Objective To understand the epidemiological characteristics of drug-resistant tuberculosis (TB) in Heilongjiang province, a high-latitude cold region, reveal its spatiotemporal transmission pattern, and predict its incidence, and provide scientific evidence for the development of effective prevention and control strategies for drug-resistant TB in Heilongjiang.

Methods Descriptive epidemiology, global trend surface analysis, spatial autocorrelation analysis and seasonal autoregressive moving average (SARIMA) model were used for the statistical analysis and prediction based on the incidence data of drug-resistant TB in Heilongjiang from 2020 to 2024.

Results A total of 6 489 cases of drug-resistant TB were reported in Heilongjiang from 2020 to 2024, with an average annual incidence rate of 4.19/100 000. The incidence rate showed a increasing trend, then a decreasing trend. The male to female ratio of the cases was 3.08∶1, and the majority of the cases were middle-aged and elderly people (68.81%) and the jobless or the unemployed (58.36%). The top three areas with high incidence rates of drug resistant TB were Hegang (7.49/100 000), Qitaihe (6.26/100000), and Jixi (6.08/100 000). Spatially, the incidence of drug-resistant TB in Heilongjiang exhibited a pattern of higher rate in southern area and lower rate in northern area, higher rate in both eastern and central areas, and lower rate in western area. In 2024, the incidence showed spatial clustering (global Moran's I>0, P<0.05) , with Qiqihar, Daqing and Suihua as low-low clustering area, Jiamusi and Shuangyashan as high-high clustering area, Mudanjiang as low-high clustering area. Time series analysis indicated that the incidence of drug-resistant TB in Heilongjiang from 2020 to 2024 demonstrated clear seasonal patterns, with the primary peak in summer (June–August) and the secondary peak in spring (March–April). SARIMA (1,1,1) × (1,1,1)₁₂, prediction model was constructed based on training data from 2020 to 2023, showing good overall model fit. Predictions for the 2025−2026 incidence of drug-resistant tuberculosis indicated continued seasonal fluctuations, with the main peaks in summer and spring.

Conclusion The prevention and control of drug-resistant TB was effective in Heilongjiang from 2020 to 2024. The incidence rate of drug resistant TB increased first and then decreased. The upward trend from 2020 to 2022 was mild, and the upward trend in 2023 was significant, and the incidence rate began to decrease in 2024. Continuous surveillance is essential, along with enhanced screening and registration management of populations at high risk, to reduce transmission and mortality of drug resistant TB.