Understanding the landscape-level determinants of West Nile virus (WNV) can aid in mapping high-risk areas and enhance disease control and prevention efforts. This study analyzed the spatial patterns of human WNV cases in three areas in South Dakota during 2003-2007 and investigated the influences of land cover, hydrology, soils, irrigation, and elevation by using case-control models. Land cover, hydrology, soils, and elevation all influenced WNV risk, although the main drivers were different in each study area. Risk for WNV was generally higher in areas with rural land cover than in developed areas, and higher close to wetlands or soils with a high ponding frequency. In western South Dakota, WNV risk also decreased with increasing elevation and was higher in forested areas. Our results showed that the spatial patterns of human WNV risk were associated with landscape-level features that likely reflect variability in mosquito ecology, avian host communities, and human activity.