T follicular helper cell profiles differ by malaria antigen and for children compared to adults

Reviewer #1 (Public Review):

Summary:

This study aims to understand the malaria antigen-specific cTfh profile of children and adults living in a malaria holoendemic area. PBMC samples from children and adults were unstimulated or stimulated with PfSEA-1A or PfGARP in vitro for 6h and analysed by a cTfh-focused panel. Unsupervised clustering and analysis on cTfh were performed.

The main conclusions are:
(1) the cohort of children has more diverse (cTfh1/2/17) recall responses compared to the cohort of adults (mainly cTfh17) and
(2) Pf-GARP stimulates better cTfh17 responses in adults, thus a promising vaccine candidate.

Strengths:

This study is in general well-designed and with excellent data analysis. The use of unsupervised clustering is a nice attempt to understand the heterogeneity of cTfh cells. Figure 9 is a beautiful summary of the findings.

Weaknesses:

(1) Most of my concerns are related to using PfSEA-1A and PfGARP to analyse cTfh in vitro stimulation response. In vitro, stimulation on cTfh cells has been frequently used (e.g. Dan et al, PMID: 27342848), usually by antigen stimulation for 9h and analysed CD69/CD40L expression, or 18h and CD25/OX40. However, the authors use a different strategy that has not been validated to analyse in vitro stimulated cTfh. Also, they excluded CD25+ cells which might be activated cTfh. I am concerned about whether the conclusions based on these results are reliable.

It has been shown that cTfh cells can hardly produce cytokines by Dan et al. However, in this paper, the authors report the significant secretion of IL-4 and IFNg on some cTfh clusters after 6h stimulation. If the stimulation is antigen-specific through TCR, why cTfh1 cells upregulate IL-4 but not IFNg in Figure 6? I believe including the representative FACS plots of IL-4, IFNg, IL21 staining, and using %positive rather than MFI can make the conclusion more convincing. Similarly, the author should validate whether TCR stimulation under their system for 6h can induce robust BCL6/cMAF expression in cTfh cells. Moreover, there is no CD40L expression. Does this mean TCR stimulation mediated BCl6/cMAF upregulation and cytokine secretion precede CD40L expression?

In summary, I am particularly concerned about the method used to analyse PfSEA-1A and PfGARP-specific cTfh responses because it lacks proper validation. I am unsure if the conclusions related to PfSEA-1A/PfGARP-specific responses are reliable.

(2) The section between lines 246-269 is confusing. Line 249, comparing the abundance after antigen stimulation is improper because 6h stimulation (under Golgi stop) should not induce cell division. I think the major conclusions are contained in Figure 5e, that (A) antigen stimulation will not alter cell number in each cluster and (B) children have more MC03, 06 and fewer MC02, etc.). The authors should consider removing statements between lines 255-259 because the trends are the same regardless of stimulations.

Reviewer #2 (Public Review):

Summary:

Forconi et al explore the heterogeneity of circulating Tfh cell responses in children and adults from malaria-endemic Kenya, and further compare such differences following stimulation with two malaria antigens. In particular, the authors also raised an important consideration for the study of Tfh cells in general, which is the hidden diversity that may exist within the current 'standard' gating strategies for these cells. The utility of multiparametric flow cytometry as well as unbiased clustering analysis provides a potentially potent methodology for exploring this hidden depth. However, the current state of analysis presented does not aid the understanding of this heterogeneity. This main goal of the study could hopefully be achieved by putting all the parameters used in one context, before dissecting such differences into their specific clinical contexts.

Strengths:

Understanding the full heterogeneity of Tfh cells in the context of infection is an important topic of interest to the community. The study included clinical groupings such as age group differences and differences in response to different malaria antigens to further highlight context-dependent heterogeneity, which offers new knowledge to the field. However, improvements in data analyses and presentation strategies should be made in order to fully utilize the potential of this study.

