ObjectivesTo document the incidence, case fatality, clinical and demographic features of invasive pneumococcal disease in central Australia.DesignInvasive isolates from the regional central laboratory were prospectively recorded over five years and case notes retrospectively reviewed. Population denominators were calculated from national Census data from 1986 and 1991.ResultsThe population estimates for the region were 14 568 for Aboriginals and 28680 for non‐Aboriginals. There were 185 episodes of invasive pneumococcal disease over the five years, 162 (87.5%) in Abori‐ginals and 23 (12.5%), in non‐Aboriginals. The incidence in Aboriginal children under two years of age was 2052.7 per 100000 and for those 20‐59 years was 178.2 per 100000. The relative risk in Aboriginals compared with non‐Aboriginals was 10.8 (95% Cl, 5.6‐20.7;P<0.0001) for those aged 0‐4 years and 20.4 (95% Cl, 9.7‐42.5;P<0.0001) for those 15‐59 years. Forty‐one Aboriginal adults aged over 14 (62%) had at least one conventional risk factor for pneumococcal disease; alcohol abuse was present in 27 (41%). There were 13 Aboriginal deaths and the case fatality rose from 2% in those under four years to 40% for those over 59 years.ConclusionsCentral Australian Aboriginals have the highest incidence of invasive pneumococcal disease reported. The rate for children under two years is 59 to 80 times the rates for children in the United States and Sweden. These data have implications for improving vaccine use, health service delivery and environmental health in Aboriginal communities.