Objective: Tuberculosis (TB) is one of the most important infectious diseases with an estimated 9.9 million people falling ill globally in 2020. We describe the epidemiology of TB in the Pacific island countries and areas (PICs) to inform potential priority actions to implement the Western Pacific Regional Framework to End TB 2021–2030. Methods: A descriptive analysis was conducted using annual TB surveillance data submitted by national TB programmes to the World Health Organization (WHO) and TB burden estimates (incidence rates and number of deaths) generated by WHO for the PICs, for the period 2000–2020. We also analysed TB case numbers, multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB), recent risk factor indicators and treatment outcomes. Results: The estimated TB incidence rate in the PICs increased between 2000 and 2020 from 62 to 69 per 100 000 population, with an 8% reduction observed since 2015. TB cases increased by 29% during 2000–2020, with 1746 cases in 2020 and a high proportion in children (19%). Bacteriological diagnosis was used for 58% of total TB cases, although some countries reported clinical diagnoses in over 60% of cases. From 2015 to 2019, 52 MDR/RR-TB cases were reported and there were 94 TB/HIV coinfected cases in 2015–2020. Treatment success was 74% in 2019 due to 18% of cases being unevaluated. In 2020, the estimated proportion of TB cases attributable to smoking, malnutrition, alcohol abuse and diabetes was 17%, 16%, 11% and 9%, respectively. Discussion: There was an increasing trend in TB cases, estimated incidence and deaths between 2000 and 2020. Laboratory services were scaled up in some PICs and case-finding activities greatly contributed to the detection of cases. In order to end the incidence of TB, continued efforts on case finding, contact investigation and scaling up TB preventive treatment should be prioritized. At the same time, collaboration with other sectors for risk factor management and decentralized management need to be considered.