Active, population-based surveillance for invasive group A streptococcal (GAS) disease was conducted in laboratories in metropolitan Atlanta from 1 January 1994 through 30 June 1995. Clinical and laboratory records were reviewed and isolates characterized. One hundred and eighty-three cases of invasive GAS disease were identified (annual incidence, 5.2 cases/100,000). The incidence was highest among blacks (9.7/100,000 per year; relative risk (RR), 1.92; confidence interval (CI), 1.69-2.19; P < .0001) and the elderly, particularly nursing home residents (RR, 13.66; CI, 7.07-26.40; P < .0001). The mean age of patients was 41.3 years (range, 0-95 years). Skin and soft-tissue infections were most common. Mortality was 14.4%; risk of death was significantly higher for patients with streptococcal toxic shock syndrome (STSS) (RR, 9.73; CI, 3.34-29; P = .0008) and individuals infected with M-type 1 (RR, 7.40; CI, 1.5-16; P = .0084). Fourteen percent of invasive GAS infections were STSS and 3% were necrotizing fasciitis. Invasive GAS disease was associated with varicella infection in children (RR, 12.19; CI, 5.58-26.62; P < .0001). M (or emm) types included M1 (16%), M12 (12%), and M3 (11%). Continued study of GAS disease is essential to further define risk factors and risk of secondary cases and to develop effective prevention strategies.