Weaknesses:

In general, most studies using multiparameter analysis coupled with an unbiased grouping/clustering approach aim to describe differences between all the parameters used for defining groupings, prior to exploring differences between these groupings in specific contexts. However, the authors have opted to separate these into sections using "subset chemokine markers", "surface activation markers" and then "cytokine responses", yet nuances within all three of these major groups were taken into account when defining the various Tfh identities. Thus, it would make sense to show how all of these parameters are associated with one another within one specific context to first logically establish to the readers how can we better define Tfh heterogeneity. When presented this way, some of the identities such as those that are less clear such as "MC03/MC04/ MC05/ MC08" may even be better revealed. once established, all of these clusters can then be subsequently explored in further detail to understand cluster-specific differences in children vs adults, and in the various stimulation conditions. Since the authors also showed that many of the activation markers were not significantly altered post-stimulation thus there is no real obstacle for merging the entire dataset for the first part of this study which is to define Tfh heterogeneity in an unbiased manner regardless of age groups or stimulation conditions. Other studies using similar approaches such as Mathew et al 2020 (doi: 10.1126/science.abc8) or Orecchioni et al 2017 (doi: 10.1038/s41467-017-01015-3) can be referred to for more effective data presentation strategies.

Accordingly, the expression of cytokines and transcription factors can only be reliably detected following stimulation. However, the underlying background responses need to be taken into account for understanding "true" positive signals. The only raw data for this was shown in the form of of heatmap where no proper ordering was given to ensure that readers can easily interpret the expression of these markers following stimulation relative to no stimulation. Thus, it is difficult to reliably interpret any real differences reported without this. Finally, the authors report differences in either cluster abundance or cluster-specific cytokine/ transcription factor expression in Tfh cell subsets when comparing children vs adults, and between the two malaria antigens. The comparisons of cytokine/transcription factor between groups will be more clearly highlighted by appropriately combining groupings rather than keeping them separate as in Figures 6 and 7.

Reviewer #3 (Public Review):

Summary:

The goal of this study was to carry out an in-depth granular and unbiased phenotyping of peripheral blood circulating Tfh specific to two malaria vaccine candidates, PfSEA-1A and PfGARP, and correlate these with age (children vs adults) and protection from malaria (antibody titers against Plasmodium antigens.). The authors further attempted to identify any specific differences in the Tfh responses to these two distinct malaria antigens.

Strengths:

The authors had access to peripheral blood samples from children and adults living in a malaria-endemic region of Kenya. The authors studied these samples using in vitro restimulation in the presence of specific malaria antigens. The authors generated a very rich data set from these valuable samples using cutting-edge spectral flow cytometry and a 21-plex panel that included a variety of surface markers, cytokines, and transcription factors.

Weaknesses:

- Quantifying antigen-specific T cells by flow cytometry requires the use of either 1- tetramers or 2- in vitro restimulation with specific antigens followed by identification of TCR-activated cells based on de-novo expression of activation markers (e.g. intracellular cytokine staining and/or surface marker staining). Although authors use an in vitro restimulation strategy, they do not focus their study on cells de-novo expressing activation markers as a result of restimulation; therefore, their study is not really on antigen-specific cTfh. Moreover, the authors report no changes in the expression of activation markers commonly used to identify antigen-specific T cells upon in vitro restimulation (including IFNg and CD40L); therefore, it is not clear if their in vitro restimulation with malaria antigens actually worked.

- CXCR5+CD4+ memory T cells have been shown to present multi-potency and plasticity, capable of differentiating to non-Tfh subsets upon re-challenge. Although authors included in their flow panel a good number of markers commonly used in combination to identify Tfh (CXCR5, PD-1, ICOS, Bcl-6, IL-21), they only used one single marker (CXCR5) as their basis to define Tfh, thus providing a weak definition for Tfh cells and follow up downstream analysis.

- Previous works have used FACS-sorting and in vitro assays for cytokine production and B cell help to study the functional capacity of different cTfh subsets in blood from Plasmodium-infected individuals. In this study, authors do not carry out any such assays to isolate and evaluate the functional capacity of the different Tfh subsets identified. Thus, all the suggestions for the role that these different cTfh subsets may have in vivo in the context of malaria remain highly hypothetical.

- The authors have not included malaria unexposed control groups in their study, and experimental groups are relatively small (n=13).