Invasive pneumococcal disease remains a major problem in certain groups of people. We undertook a hospital-based review of all cases of invasive pneumococcal disease in central Australia over a 2-year period. We observed 79 cases of invasive disease in 78 patients. The incidence of invasive pneumococcal disease was highest in Aborigines under 5 years of age (1,025 cases per 100,000 population per year). The relative risk for Aborigines compared with non-Aborigines was 31.6 (95% CI, 12.8-78.1). Pneumonia was the commonest disease observed (82% of patients). Eight patients died (10.1%), and all of these patients had identifiable risk factors for pneumococcal disease. Serotyping showed that all except two isolates were covered by the existing 23-valent pneumococcal vaccine. These data reveal that Aborigines in central Australia have the highest reported rate of invasive pneumococcal disease in the world. A vaccination program in central Australia should decrease admissions and deaths due to pneumococcal disease.