we reviewed outbreak reports to identify outbreaks associated with an imported food from the inception of the surveillance system in 1973 through 2014 , the most recent year for which data were available . we obtained additional data for some outbreaks ( e.g. , country of origin ) from the us food and drug administration ( fda ) and the us department of agriculture food safety and inspection service . we categorized implicated foods by using the schema developed by the interagency food safety analytics collaboration ( 3 ) . we conducted a descriptive analysis of the number of outbreaks over time , by food category , and by region of origin . during 19962014 , a total of 195 outbreak investigations implicated an imported food , resulting in 10,685 illnesses , 1,017 hospitalizations , and 19 deaths . outbreaks associated with imported foods represented an increasing proportion of all foodborne disease outbreaks where a food was implicated and reported ( 1% during 19962000 vs. 5% during 20092014 ) . the number of outbreaks associated with an imported food increased from an average of 3 per year during 19962000 to an average of 18 per year during 20092014 ( figure ) . number of outbreaks caused by imported foods and total number of outbreaks with a food reported , united states , 19962014 . reporting practices changed over time ; 19731997 , imported foods anecdotally noted in report comments ; 19982008 ,  contaminated food imported into u.s . included as a location where food was prepared ; 20092014 , reporting jurisdictions could indicate whether each food is imported ( yes / no ) and the country of origin . the most common agents reported in outbreaks associated with imported foods were scombroid toxin and salmonella ; most illnesses were associated with salmonella and cyclospora ( table ) . aquatic animals were responsible for 55% of outbreaks and 11% of outbreak - associated illnesses . outbreaks attributed to produce had a median of 40 illnesses compared with a median of 3 in outbreaks attributed to aquatic animals . most of the salmonella outbreaks ( 77% ) were associated with produce , including fruits ( n = 14 ) , seeded vegetables ( n = 10 ) , sprouts ( n = 6 ) , nuts and seeds ( n = 5 ) , spices ( n = 4 ) , and herbs ( n = 1 ) . other agents implicated were tetrodotoxin ( 3 outbreaks ) and campylobacter , chaconine , paragonimus , other virus , sulfite , and trichinella ( 1 outbreak each ) . foods implicated were a chicken dish , crab cake , creampuff , beer , and a wheat snack ( 1 outbreak each ) . latin america and the caribbean was the most common region implicated , followed by asia ( technical appendix ) . thirty - one countries were implicated ; mexico was most frequently implicated ( 42 outbreaks ) . other countries associated with > 10 outbreaks were indonesia ( n = 17 ) and canada ( n = 11 ) . fish and shellfish originated from all regions except europe but were most commonly imported from asia ( 65% of outbreaks associated with fish or shellfish ) . produce originated from all regions but was most commonly imported from latin america and the caribbean ( 64% of outbreaks associated with produce ) . all but 1 outbreak associated with dairy products involved products imported from latin america and the caribbean . outbreaks in this analysis were reported from 31 states , most commonly california ( n = 30 ) , florida ( n = 25 ) , and new york ( n = 16 ) . the number of reported outbreaks associated with imported foods , although small , has increased as an absolute number and in proportion to the total number of outbreaks in which the implicated food was identified and reported . although many types of imported foods were associated with outbreaks , fish and produce were most common . many outbreaks , particularly outbreaks involving produce , were associated with foods imported from countries in latin america and the caribbean . because of their proximity , these countries are major sources of perishable items such as fresh fruits and vegetables ; mexico is the source of about one quarter of the total value of fruit and nut imports and 45%50% of vegetable imports , followed by chile and costa rica . similarly , our finding that many outbreaks were associated with fish from asia is consistent with data on the sources of fish imports ( 6 ) . one quarter of the outbreaks were multistate , reflecting the wide distribution of many imported foods . systems like pulsenet have helped to improve detection and investigation of multistate outbreaks , resulting in an increased number of multistate outbreaks ( 7,8 ) . the increasing number of outbreaks involving globally distributed foods underscores the need to strengthen regional and global networks for outbreak detection and information sharing . the importance of having standard protocols for molecular characterization of isolates and systems for rapid traceability of implicated foods to their source was illustrated during the investigation of a listeriosis outbreak linked to italian cheese imported into the united states in 2012 ( 9 ) . newer tools like whole genome sequencing can also help to generate hypothetical transmission networks and in some instances facilitate traceback of foods to their origin ( 10 ) . moreover , new tools that aid visualization of supplier networks facilitate the investigation of outbreaks involving the increasingly complex global economy ( 11 ) . only a small proportion of fda - regulated foods are inspected upon entry into the united states . new rules under the food safety modernization act of 2011 , including the preventive controls rule for human food , produce safety rule , foreign supplier verification program , and accreditation of third party auditors , will help to strengthen the safety of imported foods by granting fda enhanced authorities to require that imported foods meet the same safety standards as foods produced domestically ( 12 ) . although data collection has improved in recent years , these findings might underestimate the number of outbreaks associated with imported foods because the origin of only a small proportion of foods causing outbreaks is reported . similarly , because of how data are collected and reported , the relative safety of imported and domestically produced foods can not be compared . because of changes in surveillance and changing import patterns , changes over time should be interpreted cautiously . our findings reflect current patterns in food imports and provide information to help guide future outbreak investigations . prevention focused on the most common imported foods causing outbreaks , produce and seafood , could help prevent outbreaks . efforts to improve the safety of the food supply can include strengthening reporting by gathering better data on the origin of implicated food items , including whether imported and from what country . region and country of origin of imported foods implicated in outbreaks , by food category , united states , 19962014 .
the proportion of us food that is imported is increasing ; most seafood and half of fruits are imported . 
 we identified a small but increasing number of foodborne disease outbreaks associated with imported foods , most commonly fish and produce . 
 new outbreak investigation tools and federal regulatory authority are key to maintaining food safety .