This toolkit provides comprehensive guidance for national and district neglected tropical disease (NTD) programmes, partner organizations, researchers, and communities to identify and respond to “never treatment”—individuals who have never ingested NTD medicines during mass drug administration (MDA). It covers defining never treatment, understanding its role in persistent low coverage or ongoing transmission, estimating levels using programmatic data, interpreting findings to determine when action is needed, reaching individuals for the first treatment, monitoring MDA improvements, integrating NTD activities with other public health programmes, and applying lessons from collected data to strengthen programme effectiveness.
Developed through the iCHORDS community of practice, the toolkit focuses mainly on lymphatic filariasis (LF) elimination programmes but offers guidance and adaptations applicable to other NTD initiatives. The toolkit standardizes terminology, adopting “never treatment” to capture both intentional and unintentional reasons why people miss treatment, aligning with global health principles such as Gavi’s “zero-dose children” and the Sustainable Development Goals’ commitment to leave no one behind. It emphasizes understanding individual, social, and geographical factors contributing to missed treatment, including systemic barriers, mobility, cultural practices, or lack of information.
Evidence shows that never-treated individuals may serve as reservoirs for infection, potentially undermining elimination targets and increasing the number of MDA rounds required to achieve public health goals. Mathematical modelling demonstrates that higher levels of never treatment, especially when clustered geographically or socially, can prolong LF and other NTD elimination efforts. Context-specific analysis is crucial, as prevalence and reasons for never treatment vary across districts, subdistricts, and communities.
The toolkit also provides guidance on collecting never treatment data through routine programmatic tools such as supervisor coverage tools, coverage evaluation surveys, and epidemiological monitoring surveys, as well as embedding questions into population-based household surveys and independent monitoring systems. Combining quantitative and qualitative approaches enables programmes to identify gaps, understand underlying causes, and develop targeted interventions. Overall, the toolkit offers practical, evidence-based strategies for national programmes to address inequities in MDA, improve coverage, and move closer to the elimination of NTDs while ensuring no one is left behind.
