Pacific Island Countries (PICs) lag behind global trends in water, sanitation and hygiene (WaSH) development. We conducted a systematic search of all English language papers (published before February 2015) about WaSH in PICs to evaluate the state of the peer-reviewed literature and explore thematic findings. A total of 121 papers met the criteria for full-text review following an initial search result of more than 6,000 papers. Two reviewers independently assessed the quality and relevance of each article and consolidated their findings according to four emergent themes: public health, environment, emergency response and interventions, and management and governance. Findings indicate a knowledge gap in evidence-guided WaSH management strategies that advocate for human health while concurrently protecting and preserving drinking water resources. Extreme weather events threaten the quantity and quality of limited freshwater resources, and cultural factors that are unique to PICs present challenges to hygiene and sanitation. This review highlights the strengths and weaknesses of the peer-reviewed literature on WaSH in PICs, addresses spatial and temporal publication trends, and suggests areas in need of further research to help PICs meet development goals.