1. Ciguatera is a disease caused by sodium channel activator toxins and results from the consumption of warm water fish contaminated by the ciguatoxin class of polyether toxins. 2. Other toxins, including okadaic acid and maitotoxin, have no proven role in causing human illness associated with ciguatera. 3. Ciguatera often affects only a discrete region of a reef, with flare-ups of ciguatera being both temporally and spatially unpredictable. 4. The ciguatoxins likely arise through the biotransformation and acid-catalysed spiroisomerisation of gambiertoxin-4A produced by Gambierdiscus toxicus and it is unlikely that other toxic benthic dinoflagellates are involved. 5. Events leading to a ciguatera outbreak are initiated by environmental and genetic factors that favour the proliferation of gambiertoxins, with an apparent role for anthropomorphic effects; however, the precise factors involved are yet to be determined. 6. The gambiertoxins and/or ciguatoxins are transferred from the benthos to herbivorous species (fish, invertebrates etc) and then to carnivorous fish via marine food chains. 7. Factors influencing the concentration of ciguatoxins that accumulate in fish include the rate of dietary intake, the efficiency of assimilation, the degree and nature of any toxin biotransformation, the rate of depuration, and the rate of growth of fish.