Ciguatera fish poisoning is the most common marine food poisoning worldwide. It has been hypothesized that increasing seawater temperature will result in increasing ciguatera incidence. In St. Thomas, US Virgin Islands, we performed an island-wide telephone survey (N = 807) and a medical record review of diagnosed ciguatera cases at the emergency department of the sole hospital and compared these data with comparable data sources collected in 1980. Annual incidence from both recent data sources remained high (12 per 1,000 among adults in the telephone survey). However, the combined data sources suggest that incidence has declined by 20% or more or remained stable over 30 years, whereas seawater temperatures were increasing. Illness was associated with lower education levels, higher levels of fish consumption, and having previous episodes of ciguatera; population shifts from 1980 to 2010 in these factors could explain an incidence decline of approximately 3 per 1,000, obscuring effects from rising seawater temperature.