behaviors that inform traditional surveillance approaches, and scalability from building-level monitoring to sewersheds serving millions of persons ([_2_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r2 "2")). WS has yielded actionable COVID-19 public health information across a variety of settings ([_3_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r3 "3")). Subsequently, WS platforms have expanded to include additional respiratory viruses, such as respiratory syncytial virus (RSV) and influenza virus ([_4_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r4 "4")), and have supported public health responses during respiratory virus seasons ([_5_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r5 "5")). Smaller and remote communities have had lower uptake of WS ([_6_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r6 "6")). Barriers to adoption in rural and remote areas include limited access to wastewater testing laboratories, costs, insufficient human resources, lack of centralized wastewater collection and treatment systems, and competing priorities ([_7_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r7 "7")). Local implementation of WS could overcome the high cost and logistical challenges of shipping samples to third-party laboratories, thus improving the timeliness of wastewater data ([_8_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r8 "8")). Early in the COVID-19 pandemic, a team from Canada demonstrated the feasibility and accuracy of using a rapid and user-friendly clinical PCR platform to measure SARS-CoV-2 virus levels on site in a remote community ([_9_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r9 "9")). Their WS pilot uncovered previously unknown COVID-19 infections in the community and initiated a public health response. The reported effectiveness and relative simplicity of the WS approach used by Canada team informed the implementation of WS in a remote community in Alaska, USA. Rural Alaska is home to hundreds of mostly Indigenous communities located off the road system, relying on water and air transportation for travel. Historic inequities and socio-environmental conditions, such as lack of in-home piped water and household crowding, have contributed to high rates of respiratory virus infections, particularly in rural southwest Alaska ([_10_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r10 "10")). The Yukon-Kuskokwim Health Corporation (YKHC) is a comprehensive regional Tribal Health Organization that provides most of the healthcare in the region. YKHC responded proactively to the COVID-19 pandemic with timely vaccine campaigns, physical distancing measures, and an expansive clinical testing and contact tracing program ([_11_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r11 "11"),[_12_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r12 "12")). As pandemic response measures transitioned to routine public health activities, YKHC invested in WS to monitor respiratory virus trends in the community. We analyzed 2 years of WS data for SARS-CoV-2, RSV, and influenza A and B viruses and compared wastewater viral signals with clinical testing data from the YKHC-operated YK Delta Regional Hospital. ### Methods ##### Study Setting YKHC initiated WS on October 19, 2022, in the regional hub community of Bethel, Alaska. Bethel is located 400 miles west of Anchorage in southwestern Alaska and is home to ≈6,300 residents living in 2,450 households; 74% of residents identify as Alaska Native. Many of the additional 22,000 residents in the region regularly pass through Bethel because it serves as the transportation hub and has the only hospital in the region. Wastewater management in Bethel is complex and is served by 2 different systems: a piped sewer system in the central part of town and a truck-hauled system for households and businesses outside that area. The piped system accounts for 25% of residential and commercial connections and serves 479 customers, including the YK Delta Regional Hospital. Piped services account for ≈65% of the wastewater produced by volume in the community. In contrast, the 1,373 residential and commercial hauled customers account for 75% of connections but produce only 35% of Bethel’s wastewater. Hauled customers rely on 3,000-gallon trucks to deliver water to onsite storage tanks; wastewater trucks haul away wastewater to dump into the centralized sewer system or the sewage lagoon. Hauled services are expensive to operate, resulting in higher utility costs, which causes hauled customers to minimize water use. We obtained wastewater samples from Bethel’s last lift station, which pumps raw sewage to a higher elevation so it can flow via gravity into the Bethel sewage lagoon. Previous research identified stronger viral signals from lift station samples than lagoon samples ([_13_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r13 "13")). Approximately 90% of piped wastewater in Bethel passes through that lift station, including sewage from the regional hospital and long-term care facilities. The only piped wastewater that does not pass through that site is from the Lower Kuskokwim School District campus, which discharges its sewage into the lagoon. Approximately 50% of Bethel’s hauled sewage also passes through that lift station. ##### Wastewater Sampling During October 2022–May 2024, we passively sampled wastewater by using the Moore swab method ([_14_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r14 "14")) ([Appendix](https://wwwnc.cdc.gov/eid/article/32/13/26-0709-app1.pdf)). During October 19, 2022–January 24, 2023, and June 28–September 19, 2023, sampling frequency ranged from 1 to 3 (mean 1.7) times/week. During January 25–June 27, 2023, and September 20, 2023–May 31, 2024, sampling frequency ranged from 3 to 5 (mean 4.7) times/week. Initially, we conducted sampling once per week while we developed collection and processing methods; we also reduced sampling to 1 time/week during periods of low respiratory virus activity. Sampling frequency increased with virus activity but varied depending on staffing and supply constraints. We collected Moore swabs 24 hours after placement except for swabs placed on Fridays, which the team collected the following Monday, resulting in 72-hour samples. ##### Wastewater Analysis We analyzed wastewater samples via real-time PCR on a GeneXpert Xpress with Xpert Xpress CoV-2/Flu/RSV plus viral respiratory cartridges (both Cepheid, [External Link](https://www.cepheid.com)), which test for SARS-CoV-2, influenza A and B viruses, and RSV. That system includes sample processing and probe check controls and reports results as cycle threshold (Ct) values. Scientists with the Public Health Agency of Canada validated the use of a clinical testing platform for wastewater analysis ([_9_](https://wwwnc.cdc.gov/eid/article/32/13/26-0709_article#r9 "9")), but YKHC did not validate this laboratory method. We evaluated a concentration step before PCR analysis in samples collected during October 2022–May 31, 2023 ([Appendix](https://wwwnc.cdc.gov/eid/article/32/13/26-0709-app1.pdf)). However, we elected to use unconcentrated samples for surveillance because the concentration step required additional resources and time without notable improvement in virus detection ([Appendix](https://wwwnc.cdc.gov/eid/article/32/13/26-0709-app1.pdf) Tables 1, 2). To analyze the unconcentrated wastewater samples, we added 300 µL of wastewater to a Cepheid GeneXpert cartridge and followed the manufacturer’s protocol for testing clinical specimens. ##### Clinical Testing Clinical respiratory virus testing followed YKHC standards of care. Patients of all ages with respiratory symptoms in the ambulatory, emergency, or inpatient settings at the YK Delta Regional Hospital (the only hospital in the region) were tested via collection of midturbinate nasal swab sample as part of routine clinical care. Swab samples were analyzed in the hospital’s medical laboratory by using the Cepheid GeneXpert respiratory panel kit to detect SARS-CoV-2, influenza A and B viruses, and RSV. We extracted deidentified clinical testing data from YKHC’s electronic health record system. During the study, some community members reported results from SARS-CoV-2 tests to the YKHC Department of Public Health. We conducted a separate correlational analysis by using self-reported SARS-CoV-2 test results.
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