Story Highlights• Cases now reported in 21 states
• FDA warns consumers not to eat any fresh spinach
• Number of people sickened by E. coli on spinach now at 111
• Recall expanded Sunday night to three more brands
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WASHINGTON (CNN) -- The nationwide health scare over bacteria-ridden spinach widened Monday, as the number of states reporting sickness linked to the outbreak increased to 21.
Illinois and Nebraska each reported a case linked to the E. coli bacteria alert believed to be caused by fresh spinach. Earlier Monday, the Food and Drug Administration widened its warning against eating any bagged spinach to include all fresh spinach.
At least 111 people have become ill. One death is blamed on the outbreak.
In the latest cases, an elderly woman in La Salle County, in northern Illinois, was hospitalized with kidney failure linked to E. coli thought to have been contracted from contaminated spinach, said Melaney Arnold, communications manager for the Illinois Department of Public Health.
A Douglas County, Nebraska, resident was sickened by the same strain of the bacteria, the state's public health department said in a written statement. The patient did not require hospitalization and has since recovered.
Dr. Robert Brackett of the FDA told CNN, "We've expanded the warning actually to all of the fresh spinach. That's because we learned that some of the companies that produced the consumer bag spinach also produced larger food-service size." (Watch why the scare is widening -- 2:09)
Brackett said another concern is that restaurants or stores may use consumer-size bags of spinach to stock their salad bars or bulk bins.
"We want to make sure consumers are aware that they don't consume any of the fresh spinach. We don't know whether it came from the bag or another state. We just don't have the focus down that much yet," he said.
Spinach producers are voluntarily recalling their products. Brackett said the FDA does not have the power to order a recall but is working with the producers.
They do have the power to seize contaminated products, but Brackett said investigators can't do that until they determine the exact source of the contamination.
"It could come from the irrigation water, animals in the field, from the workers, from a piece of equipment that's contaminated. We just don't know," he said. "Until we figure that out, we don't want to go down the wrong road. We're looking at all possibilities." (Watch how FDA searches for clues to outbreak -- 2:40)
One death blamed on outbreak
Investigators have blamed a death in Wisconsin on the outbreak, said Dr. David Acheson of the FDA.
The victims are believed to be infected with the strain of E. coli called 0157:H7, he told reporters in a telephone conference call Sunday night. Fifty-six were hospitalized, at least 16 with a form of kidney failure called hemolytic uremic syndrome.
As it is, he said, "This is unquestionably a significant outbreak."
Also Sunday, authorities expanded their recall of products containing spinach to include "Spring Mix" made by the River Ranch Fresh Foods, LLC, in Salinas, California. The company obtained its spinach from Natural Selection, the company that issued the initial recall of spinach products on Friday.
Sunday's recall affects three brands: Farmers Market, Hy Vee and Fresh and Easy, Acheson said.
River Ranch President and CEO Robert V. Jenkins said he was advised Saturday of the need for the voluntary recall.
"We are all eagerly waiting for them to come up with a cause for this so that we are able to identify solutions," he said.
The ongoing investigation is being carried out jointly by the FDA and the California Department of Health Safety's Food and Drug Branch.
Investigators will begin Monday carrying out "traceback" studies, where they go to the farms that grew the suspect vegetables for Natural Selection, to see if they can find the source of the bacteria.
So far, the evidence implicating spinach is based on epidemiological data that show the people who became sick ate the spinach, Acheson said. It can take two weeks or longer from the time a person seeks medical attention until the time a laboratory is able to confirm the diagnosis, he said.
Asked if he had any advice for farmers, many of whom are bewildered over what they should do with the spinach in their fields, he said, "Given the state of the investigation, I don't."
Asked when it would be safe for Americans to resume eating fresh spinach, he said, "As soon as we are sure that we've got this under control and that the outbreak is over and that we have figured out, as best we can, what the problems are and fixed them."
No evidence of foul play
Washing the leaves well will not necessarily offer protection, he said, noting that there is evidence that E. coli can get inside the leaf.
The FDA said Friday it linked the outbreak to products packaged by the California-based Natural Selection Foods/Earthbound Farm. The company initiated a voluntary recall of all its spinach products with "best if used by" dates of August 17 through October 1.
Asked whether terrorism or foul play may be involved, Acheson said he had seen no evidence to support that theory, but did not rule it out. "In my job, I always have to keep that in the back of my mind as a possibility," he said.
Acheson said the CDC determined that the first illness from E. coli bacteria happened August 2.
Symptoms of E. coli infection include diarrhea and vomiting, and the bacteria can lead to more severe complications, particularly in the very young or elderly, including anemia and kidney failure.
FACT BOXNatural Selection Foods has recalled all packages of its fresh spinach and any salad with spinach in a blend because they are possibly contaminated with E. coli. The affected packages have "Best if Used by Dates" of August 17 through October 1. Consumers with questions can contact the company at 800-690-3200.
The recalled brands are:
Fresh and Easy
Mills Family Farm
Natural Selection Foods
Pride of San Juan
Tanimura & Antle
The Farmer's Market
Source: Natural Selection Foods LLC