Various emerging and re-emerging diseases, such as streptococcosis, tilapia lake virus disease and infectious spleen and kidney necrosis virus disease, have had a significant economic impact on the tilapia industry over the last decade. These diseases have resulted in high levels of morbidity and mortality, production losses and trade restrictions. In the absence of effective husbandry management, disease prevention strategies and appropriate biosecurity measures, infectious diseases will continue to challenge the sustainability of global tilapia aquaculture. Strategies used to reduce the impact of disease include feeding probiotic and prebiotic supplements to enhance tilapia health and to modulate the fish's gut microbiota to improve gut health. Herbal medicines and immunostimulants are also used to enhance immunity to disease, while vaccines are available, or are under development, for a number of economically important pathogens affecting tilapia culture. This review provides an overview of the benefits of enhancing the immune response of tilapia to improve their health, and in turn reduce the levels of pathogens within tilapia farming systems.