Influenza vaccine uptake, willingness, and reasons for non-vaccination among South African Hajj pilgrims in 2025

Influenza is a leading cause of morbidity at the annual Hajj pilgrimage, yet vaccination uptake among pilgrims varies across settings. This study assessed influenza vaccination uptake, willingness to accept vaccination before Hajj, and factors associated with vaccine hesitancy among South African pilgrims attending the 2025 Hajj. We conducted a cross-sectional electronic survey among South African pilgrims accredited for the 2025 Hajj. Data were collected after pilgrims returned to South Africa. The questionnaire captured demographic characteristics, self-reported chronic medical conditions, influenza vaccination within the preceding 12 months, willingness to receive influenza vaccination before Hajj among unvaccinated pilgrims, reasons for non-vaccination, and perceived awareness of influenza risk. Associations were assessed using chi-square tests and logistic regression. A total of 541 pilgrims participated, representing a response rate of 21.6%. Overall, 290 participants (53.6%) reported receiving influenza vaccination within the previous 12 months. Among 251 previously unvaccinated pilgrims, 72 (28.7%) indicated that they would have been willing to receive influenza vaccination before Hajj, while 179 (71.3%) were unwilling. Vaccination uptake increased with age, but no sociodemographic, behavioural, or clinical factor independently predicted willingness among previously unvaccinated pilgrims. The most common reasons for unwillingness were the perception that vaccination was unnecessary or of limited benefit, concerns about side effects, and vaccine distrust. Influenza vaccination uptake among South African Hajj pilgrims was moderate, but willingness to receive pre-Hajj vaccination among previously unvaccinated pilgrims was low. The contrast between prior uptake and stated willingness suggests that vaccination behaviour may reflect routine healthcare engagement rather than Hajj-specific vaccine confidence. Strengthening pre-Hajj counselling, provider-led vaccine recommendations, and access to structured vaccination pathways may improve influenza vaccine acceptance among South African pilgrims. Influenza vaccination uptake among South African Hajj pilgrims was moderate (53.6%) relative to international Hajj pilgrim cohorts. Willingness to receive pre-Hajj influenza vaccination among previously unvaccinated pilgrims was low at 28.7%. Older age was associated with higher prior influenza vaccination uptake, but not with willingness to receive pre-Hajj influenza vaccination. Perceived lack of benefit, concerns about side effects, and vaccine distrust were main reasons for vaccine hesitancy. Provider-led counselling and structured pre-Hajj vaccination pathways may improve vaccine acceptance.