Table 5. Recommendations based on the reviewed data about the past and the ongoing outbreak.

MPVX: monkeypox virus; H- MPVX: human-monkeypox virus; HCP: healthcare personnel; PPE: personal protective equipment; MSM: men who have sex with men; STIs: sexually transmitted infections; R0: basic reproduction number

Conclusions	Recommendations
Information about previous MPVX outbreaks and the current outbreak is lacking.	International collaboration and studies exploring the epidemiology and risk factors of the disease are vital for optimising public health protocols for tackling the pandemic.   HCP training about effective diagnostic, therapeutic and preventive protocols should be initiated.   Social media campaigns to make the general public aware of all aspects of H- MPVX, including identification, isolation, information, prevention, and treatment of H-MPVX infection.
Randomised controlled trials assessing the effectiveness of Cidofovir, Brincidofovir and Tecovirimat and other antivirals in H- MPVX are lacking.	Well-controlled studies or observational studies of Cidofovir, Brincidofovir and Tecovirimat in H- MPVX need to be planned.
The clinical picture is changing a.A milder form of disease b.Pleomorphic lesions c.Asynchronous lesions d. More frequent genital lesions and rash e. Fewer skin lesions than before f. Presence of ulcerating genital lesions/single lesion g. New symptoms- rectal pain, proctitis	Observational studies and case reports should be published.   Unusual signs and symptoms should be kept in mind by physicians   A high index of suspicion is to be kept in any patient who presents with features suggestive of MPVX and any other hitherto unknown sign.   Early recognition and timely intervention are the keys to success
Orthopoxvirus-mediated immunity is waning, and the R0 of the virus has increased. New and evolved outbreaks may happen in future.	Vaccination is going to be vital in the control of future outbreaks. Ring vaccination and vaccinating contacts of the index case and high-risk groups can curtail the spread of the disease. Mass immunisation might be an option in areas where MPVX becomes endemic.
Vulnerable groups- children, pregnant and immunocompromised may have severe infections and bad outcomes.	Children with H-MPVX infection should be kept under close surveillance in their homes or preferably in hospitals. Drug therapy might be considered.   A high index of suspicion in pregnant females with a rash and lymphadenopathy is to be maintained.   Further epidemiological investigations about the complete picture of the disease in vulnerable groups need to be conducted.
The long incubation period of the virus might be a problem for HCPS and caregivers.	Appropriate information about masks, PPE, isolation, disinfection of fomites, bed linen and clothes should be provided to people who might come in contact with confirmed or suspected cases of MPVX.
The virus has spread globally.	Travel at this time could be avoided completely, or at least to locations with reported cases.   Factors facilitating this massive multi-country transmission as of now need to be explored and addressed.   Efforts should be taken to contain the virus through identification, isolation, information, contact tracing, ring vaccination, post-exposure vaccination and mass immunisation if need be.
The virus is currently mostly clustering around the MSM community.	A strongly worded message avoiding high-risk sexual behaviour needs to be sent out there.   MSM suspecting MPVX infection need to be able to visit a physician immediately without fear of social alienation   The potential for H- MPVX cases being confused with STIs must be kept in mind.   Active Tracking for Monkeypox as a communicable disease can be started, similar to what is being done for COVID-19.   Studies should be planned to explore how exactly the virus is travelling, especially in these communities.
The sequenced viral genome of the current outbreak closely resembles the West African clade with low mortality of about 1%. However, different studies have different genome sequencing reports	Genome sequencing from both the primary and the disseminated rash is essential to understand the evolution and adaptations of the virus during the current outbreak.
A “misinfodemic” with several myths and doubts about MPVX is creating panic.	Social media campaigns providing the correct information about MPVX prevention and control will help not only allay the panic but serve as an important control strategy.
Little data exists about lab abnormalities seen in H- MPVX cases.	More focus needs to be given to the collection of such data through well-planned observational studies.
Animal sources will continue to be a source of zoonotic infection	Veterinarians have an important role to play in the current outbreak. Screening of animals especially coming from endemic regions, is vital to prevent zoonotic transmission.